Resilient Healthcare Catering to Resilient Communities: An Examination of Peru's Healthcare System and its Degree of Resilience

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MSc Crisis and Security Management Faculty of Governance and Global Affairs

Leiden University – Campus The Hague

Master Thesis

“Resilient Healthcare Catering to Resilient Communities:

An Examination of Peru’s Healthcare System and its Degree

of Resilience”

Course: Master Thesis Crisis and Security Management Supervisor: Drs. G.M. (Jelle) van Buuren

Second Reader: Dr. Anouk L. van Leeuwen Student: Francesca Barco

s1644858

f.barco@umail.leidenuniv.nl

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Acknowledgements

"When they go low, we go high” Michelle Obama

Developing this thesis was a long process at the end of a long journey. It would have never been possible without a few people:

My supervisor, Jelle van Buuren, for his support, patience and advice. Thank you from the bottom of my heart!

My parents, Alessandra and Gianfranco, and all my family, for allowing me the audacity of dreaming big since I was very little. I love you very much.

The people I truly love, for being by my side, fighting for me and with me. You are my world.

My previous teachers Hillary, Vilma, Tex and Farhang, and those who helped me with this thesis. You all gave me the opportunity to get here, I hope I made you proud. And finally, myself, for the resilience.

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4.3PROBLEM SITUATION: ACHIEVEMENTS AND PITFALLS OF PERU’S HEALTHCARE SYSTEM ... 49 4.3.1INFRASTRUCTURE DISTRIBUTION ... 49 4.3.2HEALTH WORKERS ... 51 4.3.3BLOOD DONATIONS ... 54 4.4CHAPTER CONCLUSION ... 55 5.RESULTS 56 5.2HOW RESILIENT IS PERU’S HEALTHCARE SYSTEM FROM BOTH A TOP-DOWN AND A BOTTOM-UP PERSPECTIVE? ... 58

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5.2.2CRITICAL INFRASTRUCTURE PROTECTION AND SAFE HOSPITALS ... 59

5.2.3ACCESS:SIS–SEGURO INTEGRAL DE SALUD ... 61

5.2.4ENGAGEMENT:RELIANCE ON THE HEALTHCARE SYSTEM ... 62

5.2.5ENGAGEMENT AND ACCESS: VULNERABLE SECTORS OF SOCIETY ... 65

5.5CHAPTER CONCLUSION ... 68

6. CONCLUSION AND DISCUSSION 71 6.1TO WHAT EXTENT IS PERU’S HEALTHCARE SYSTEM RESILIENT AND HOW CAN THIS DEGREE OF RESILIENCE BE EXPLAINED? ... 71

6.2POLICY RECOMMENDATIONS ... 73

6.3FINAL REMARKS -SUGGESTIONS FOR FURTHER RESEARCH AND LIMITATIONS OF THIS STUDY ... 74

BIBLIOGRAPHY 76 JOURNAL ARTICLES ... 76

BOOKS AND BOOK CHAPTERS ... 83

GOVERNMENT AND ORGANIZATIONS’DOCUMENTS,REPORTS ... 86

LAWS AND BILLS ... 91

DATASETS ... 91

WEBSITES ... 93

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Introduction

While discussing the belle époque, Ward Wilson (2014) found consistent parallels in several countries around the globe. Deep economic crisis, a widening gap between the poorest and wealthiest sectors of society and overcrowding in metropolises

heightening risk and criminality made communities and states more insecure in the 1890s and 1910s, but today these are still matters subject of debate and policymaking decisions worldwide. A factor that was overlooked then is how these relate to disaster, when it hits. After decades of failed treaties and conventions, in December 2015 the United Nations Climate Change Conference (COP 21 or CMP 11) in Paris made a breakthrough in matters of environmental policy, putting the world’s worsening environmental conditions at the top of the political agenda. At the time of writing, it is yet to be seen if the Agreement will be ratified by enough states to become reality, but it has the potential to benefit socio-environmental systems and subsystems that are struggling to thrive. Coupled with the Hyogo Framework for Action 2005–2015: Building the resilience of nations and communities to disasters, we can notice an attention to the wellbeing of peoples in the circumstances they live in, therefore paving the way to implement solutions that can empower communities when facing crisis. Nonetheless, these measures are not pre-emptive but forced by the worsening circumstances to which all regions of the world are increasingly exposed. The next decades are going to be affected by disruption and disaster therefore it is necessary to tackle the problem with real strategies involving all areas of crisis management. But what does this all mean? The Paris Climate talks, the Hyogo Framework and exposure to disaster? There is an element pulling together these rather distant topics and it is resilience: resilience as an outlet for real change in facing crisis, which is a constant threat in present and future endeavours for wealthy and not-so-wealthy countries; and resilience as a way to adapt to the environment around people and boost recovery from disaster, overall promising stronger adaptability in the future. Resilience has become the answer to worsening climate conditions and disaster, but what is it exactly? What does it entail? The concept is not easily quantifiable and cannot be isolated to be studied. Instead, it has to be analysed in relation to the context in which it originates.

