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Resilient and Responsive Health Systems (RESYST)


Resilience and responsiveness are key to understanding how health systems in low and middle income countries can sustain progress towards health and health equity improvements. Resilient health systems delivery needed health services and offer financial protection in an equitable manner, despite changing demands and unexpected shocks. Responsive health systems offer respectful care while recognising differences in need among population groups and working to address these differences in equitable ways.


RESYST is an international consortium with a six year research programme that aims to encourage policy and management changes that enhance the resilience and responsiveness of health systems to promote health and health equity and reduce poverty. It achieves this by engaging in a programme of research to support the development of resilient and responsive health systems. CHP is the co-leader of the health workforce theme of this DFID-funded programme, and contributes to the governance key themes.

Key Themes

Health workforce:

• What is the relative importance of the different actors influencing health professionals’ job location choices?
• What are the impact, quality and cost of health workforce training by private institutions?
• How do different remuneration mechanisms influence providers’ decisions and provider-patient relationships?

CHP's work has included innovative methodologies to identify pro-social preferences and financial incentives. In the first of its kind, researchers from CHP and the London School of Hygiene and Tropical Medicine designed a real-effort experiment to simulate the incentives and context around providing health care services. The study examined the effects of fee-for-service, capitation and salary, as well as the presence of benefits for patients on the quantity and quality of effort by medical students. Participants undertook a timed task for which they were remunerated according to a specified rate and method. The results showed that salary produced the lowest quantity of output, but the data did not show that fee-for-service leads to a higher quantity of output over capitation. The experiment showed that the highest quality was achieved when participants were paid by salary, followed by capitation, and that there was less shirking under salary.

The behaviour of healthcare providers is a significant determinant of the quality and efficiency of health service provision. The South African government has embarked on a series of health reforms in its move towards universal health coverage which include the contracting of private doctors to provide primate care services in public sector clinics. Researchers at CHP and the London School of Hygiene and Tropical Medicine are conducting an investigation of the performance of sessional general practitioners in National Health Insurance (NHI) pilot sites in South Africa. The objective of the study is to investigate the performance and the gap between what doctors working at three of these sites know they should do and what they actually do in practice (the so-called ‘know-do’ gap). It will compare the personal characteristics, work settings, clinical competence and quality of care of public medical officers, sessional GPs in public sector clinics, and sessional GPs working in their private practices.

CHP is undertaking a longitudinal study over five years of the job choices of a cohort of South African nurses to inform human resource policy interventions. The aim of the project is to enhance knowledge on health professional mobility by providing a detailed analysis of the mobility patterns of cohort members. This includes where they work, where they move to when they move, and the reasons for their mobility. This will generate insights for effective policies and interventions, and will shed light on how nurses’ job preferences change over time.

Health system governance and management:

• How can health system accountability be strengthened to support improved responsiveness?
• What specific strategies can support effective implementation of equitable health system financing and human resource policies?
• How can health system leadership capabilities be strengthened?

District health systems have been promoted as a way to provide responsive services that meet the needs of poor communities. However, failure to deliver quality services in low and middle income countries is not only due to financial constraints, but often insufficient leadership capacity among district managers. CHP is involved in a three year study known as the Siyaqinisa’ (We strengthen together) District Learning site. This aims to support the Sedibeng District Management with an organisational development process involving researchers and colleagues to strengthen leadership capacity to improve staff engagement and team effectiveness. Read more about this project here.

Health system financing:

• How can progressive financing systems be developed in different fiscal and health system contexts, particularly through increasing domestic public funding?
• What features of pooling and purchasing arrangements promote health equity, services that are responsive to community needs and better financial protection for the poor?


The Health Economics and Systems Analysis group at the London School of Hygiene and Tropical Medicine, UK
The KEMRI-Wellcome Trust Research programme, Kenya
The Centre for Health Policy, University of the Witwatersrand, South Africa
The Health Economics Unit, University of Cape Town, South Africa
The International Health Policy Programme, Thailand

Affiliate members enable the RESYST Consortium to undertake research in a wide range of low and middle income settings. Affiliate members are:

African medical and Research Foundation (AMREF) headquarters, Kenya
Health Policy Research Group, University of Nigeria (Enugu), Nigeria
Health Strategy and Policy Institute, Vietnam
Ifakara health Institute, Tanzania
Indian Institute of Technology (Madras), India
Marie Stopes International, UK

Capacity Development

A core component of the RESYST research programme is capacity development which strives to strengthen the capacity of all consortium members to identify, develop, sustain and effectively disseminate a health systems strengthening research programme which responds to the priorities and needs of policymakers. With a strong emphasis on research uptake, RESYST identifies opportunities to engage with policymakers on the use of research findings and produces research outputs which are most likely to be effective in influencing health system policies and practices.

