Editorial

Hamid Ravaghi¹, Merette Khalil², Jonathan Abrahams³, Hala Sakr4, Dalia Samhouri⁵, Awad Mataria⁶, Richard Brennan⁷, Maha El-Adawy⁸, Rana Hajjeh⁹, Ahmed Al-Mandhari¹⁰

¹Regional Adviser, Hospital Care and Management, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. ²Consultant on Hospital Resilience, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. ³Technical Officer, WHO Emergencies, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. ⁴Regional Adviser, Violence, injuries and disabilities, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. ⁵Regional Manager, Emergency Preparedness & International Health Regulations, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. ⁶Director, Universal Health Coverage/Health Systems, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. ⁷Director, Regional Emergency, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. ⁸Director, Health Protection and Promotion, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. ⁹Director of Programme Management, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. ¹⁰Regional Director, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt.

Citation: Ravaghi H, Khalil M, Abrahams J, Sakr H, Samhouri D, Mataria A, et al. Strengthening hospital resilience in the Eastern Mediterranean Region. East Mediterr Health J. 2023;29(4):229–231. https://doi.org/10.26719/2023.29.4.229 

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

---

“Adaptation is surviving but resilience is for thriving.”

In recent years, the multiple threats of COVID-19 and other disease outbreaks, intensified climate change and severe weather events, and increasing conflicts and humanitarian emergencies have highlighted the need to strengthen resilience in the different sectors, including social, economic, environment, and health (1-3). Resilience is the ability of a system, community or society exposed to hazards to resist, absorb, accommodate, adapt to, transform, and recover from the effects of a hazard in a timely and efficient manner, including through the preservation and restoration of its essential basic structures and functions through risk management (4).

Hospitals are complex organizations which play a fundamental role in the provision of health services during health emergencies (5,6). The COVID-19 pandemic exposed the overwhelming pressures on hospitals and healthcare delivery systems generally, and the need for proactive preparedness, innovation, learning, collaboration, and community engagement for the preservation of health system functions and resources (3,7).

Resilient hospitals contribute to building stronger and more resilient health systems and healthy communities, and ultimately impact sustainable development (5). Health authorities, policymakers and scholars alike have agreed on the importance of strengthening hospital and health systems resilience, yet there is limited evidence and limited practical guidance for effective resilience strengthening in peer-reviewed literature (8,9). Building on the principles of disaster, community, organizational, and health systems resilience, this editorial conceptualizes the divergent aspects of hospital resilience using 4 questions, and outlines relevant considerations for operationalization (10).

1. Hospital resilience for what?

Hospitals are resilient when they maintain their functions and provide high-quality and continuous critical and essential services amid crises caused by multiple hazards, while leaving no one behind (9). In 2015, 187 Member States adopted the Sendai Framework for Disaster Risk Reduction 2015–2030, which identifies safe and resilient hospitals as a global priority to increase access to healthcare services before, during and after emergencies, guided by people-centred and all-hazards approaches (11). Strengthening hospital resilience will ultimately help improve access to healthcare, reduce vulnerabilities and challenge inequalities, further contributing to the advancement of Universal Health Coverage (UHC), health security, and health equity (9,10,12).

2. Hospital resilience to what?

Informed by WHO’s integrated approach to health emergency and disaster risk management (HEDRM), hospitals require a systematic, risk-informed and all-hazard approach to strengthening resilience to different types of hazards (12). They must continuously update their resilience plans, informed by regular multi-hazard risk assessments.

In the Eastern Mediterranean Region, hospitals are faced with multiple challenges and risks, including limited and maldistributed resources (human, financial and material), fragmentation of service delivery, weak health information systems, suboptimal governance arrangements, and low-quality services. These challenges and risks are exacerbated by the high number of humanitarian emergencies in the region (13-15). In 2022, 55 infectious disease outbreaks were reported from 19 of the 22 countries and territories in the Region, mostly from the fragile settings affected by conflicts and violence, where hospitals are struggling to adapt and respond to simultaneous disasters and emergencies (2). Within these contexts, challenges compound over time and limit the capacities of hospitals to respond to the needs of the populations they serve. Hospitals must demonstrate continuous resilience to maintain functionality.

3. Hospital resilience through what?

Strengthening hospital resilience as part of overall health systems resilience requires embedding hospital resilience in organizational culture, structure and management by mainstreaming HEDRM in routine hospital operations and integrating lessons learned from acute events (3,11,12). Hospitals should strengthen their absorptive, adaptive, transformative, and learning capacities throughout the prevention, preparedness, response, and recovery (PPRR) phases (9,10,13).

4. Hospital resilience of what?

Hospitals need both hard and soft resilience, defined by 6 interdependent components (the 6 Ss): space (including constructive and infrastructural resilience and agility), staff, stuff (finance, logistics and supply chains stuff), strategies and systems (including leadership and coordination, community engagement, communication, information, and learning), and service delivery (9,14). Strengthening leadership and capacitating hospital managers are critical steps for building hospital resilience in the Region (3,14).

Strengthening hospital resilience is embedded in, and intricately interdependent with, improving health systems and community resilience (9). A paradigm shift is required to transform hospitals in the Region towards integration, preparedness and sustainability and make them people-centred (14–16). Hospitals contribute to physical, political, sociocultural, and economic development of societies (15). They should empower communities and respond to their evolving needs while also reducing and mitigating their impact on the environment and contributions to climate change (14–16).