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In recent decades, resilience has become a go-to concept for policymakers and in crisis management discourse. While previous approaches sought a top-down type of resolution for disruption within communities, currently more attention is paid to what people can do in the present and the future, when the threat of climate change will be reality for many populations around the globe, the poorest in particular. Resilience is becoming more and more a concept on its own, not just a tool for bureaucracies and the security apparatus of a country. At the same time the concept suffers from gaps in the knowledge, as it adapts to the circumstances of crisis affecting an individual or a community and cannot be studied on its own. Moreover the practical applications of resilience vary greatly from one occasion to the other, contributing to a continuous revision of its theoretical connotations. Contemporary thinking frames resilience as an element of a sustainable future, but not all agree on the extent of its importance

compared to other matters or actors in it and at times it is used by organizations and institutions as a buzzwords. As per Christoplos et al. (2012) “the need to choose different indicators for measuring resilience per se, in order to understand if adaptation has been achieved, seems not to have been considered in most planning processes “, therefore research on resilience is of great value because it contributes to expanding its understanding and the understanding of the role other elements play in resilient contexts.

The concept is increasingly incorporated into development policy focusing on

sustainable future planning and decreasing vulnerability to risk. It initially developed from a number of ideas in the body of literature: ecosystem stability and biology (Holling, 1973); engineering, psychology and behavioural sciences (Norris, 2010; Lee et al., 2009); urban and regional development (Simmie and Martin, 2010); and

disaster risk reduction. For communities, too, it has become source of empowerment when these are included in governance. There is ideological tension between

grassroots movements and more liberal policymakers in what resilience comprises of, and this is likely to continue in future decades. But what exactly is required from resilience? The perpetuation of security? Security is a social construction. Following the English School’s concept of securitization, security is not unitary and can be seen under various aspects, making Environmental and Societal security have an impact on the overall security of the people of a nation or even a system of nations (Buzan, de Wilde and Wæver, 1997). According to this point of view, the referent of security is

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and recover in critical situations. Consequently, the threats to the security of individuals include problems that may not always be foreseeable, such as disease outbreaks, poverty, crime, natural disasters, abuses to human rights after conflict, etc. (2004).

Relevance of the study

In the context of this thesis, resilience is defined as the capacity of a system, community or society potentially exposed to hazards to adapt, by resisting or changing in order to reach and maintain an acceptable level of functioning and structure (United Nations’ International Strategy for Disaster Risk Reduction, 2005) and it will be thoroughly analysed throughout the literature review. The idea behind this thesis project originates from the consideration that although crises are not exclusive to global warming, their occurrence will not be halted by it, rather, it will increase. Therefore, are countries prepared? Are communities going to be able to ‘bounce back’ from disasters? How is it possible to put resilience in practice? These questions led to finding the final question leading this research, with specific

reference to the case at hand: to what extent is Peru’s healthcare system resilient and how can this degree of resilience be explained?

The theoretical ambiguity of the concept, especially when it falls into in particular areas of study, makes it difficult to analyse it. Consequently the first achievement for this thesis was to find workable indicators that could be applied to the case at hand. Without clear indicators problem-solving becomes impossible both for the researcher and the policymaker, therefore having ad-hoc indicators was a solution for academic purposes but also for potential policy recommendations. For this reason, this

assessment of Peru’s healthcare resilience is based on indicators developed

specifically for this thesis that are not only answering the main research question, but also proposing further research and policy alternatives.

The relevance of this study is therefore both academic and societal. From an academic point of view, finding suitable indicators to conduct this type analysis is challenging, but allows using theoretical inputs while delving in the most technical aspects of the matter, finalizing objective parameters and providing insight into the case.

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providing data and information of use for future improvements and policy changes. Knowledge from the evidence can be used for practical matters enhancing capacity for both policy makers and crisis managers, as the underlining belief of this thesis is that the successfulness of crisis relief derives from the efficiency of the sectors contributing to it. As we will also study in the next chapter, using this mechanism in policy would allow the possibility of going beyond the status quo and engage in social change and development.

The case of Peru’s healthcare system was picked for availability of information and peculiar national situation: it is a developing country, it is demographically unique and it has a variety of ecosystems throughout its territory, but at the same time healthcare expenditure by the government is very low and spread unevenly. Resilient healthcare is a pillar of crisis recovery and as such, for communities hit by an

emergency, therefore the complexity of Peru’s case serves the topic well and is a starting point for further developments and studies.