RESYST-related publications on financing:

Ataguba JE, Goudge J. The Impact of Health Insurance on Health-care Utilisation and Out-of-Pocket Payments in South Africa. The Geneva Papers, 2012, 37: 633-654

Goudge J, Akazili J, Ataguba J, Kuwawenaruwa A, Borghi J, Harris B, Mills A. Social solidarity and willingness to tolerate risk- and income-related cross-subsidies within health insurance: experiences from Ghana, Tanzania and South Africa. Health Policy and Planning2012 27 Issue Suppl 1:i55-i63

Mills A, Ally M, Goudge J, Gyapong J, Mtei G. Progress towards universal coverage: the health systems of Ghana, South Africa and Tanzania. Health Policy and Planning. 2012 27 (Suppl 1): i4-i12

Mills A, Ataguba, JE, Akazili J, Borghi J, Garshong B, Makawia S, Mtei G, Harris B, Macha J, Meheus F, McIntyre D. Equity in financing and use of health care in Ghana, South Africa, and Tanzania: implications for paths to universal coverage. The Lancet (Online Publication). 15 May 2012: 1-8.

Macha J, Harris B, Garshong B, Ataguba JE, Akazili J, Kuwawenaruwa A, Borghi J.Factors influencing the burden of health care financing and the distribution of health care benefits in Ghana, Tanzania and South Africa. Health Policy and Planning. 2012 27:i46-i54

Why does social protection work for some households but not others? Goudge J, Russell S, Gilson L, Gumede T, Tollman S, Mills A, 2009

RESYST-related publications on the Health Workforce:

Blaauw D, Lagarde M. (2015) Uptake of public sector sessional contracts by private general practitioners in South Africa. RESYST Working Paper 8. December 2015.

Lagarde M, Blaauw D. (2014) Pro-social preferences and self-selection into jobs: Evidence from South African Nurses. Journal of Economic Behavior & Organization; 107:136–152.

Blaauw D, Ditlopo P, Rispel LC. (2014) Nursing education reform in South Africa - lessons from a policy analysis study. Global Health Action 7: 26401.

Ditlopo P, Blaauw D, Penn-Kekana L, Rispel LC. (2014) Contestations and complexities of nurses' participation in policy-making in South Africa. Global Health Action 7: 25327.

Munyewende P, Rispel LC, Chirwa T. Positive practice environments influence job satisfaction of primary health care clinic nursing managers in two South African provinces. Human Resources for Health 2014, 12:27 doi:10.1186/1478-4491-12-27

Rispel LC, Blaauw D, Chirwa T, de Wet K. (2014) Factors influencing agency nursing and moonlighting among nurses in South Africa.Glob Health Action;7:23585.

Rispel LC, Chirwa T, Blaauw D. (2014) Does moonlighting influence South African nurses' intention to leave their primary jobs? Global Health Action 7: 25754.

Van Zyl G
, Christofides N. International Nurses Day and press coverage in South Africa. International Nursing Review, 61(2): 186-193. June 2014 DOI: 10.1111/inr.12101

Lagarde M and Blaauw D. Rural or urban? The role of nurses’ dedication towards patients in their choice of job. June 2014 (Policy Brief; written by Rebecca Wolfe, RESYST)

Rispel LC. Moonlighting, agency nursing and overtime among South African nurses. Policy Brief. May 2014

Munyewende P. What influences job satisfaction of PHC Clinic Nursing Managers? Findings from two South African provinces. Policy Brief. July 2014

Nxumalo N and Choonara S. A rapid assessment of ward-based PHC outreach teams in Gauteng Sedibeng District, Emfuleni sub-district.Policy Brief. February 2014.
Click here to read the report.

Blaauw D, Ditlopo P, Maseko, F, Chirwa, M, Mwisongo, A., Bidwell,P, Thomas, S, Normand, C. Comparing the job satisfaction and intention to leave of different categories of health workers in Tanzania, Malawi, and South Africa Glob Health Action 2013, 6: 19287 -http://dx.doi.org/10.3402/gha.v6i0.19287

Lagarde M, Blaauw D, Cairns J. Cost-effectiveness analysis of human resources policy interventions to address the shortage of nurses in rural South Africa. Social Science & Medicine. 2012 doi:10.1016/j.socscimed.2012.05.005:1-6

Fonn S, Ray S, Blaauw D. Innovation to improve health care provision and health systems in sub-Saharan Africa - promoting agency in mid-level workers and district managers. Glob Public Health. 2011 Sep;6(6):657-68. Epub 2011 May 24.

Ditlopo P, Blaauw D, Bidwell P, Thomas S. Analyzing the implementation of the rural allowance in hospitals in North West Province, South Africa. Journal of Public Health Policy. 2011 32, S80–S93.

Mullei K, Mudhune S, Wafula J, Masamo E, English M, Goodman C, Lagarde M, Blaauw D Attracting and retaining health workers in rural areas: investigating nurses' views on rural posts and policy interventions. BMC Health Serv Res. 2010 Jul 2;10 Suppl 1:S1.

Policy interventions that attract nurses to rural areas: a multicountry discrete choice experiment. Blaauw D, Erasmus E, Pagaiya N, Tangcharoensathein V, Mullei K, Mudhune S, Goodman C, English M, Lagarde M, 2010

Understanding nursing students' attitudes towards working in rural areas in South Africa: The results of a cohort study. Erasmus E,Blaauw D, 2010. [policy brief]