Moreover, and guided by a whole-of-society approach to advancing the dual goals of UHC and health security, it is crucial to integrate hospitals within multisectoral national health system plans, clearly defining their roles in fulfilling essential public health functions and their contributions to primary healthcare-oriented models of care, as highlighted in a resolution of the WHO Regional Committee for the Eastern Mediterranean adopted in October 2022 (2,6,11).

Strengthening hospital resilience contributes to WHO’s mission and the EMR vision 2023 (17). To guide hospital managers, a hospital resilience conceptual framework and operational guidance embedded with specific tools has been developed, which interlinks resilience “through what” and “of what” with specific interventions for each of the 6S components across the PPRR stages (9,10). For instance, operationalizing hospital resilience necessitates that hospitals have risk-informed emergency preparedness and response plans, complemented by routine measures to ensure the integrity and agility of their structural, non-structural and functional elements (3,5,10). Plans should include institutional arrangements for managing emergencies of prioritized hazards, with clear allocation of roles and responsibilities among the management, clinical and support staff (11–13). Similarly, the role and contributions of hospitals must be integrated and embedded within national and subnational HEDRM and health systems resilience strategies (3,7,9,11,15). Furthermore, continually building the leadership and managerial capacities of hospital managers is a crucial strategy in disaster and emergency management (3,12,15).

References

1. Mataria A, Brennan R, Rashidian A, Hutin Y, Hammerich A, El-Adawy M, et al. “Health for All by All” during a pandemic: “Protect Everyone” and “Keep the Promise” of Universal Health Coverage in the Eastern Mediterranean Region. East Mediterr Health J. 2020 Dec 9;26(12):1436–9.
2. World Health Organization. Building resilient health systems to advance universal health coverage and ensure health security in the Eastern Mediterranean Region. Cairo: World Health Organization Regional Office for the Eastern Mediterranean, 2022. https://applications.emro.who.int/docs/Build-resilient-health-systems-UHC-EMR-eng.pdf?ua=1.
3. Khalil M, Mataria A, Ravaghi H. Building resilient hospitals in the Eastern Mediterranean Region: lessons from the COVID-19 pandemic. BMJ Global Health 2022;7(Suppl 3):e008754.
4. UNDRR. Resilience. Geneva: UNDRR. https://www.undrr.org/terminology/resilience.
5. World Health Organization. Health service continuity planning for public health emergencies: a handbook for health facilities: interim version for field testing. Geneva: World Health Organization, 2021. https://apps.who.int/iris/handle/10665/344796.
6. World Health Organization. WHO’s 7 policy recommendations on building resilient health systems. Geneva: World Health Organization, 19 October 2021. https://www.who.int/news/item/19-10-2021-who-s-7-policy-recommendations-on-building-resilienthealth-systems.
7. Haldane V, De Foo C, Abdalla SM, Jung AS, Tan M, Wu S, et al. Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries. Nature Medicine 2021;17:1–17.
8. Saulnier DD, Blanchet K, Canila C, Muñoz DC, Zennaro LD, Savigny D de, et al. A health systems resilience research agenda: moving from concept to practice. BMJ Global Health 2021; 6(8):e006779.
9. Khalil M, Ravaghi H, Samhouri D, Abo J, Ali A, Sakr H, et al. What is “hospital resilience”? A scoping review on conceptualization, operationalization, and evaluation. Frontiers in Public Health 2022; Oct 16:10. https://www.frontiersin.org/articles/10.3389/fpu-bh.2022.1009400.
10. World Health Organization. Summary report on the expert consultation on hospital resilience in the Eastern Mediterranean Region. East Mediterr Health J. 2023;29(1):73–74. https://doi.org/10.26719/2023.29.01.73
11. UNDRR. Sendai Framework for Disaster Risk Reduction 2015-2030. Geneva: UNDRR, 2015. https://www.undrr.org/quick/11409.
12. World Health Organization. Health emergency and disaster risk management framework. Geneva: World Health Organization, 2019. https://apps.who.int/iris/handle/10665/326106.
13. World Health Organization. Strengthening hospital resilience in the Eastern Mediterranean Region: A policy paper on facility-level preparedness. Cairo, Egypt: WHO Regional Office for the Eastern Mediterranean, 2022. https://applications.emro.who.int/docs/9789290229582-eng.pdf.
14. Al-Mandhari A, Ardalan A, Mataria A, Rifaey T, Hajjeh R. Refugee and Migrant Health Strategy for the Eastern Mediterranean Region. East Mediterr Health J. 2021;27(12):1129–1131 https://doi.org/10.26719/2021.27.12.1129.
15. World Health Organization. Introducing the strategic framework for action for the hospital sector in the Eastern Mediterranean Region. Cairo: WHO Regional Office for the Eastern Mediterranean, 2019. https://applications.emro.who.int/docs/RC_Techni-n cal_Papers_2019_5_en.pdf.
16. World Health Organization. WHO guidance for climate resilient and environmentally sustainable health care facilities. Geneva: World Health Organization, 2020. https://apps.who.int/iris/handle/10665/335909.
17. El Rabat M, Assaedi A, Suleiman O, Mabry R. Vision 2023: midterm push forward plan for Health for All by All in the WHO Eastern Mediterranean Region. East Mediterr Health J. 2022;28(12):853–855. https://doi.org/10.26719/emhj.22.088.