The idea behind this thesis was informed by a variety of sources. First and foremost, an increased debate on the media and in academia of the possible, damning effects climate-change. As important was my fascination with Latin America, a continent often forgotten by Western academia. Moreover the influence resilience has in top-down and bottom-up action in crisis settings is not going to diminish in time, especially since it has been adopted by a variety of international institutions and organizations. Finally, community resilience in the aftermath of natural disasters was not one of the first subjects to arise when discussing crisis management in class, even though the harrowing experiences of Haiti in 2010, Hurricane Katrina in 2005 and the Zika epidemic in the Americas in more recent times have shown how relevant to the topic can low-income communities be in such critical times. Health problems after crisis were not often tackled, too, even though these can often take place in refugee camps, or makeshift camps.

I personally believe natural disasters and climate-related disruptive events are going to become the most dangerous threat to our and future generations, therefore it deserves smart and forward-thinking planning to be tackled – starting from healthcare. Resilience in times of crisis may be a hot topic for policymakers and media outlets when dealing with war and revolutions, but neglecting it when

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counterproductive.

Thesis outline

In the following chapters the thesis will cover theoretical doubts over what resilience is and how it takes shape in practical contexts such as healthcare, and then it will provide the analysis of the case, Peru, with the help of the main research question and consequent sub-questions.

Chapter 2 is an investigation on resilience that goes from a general outlook on the concept to the specifics of resilient healthcare. The conceptualization starts with definitions and the relation of resilience to crisis management, exploring critiques and ramifications into the crisis realm. It then moves into the ‘top-down’ and ‘bottom-up’ debate, giving an overview of the complex tension between the two points of view and offering examples of how bottom-up resilience can improve communities’

conditions after crisis. In order to introduce healthcare resilience, the chapter will also take into account community resilience. Finally, the chapter ends on resilient

healthcare, considered to be a pillar for community resilience and the ‘bounce back’ property of the concept.

Chapter 3 introduces the specifics of the research design and methodology starting from the research questions. Following, the analysis of a single case study (Peru’s healthcare system) is going to be motivated and indicators are going to be presented in order to operationalize all concepts and then proceed with explaining triangulation of methods and validity.

Chapter 4 functions both as a case introduction and initial analysis of data. As a matter of fact, the contextual insights on Peru as a country and as a case study will be presented, but this in the outlook of the case also being part of two of the

sub-questions, the particular downfalls and achievements of the country’s healthcare system are going to be described.

Chapter 5 presents the results of the data researched and the answer to the remaining sub-questions. The debate looks at government plans, technical analyses by third part

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examiners such as WHO and PAHO, and it keeps into account the peculiarities of Peru, as a nation and as an ensemble of realities, often very different from each other. Chapter 6 is devoted to a summary providing the conclusive remarks on the research, an answer to the leading research question and the recommendations for improvement of the sector in order to make it resilient.

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2. Body of knowledge

The following chapter is going to present a discussion on resilience. This is a contested concept in public administration and crisis management because its

definition and peculiarities vary according to the context in which it works. Although the concept has gained popularity, the lack of a clear definition brings to an overall absence of an operative framework for assessing its progress asking for it to be framed within a context in order to be understood. For this reason this chapter is starting from the general understanding of the concept in relation to the realm of crisis management, touching on the various approaches by academia and eventually going into detail on the matter of healthcare as a functional component of community resilience. In going from the general concept to a more particular area, this chapter aims at tackling the increasing popularity of the term and the differences we may encounter from one discipline to another. In a second moment, this theoretical framework will approach community resilience in order to decide which ‘side’ of the concept is more useful to the overall analysis: top-down or bottom-up? This is going to allow further debate on healthcare resilience as the main topic of this research is Peru’s healthcare system’s active contribution to the empowerment of communities and effectiveness of resilience to prepare for future crises that are likely to struck South America. Successful crisis relief requires functioning infrastructure catering to its needs. Of the many components of community resilience, healthcare is of interest because it has immense societal value by being an agent of change in both crisis and ‘normal’ settings. At the same time, the problems that one healthcare system

encounters can differ profoundly from another one, making this research dynamic because it demands for the analyst to delve deep into what the indicators for the study are, as we will see in the end of the chapter with an assessment of the variables suggested by the literature that can provide an answer to the research question.

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2.1 Resilience: a complex and dynamic concept

Due to worsening climate change, the globe is entering a phase of ‘ongoing emergency’, calling for an acceptance of life as a permanent process of continual adaptation in light of more frequent and complex hazardous events (Evans and Reid, 2013). The need of resilience as a response to almost perpetual contingency requires looking for its implications in specific spheres of security politics and policy. For this reason it is necessary to trace “this transformation of an ensemble of difficulties into problems to which diverse solutions are proposed” (Foucault, 2003: 47) in order to find an organic strategy for the utilization of resilience in securitizing at-risk communities and countries.

