Paper short abstract:

We studied resilience work of Dutch health system actors, whilst staying sensitive to the ‘dark sides’ of resilience. In our analysis we zoom in on the interplay of three crucial types of resilience work by actors; representing, layering, and accounting.

Paper long abstract:

Resilience as concept is gaining traction in discussions about crises and disasters in healthcare. There is a plethora of frameworks that propose the characteristics or building blocks of resilient health systems. Yet, we know little about how resilience is actually practised in healthcare. Hence, we studied how Dutch health system actors practised resilience, whilst staying sensitive to its ‘dark sides’. We thereby break away from resilience as descriptive and apolitical notion, as this ignores the vulnerabilities it induces. We conducted an ethnographic study with 20 interviews throughout the Dutch health system, an analysis of international literature and policy documents, and a secondary data analysis of a previous project on resilience during the pandemic.

We zoom in on the interplay of three types of resilience work. First, actors work to represent the needs of their wider communities. They strategically and dynamically position themselves as spokesperson for themes such as acute care or public health, whilst safeguarding the interests of particular groups. Representation also works as a means of communicating across different governance layers. Second, we observed constant efforts directed at layered governing, which includes redrawing institutional boundaries. Another important topic was the sharp ‘acute’ edge of a crisis versus its longue durée. Finally, actors work to account for deviations from common practice, or more generally to justify choices made under pressure. We note how accountability structures tend to be based on how we expect crisis to evolve, rather than being able to move along with what happens in practice.