The contribution of community health systems to resilience: Case study of the response to the 2015 earthquake in Nepal

Background Understanding how to build resilience in health systems is essen-tial to ensuring countries can respond to shocks and has become increasingly important in the context of climate change. The 2015 earthquake in Nepal of-fered an opportunity to capture lessons learned and advance our understanding of resilience. Community members, especially female community health volun-teers (FCHVs), were central to the response. We aimed to describe the successes and challenges with building resilience in community-based health systems after the earthquake response from multiple perspectives within the health system.Methods Key informant interviews and focus group discussions were utilised. Participants included FCHVs, primary healthcare workers, community lead-ers and mothers, district health managers, representatives from the Ministry of Health and Population, multilateral health organisations, bilateral develop-ment partners, local non-governmental organisations, community-based organ-isations, and international non-governmental organisations. We used thematic content analysis to identify emerging themes.Results Seventy-seven people participated in the study in September 2016 from communities (n = 53, 69%), districts (n = 8, 10%), and national levels (n = 16, 21%). Strong coordination, international and national support, and communi-ty engagement and participation were reported as successes of the earthquake response. Challenges included a lack of preparedness and supplies, a lack of earthquake-resistant infrastructure, and the centralisation of the response. FCH-Vs continued to work, despite being victims of the earthquake themselves. Facil-itators of the continuation of the FCHVs' duties included their strong ties with the communities and facilities, international support, and the ability to mobilise existing community resources. Barriers included fear, communities' attitudes, high workloads, large geographic distances, and difficult geography. Participants identified the importance of having strong, connected, and supported commu-nities, adaptable funding and policies, and decentralised decision-making with-in strong health systems. Conclusions Building resilience in community-based health systems must start with strong communities that are prepared, trained, equipped, and empowered. Health systems must be decentralised and adaptable, with strong coordination and leadership. Capable community health workers such as FCHVs were an important part of building resilience during the earthquake. These lessons can assist countries in strengthening decentralised health systems to better respond to a multitude of shocks, while still providing essential health services for com-munities.