From the Latin ‘resilio’ and ‘resiliere’, to rebound, to recoil or to spring back, the term ‘resilience’, or ‘resiliency’, originally derives from engineering where it was used to indicate the elastic quality of a certain a substance (Joseph, 1994), and from biology and psychiatry (Boin et al.,). Resilience is a concept “for which both its appeals and frustration come from the elasticity of its meaning” (Brown and Kulig, 1996/97: 29). As a matter of fact, the concept carries a variety of meanings depending on the context in which it is used, causing disagreement on a single and uniform definition among scholars and critics, who in turn argue against the ambiguity of the term (Folke, 2006; Hunter, 2012; McAslan, 2010, 2011; Tanner et al., 2009).

Theorists have often pointed at the shortcomings of resiliency, Rigsby (1994) argued that the underlining assumption of success in resilience may lead to simplistic

predictions when analysing risk. Others directed their critique to the ambiguity of the definition, pointing out that it may not be a single construct (Gordon and Song, 1994). Resilience is clearly a complex and dynamic subject of study, which is far reaching and evolves with the progress of research. Nonetheless its essence stems in the ability to bounce back from distress, change and/or disruption, which is not dissimilar from the definition by Webster’s New Twentieth Century Dictionary of English Language (1958): “the ability to bounce or spring back after being stretched or constrained or recovering strength or spirit.” Resilience therefore encapsulates the capacity of a system, community or society that are potentially exposed to hazards to adapt by resisting or changing in order to reach and maintain an acceptable level of functioning and structure (United Nations’ International Strategy for Disaster Risk Reduction, 2005).

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2.1.1 Resilience: shaping the concept through the context

In context, the term is shaped by the researcher, who filters it through the use of adjectives and nouns to shape its essence and orient it towards new fields of study. There is a number of contexts in which resilience is used, business, science, engineering, etc. In this case, human resilience, institutional resilience and social-ecological resilience are worth mentioning in order to provide examples of the

concept assuming new meaning in different fields. Human resilience ensures focus on individuals and communities when coping with adversity and on their adaptive and learning capabilities. Furedi (2008) for example perceives as resilient those groups and people showing natural propensity in coping with contingency, although this must not be taken as an innate quality, rather a “developmental process that incorporates the normative self-righting tendencies of individuals” (Masten, 2001). Institutional resilience, on the other hand, studies the anticipation and level of absorbance of shock for institutions, which need to maintain their functions and identity in contingency. Finally, social-ecological resilience places human society in its habitat. It is

preoccupied with the interaction between people and the environment or ecosystem surrounding them, and how they can sustain their livelihoods through disaster (Walker et al., 2004).

2.1.2 Epistemic regimes and ramifications

The emergence of resilience as concept and construct to be used as solution to disruptive events should be studied from the perspective of these emergencies, in relation to crisis (Aradau, 2014). In order to understand her point, Aradau finds three epistemic regimes (ignorance/secrecy; risk/uncertainty; surprise/novelty) that present different views on problematizing contingency and “are underpinned by different assumptions about what can be known, how knowledge can be acquired and how contingency can be ‘tamed’” (Aradau, 2014: 76).

The assumption underpinning the epistemic regime ‘ignorance/secrecy’ is that what is unknown can be discovered and made transparent, therefore rendered tangible.

Ignorance and secrecy are examined in relation to knowledge, for this reason lack of it gives access to ‘depth’ - the opposite on ‘surface’, non-knowledge (2014).

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the existence of parallel worlds” instead of surface and depth. In modelling a parallel reality, mimicking the one we live in, risk management can frame uncertainty. To do so, though, it requires governing contingency through patterns and multiples without focusing on a single event.

Events are a constant potential when discussing the ‘surprise/novelty’ epistemic regime. Surprise is inevitable and a continuous process, making the unknown integral to the world, although it cannot be visible or made visible through either taming non-knowledge or drawing patterns. Contingency becomes part of reality through

resilience. Surprise has different meanings also in the other regimes, but in this it paves the way for resilience. In resilient individuals and communities we find that the process stimulates growth, giving additional skills than prior to the contingency (Richardson et al., 1990: 34; Higgins, 1994: 1), making it a construct involving exposure to disruptive events and a positive outcome in adaptation and adjustment (Luther and Cicchetti, 2000).

Once again, the relationship with resilience and change is common to various fields, although the subject of study varies and brings to different conclusion on the concept itself.

Castelden et al. (2011), find that the many definitions of the concept share common components, regardless of their originating discipline, and proceed to pinpoint them:

• Communication is the first major feature of a significant amount of literature, bringing as example the United States’ Coast Guard’s actions during

Hurricane Katrina. With the establishing of number of communication channels and a solid coordination effort with all levels of government guaranteed effectiveness (Baker and Refsgaard, 2007).

• Learning (education, knowledge) is vital in preparedness in front of crises, as the 1994 California earthquake showed. Compared to the 1989 earthquake in Armenia, which caused 25000 fatalities, in California only 61 died due to the seismic shocks (Gilbert, 2008).

• Adaptation, showed by Project Lyttleton after the 2011 Christchurch earthquake in Aotearoa, New Zealand. The activists supported the town of Lyttletown engaging in food security activities and supporting decisions through open democracy when isolated from the rest of the country (Bond and

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Cretney, 2014: 24).

• Risk awareness, which stimulated community hazard awareness activities and Civil Protection Clubs in Portugal after a period of floods, landslides and forest fires (Mendes and Tavares, 2009).

• Social capital (trust, social cohesion), often prompted by loss of trust in authorities (Castelden et al., 2011).

• Good governance, as opposed to poor governance, is essential in emergency planning, especially decentralization and giving responsibility to local level authorities (Fundter et al., 2008).

• Planning/preparedness, measures concerning warning systems, relief

operations and evacuation organization and regular drills all contribute to the resilience of potentially vulnerable communities (Castelden et al., 2011; Chen et al., 2008).

• Redundancy, the multiplication of critical components to emergency planning such as the case of communication insures functioning in highly critical situations.

• Economic capacity and diversification is significant in building resilience, especially in agricultural communities, as the diversification in agriculture since the 1970s in the Sahel region has showed (Chhibber and Laajaj, 2008). • Population physical and mental health plays an important role in community

resilience, as we will see later on in this chapter, and enhancing vital

infrastructure to sustain disruption has to be a priority in policy, especially in countries that are subject to climate change-related contingency (McDaniels et al., 2008).

This information is to be used as a magnifying lens to understand the topic of the research. In this analysis, the dimension of adversity is to be intended within the realm of crisis management while positive outcomes are relative to Peru’s healthcare system’s degree of contribution to the resilience of communities. Resilience is therefore premised upon a vulnerable subject’s ability to internalize conditions of on-going contingency by re-emerging from them (Evans and Reid, 2013), a quality that to some is proper of a “healthy system” (Boin and McConnell, 2007; Longstaff, 2005).

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2.2 Resilience and crisis: exacerbating the process

Firstly developed within the field of system ecology in the 1970s, resilience has evolved as an operational strategy in risk management and as a frequent discourse of resource management, especially in the public administration sphere. As previously mentioned, the United Nations International Strategy for Disaster Risk Reduction (UNISDR)’s Report of the World Conference on Disaster Reduction 2005 associates the concept with crisis: “The ability of a system, community or society exposed to hazards to resist, absorb, accommodate to 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 . . . determined by the degree to which the community has the necessary resources and is capable of organizing itself both prior to and during times of need.” (2005). The concept has become undoubtedly popular and as we will see it is often associated with a ‘bounce back’ property of individuals and communities. As a matter of fact this sub-chapter is intended to open to the debate on community resilience itself, but it also has to explore top-down approaches to the matter and crisis.

Resilient practices often tend to stem from informal solutions found with the available means in the aftermath of disaster or significant change, something Kendra and Wachtendorf identify as “creative thinking, flexibility and the ability to improvise” (2002: 52), considered vital in sudden disruption. According to Adger et al. (2011), disregarding the resilience of a system when dealing with risk can lead to counter productive responses that undermine long-term development. Crisis management governance tends to only recognize resilience when this serves policymakers’ purpose (Furedi, 2008), but the discipline is in need to understand and facilitate resilience to promote healthy systems capable of facing newly emerging situations (Longstaff, 2005).

With the threat of transboundary crisis within inter-related areas of social life, promoting resilience becomes a necessary strategy to the basic methods of crisis management. Modern societies rely on infrastructures in order to deliver “public services, enhance quality of life, sustain private profits and spur economic growth” (Boin and McConnell, 2007) but these are particularly sensitive in disasters. The breakdown of critical infrastructure is not always predictable with precision, nor are

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its consequences. Regardless, it is still a matter that deserves preparation both by policymaker and the public. Top-down approaches and traditional crisis management contingency planning are limited in critical infrastructure breakdowns (2007).

Managing a crisis from a resilient perspective increases the chances for a strong recovery, especially if this involves all strata of society and goes beyond emergencies. Furthermore, contingency planning is too often done overconfidently when in fact it requires to go beyond what Clarke (1999) calls ‘fantasy documents’, fundamentally incomplete lessons-learned studies looking to shift the authority in the hands of few (‘t Hart, Rosenthal and Kouzmin, 1993) and reiterating the status quo by halting the natural course of resilience mechanisms. Disasters and emergencies do not necessarily guarantee significant change of previous systems, nor learning, (Birkland, 1997; Boin et al., 2006) but can convey a change of course in policies, procedures, legitimacies and even cultures (Baumgartner and Jones, 1993). Clearly, galvanizing society to embrace resilience is more difficult when emotions such as fear are not persistent, leading the management of risk solely in the hands of governments. Administrative and societal capacities have to be harmonious in order to cope and to avoid

politicization, therefore the promotion of resilience is the tool to do so (Boin,

McConnell, 2007). As a matter of fact, the effectiveness of response in the first hours and days in the aftermath of a crisis is critically determined by citizens on site, by first responders and by operational administrators (Barton, 1969; Dynes, 1970; Drabek, 1986), proving the level of good governance present in risk management. A quick recovery from disruption therefore should be seen as a property of a system capable of decentralization and subsidence (Longstaff, 2005). As a matter of fact the United Nations Development Programme’s motto for its 2030 development goals is

“Empowered Lives. Resilient Nations”, the goal to end poverty and hunger also implies to manage disaster risk from a resilient point of view.

2.2.1 Addressing disaster risk with a reformed approach

The Hyogo Framework for Action 2005-2015 drafted by the United Nations

International Strategy for Disaster Risk Reduction, recognizes that climate variability strongly impacts on disaster risk. Climate change is undeniably becoming a major issue for policymakers since its threat has the potential to hinder the efforts to reach a more sustainable future. The special report “Managing the Risks of Extreme Events

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and Disasters to Advance Climate Change Adaptation” of the Intergovernmental Panel on Climate Change (2012) indicated that there is margin for integration in disaster risk management and adaptation-oriented policies through careful

coordination across several domains on both sides (2012: 439). Adaptive capacity is characterized by dynamism, with economic and natural resources, social dynamics, technology, institutions and governance influencing it (Parry et al., 2007). With changing climate extremes resilient and sustainable development as illustrated by the Sustainable Development Goals could benefit from a systematic questioning of pre-established paradigms and assumption in disaster risk management. Reducing disaster risk and adapting to climate change are critical elements for ensuring the

sustainability of economies, societies and the environment in the long term (Wilbanks and Kates, 2010).

Addressing disaster risk with a reformed approach that enhances coping mechanisms while addressing multiple perspectives and obstacles favors the developing of new patterns of response. The challenges that both disaster risk management and climate change pose are related, from “reassessing and potentially transforming the goals, functions, and structure of institutions and governance arrangements;” (IPCC, 2012: 440) to “creating synergies across temporal and spatial scales;” (2012: 440) and “increasing access to information, technology, resources, and capacity” (440). Where climate change is supposedly going to hit the hardest, the challenges for disaster risk management become more demanding, since the level of adaptive capacity across administrative, social and physical areas of each country (O’Brien et al., 2006). Furthermore, important for our overall analysis is also the level of wealth of a country, which potentially factors in determining adaptive capacity in practical

matters such as infrastructure protection and healthcare availability (Moss et al., 2010; Ford and Ford, 2011). Other factors that influence adaptive capacity are the ability of identifying problems and vulnerabilities under significant pressure, the best practice of previously learned scientific notions and the implementation of projects and programs (Moser and Ekstrom, 2010).

The wealthiest countries with a strong record on addressing risk can benefit from addressing these challenges, too. Since there are several coefficients influencing adaptive capacity and vulnerability, wealth can also not factor in it depending on the situation. Extreme events may also impact wealthy countries severely (Salagnac,

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weakest link” (IPCC, 2012).

Resilience has the potential of complementing negotiation and decision-making processes in climate change response. The concept is already being incorporated into disaster risk management policy for reduction and adaptation, slowly becoming the guiding principle of the most advanced responses in developed and developing countries (Cutter et al., 2008). Resilience thinking strengthens analyses on adaptation and climate change since adaptation is part of a trajectory towards change (Nelson et al., 2007). The concept of resilience provides different key approaches to adaptation to extremes: a holistic framework for socio-ecological systems in need of evaluating hazards; emphasis on how to deal with them; exploring options for dealing with future disruptive events; and identifying factors able to build strong responses (Berkes, 2007; Obrist et al., 2010). Resilience may also present shortcomings in dealing with crisis when the concept is misinterpreted and the status quo is perpetuated without giving space to support, learning and inclusiveness in decision-making. Every single stressor influencing an interconnected socio-ecological system deserves identification while enhancing the ability of said system to absorb shock and adapt while improving (IPCC, 2012: 454). Furthermore, as difficult as this may seem, particularly in

developing countries, dealing with specific types of risk without an integrated picture of the system complexity does neither produce long-term stability nor resilience (Walker et al., 2002; Lebel et al., 2006).

Ultimately, although it requires careful analysis and measures, using resilience proves productive in crisis management, as it handles change without unnecessary fears and responsabilizing citizens (Boin and McConnell, 2007). Disaster risk management and resilience can work in synergy, especially when dealing with threats such as climate change – which contributes to social, economic and environmental disruption. There is no single approach to achieve this cooperation in the field, but a reconciliation of long- and short-term goals, an in depth analysis of potential stressors, the introduction of resilience in socio-economic systems, support for an adaptive response,

responsibilization of citizens and promotion of resilient thinking are contributing factors that can improve response to natural disasters and adaptation to change. Full security is not achievable and resilience accepts it by fostering survival, adaptation and a ‘bouncing forward’ capacity, as ecological systems do.

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2.2.2 Top-down resilience and the status quo: a paradox in policy-making After being an increasingly studied subject in the 1990s and also due to the effect of the 9/11 attacks, resilience has become prominent in security responses and in the discourse of agencies in charge of it (Walker and Cooper, 2011). Building resilience is now the go-to catchphrase that institutions use to prepare for a critical future. The subject of this analysis, the healthcare system’s contribution to enforcing resilience in communities in order to face future threats coming from climate change, requires looking at the concept both from its the bottom up and the top down aspects.

Liberalism and neoliberalism represent the top down side of the concept and often are the underlining ideologies upon which modern states are built, therefore also the starting point from which policies are assembled. For this reason there is a need to examine the relationship between resilience and liberalism in-depth.

While the concept is often used and misused in global governance it is also true that “the science of complex adaptive systems has become a theoretical reference point for the full spectrum of contemporary risk interventions” (Walker and Cooper, 2011: 3). Furedi (2008) uses this peculiarity to tackle the issue of vulnerability-led response, which often fosters insecurity. Doing a comparison between official discourse and the literature – which sees it as the capability to confront shock (Kendra and

Wachtendorf, 2002: 11) - Furedi (2008) points out that resilience is often presented in pair with possibilistic thinking, leading to a paradoxical situation in which we

cultivate helplessness but do not give enough relevance to risk calculation. Resilience demands a rejection of the pre-conceived notion of security to shape a more nuanced one. Naturally, humans aim at survival, at enduring in all circumstances. We must accept that life and survival are continuous and non-fixed processes and that dangers are often outside our control, therefore we partake in a world where we continuously have to adjust and permanently struggle in order to survive threats that are now seen as endemic (Evans and Reid, 2013). Vulnerability has not to be seen with fear, but as a reality we must adapt to. To absorb change and continue life we learn from

catastrophes in order to improve responsiveness and adaptability to future disasters. By doing so, we accept our fundamental vulnerability and overcome the idea of it in itself. Life is not securable and, regardless of how much Liberalist theory tries to prove the contrary, we are never free from danger. Liberal regimes, adopting

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To explain this, Reid uses ecology, stating that “exposure to threats is a constitutive process in the development of living systems, and thus the problem for them is never simply how to secure themselves but how to adapt to them. Such capacities for adaptation to threats are precisely what ecologists argue determines the ‘resilience’ of any living system” (2012: 71). Every hazardous event is to be recovered from, but in policy there is little absorbance of it, indeed the instances in which institutions expand their capacity of planning ahead and engage with contingency are rare (Boin and McConnell, 2007; Clarke, 1999). Overall, in official text the bottom up role of communities, especially the poorest ones, in resilient processes is downplayed if not completely forgotten. Only if communities accept being subjectivised they can be agents of their own change (Reid, 2012) and become able to “make sustainable management decisions that respect natural resources and enable the achievement of a sustainable income stream” (UNEP 2004: 5). However oftentimes resilient

individuals “do not look to states to secure their wellbeing because they have been disciplined into believing in the necessity to secure it for themselves” (Reid, 2012: 69). The question become then: are top-down resilience practices completely inefficient? Or can they cater to communities looking to adapt and ‘bounce back’ from crisis?

Policymakers that over-use the concept of resilience but displace the role of the public and communities forget the real protagonists of disruptive events and subsequent adaptation. Maintaining that resilience is an exceptional measure serving constant vulnerability within the public and focusing policies on the helpless society is misleading and fosters insecurity among the same group of people that is resilient. Resilience embraces change, it does not promise security. An important example of how resilience is in place within communities comes from the 2011 Christchurch earthquake in Aotearoa, New Zealand: activists from grass-roots organization ‘Project Lyttelton’ experienced disaster first hand in a semi-isolated area and were able to support the community of Lyttelton, in the Canterbury region. The central

government was not able to reach the location, therefore the community group dedicated to environmental causes and social change, showed resilience in managing the aftermath of the crisis from within the community (Cretney and Bond, 2014: 24). After the situation was restored, Project Lyttelton was able to continue in the

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aimed at improving resilience in a region were seismic activity is particularly strong (2014: 24). This example regards a Western country, where liberal policymaking dictates crisis management measures that could not be put in place as soon as the earthquake hit as the Lyttelton area was disconnected from the rest of society due to damages in transport routes. This case of a community tackling the aftermath of a crisis with “its own” resilient measures demonstrates “contingency is not tamed, but incorporated, literally lived with” (Aradau, 2014: 77).

Resilience is a radical concept that should not be misused in order to maintain the status quo of institutions because it essentially does not entail the existence of one. Embedding resilience in liberal crisis management policy makes it inherently non-radical. This is also a problem stemming from its increasing popularity, making it a concept of both grass-roots and top-down approaches to the extent of some scholars discouraging groups from adopting the concept and its framework (MacKinnon and Derickson, 2012). Regardless, it is being applied to various types of social

environment, from rural to urban settings, from highly developed to low-income countries. Theoretical advances look to include adaptation and transformation into Social Ecological Systems (SES) resilience (Bond and Cretney, 2014), therefore providing ground for a new definition of the concept, looking to ‘bounce forward’ after a crisis (Magis, 2010). Incorporating the idea of adapting capacity finds solid proof in situations like the previously described Lyttelton earthquake, but other situations can differ substantially depending on a variety of factors. As a matter of fact “adaptive capacity involves a framework that acknowledges the multiple, ever-changing nature of systems and the need to prepare for uncertainty and make changes in response to disruptions” (Bond and Cretney, 2014). Nonetheless, even when adding adaptive capacity to the concept, resilience can still be serving the establishment or re-establishment of the status quo. The case of resilience articulated as desire for focusing on the recovery of social systems and infrastructure after disruptions is an example (Engle, 2011), especially after a crisis, when it serves as an opportunity to implement selective neoliberal projects (Walker and Cooper, 2011). This use of resilience is aimed at justifying “actions that increase inequality and disadvantage marginalized communities through the use of market-driven rationale” (Bond and Cretney, 2014). Because neoliberal ideologies are not confined to their original economic and political spheres but influence all aspects of subjectivities and societal

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security and crisis management even if not all concepts in these disciplines pertain to the neoliberal realm. Perpetuating neoliberal discourses hinders the dynamism embedded in the concept of resilience, favouring a capitalistic take on the notion that is aimed at maintaining existing structures of power (Joseph, 2013). Resilient

communities work within the system they are in, adapting and responding to contingency in order to overcome it, not to maintain the status quo that may or may not favour them, depending on the case. The question therefore is whether the outcomes of state-sponsored resilience are indeed beneficial to different types of communities with different needs. Limitedly and depending on what exactly the programs aim for, leading to the questions formulated by Cote and Nightingale (2012): resilience of what and for whom?

Resilience “evidences most clearly how liberal power is confronting the realities of its own self-imposed political foreclosure as the reality of finitude is haunted by infinite potentiality” (Evans and Reid, 2013: 91). This paradox is particularly difficult to accept in liberal regimes, as it plays on a multitude of levels, first and foremost in human subjectivity.

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2.3 Community resilience: shaping the process

Orienting this analysis towards community resilience - and healthcare in particular - requires an emphasis on the role of community in itself, both in geographical and cultural terms. Individuals form communities and the social relationships they create within them constitute resilient behaviour that manifests at times of disruption and change. In “disabling of the political habits, tendencies and capacities of peoples and replacing them with adaptive ones” (Evans and Reid, 2013: 85), actors learn from catastrophes to become more responsive during future ones. ‘Community resilience’ is defined by Magis as “the existence, development, and engagement of community resources by community members to thrive in an environment characterized by change, uncertainty, unpredictability, and surprise” (2010).

The term ‘community’ usually refers to a social entity, group of people living in a certain geographical area, often sharing common values, norms and culture and who arrange themselves according to a structure developed overtime (IFRC, 2014). The term may also refer to a group on a local or international level with specific interests (2014). By sharing habitat and or culture, communities are also groups of people exposed to the same threats, whether these are man-made or not (2014). The vulnerability of communities varies with the community itself, with several factors (physical, technological, financial, natural, etc.) contributing to it. Moreover,

communities also contain a variety of social groups differing significantly. In general, individuals are part of several communities throughout their lives, whether they live in a specific place, are part of a certain minority, etc. Some groups in communities, depending on their vulnerability, may be less resilient than others. Communities also depend on the environment they live in, with their resilience being undermined by disturbance in markets or ecological conditions. The diversity of the ecosystem communities live in determines social systems making them more or less vulnerable depending on the case. Change of course is constant in the environment and in

society, but in cases of resource-dependence, resilience is going to be more difficult to achieve in case of crisis. The factors influencing differences and vulnerability are interconnected as well, requiring for a multidisciplinary approach when doing an analysis. For this reason, the concept of ‘community resilience’ raises as many concerns as the concept of resilience in itself. Many note that an ensemble of resilient

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individuals does not necessarily make a resilient community because the latter is more than the sum of its parts (Pfefferbaum et al., 2005; Rose, 2004). Of course, enabling individuals and offering them access is the first step to strengthen a community, but viewing resilience on an individual level is insufficient and does not allow it to significantly improve, rather, it requires attention on a societal level to empower all against crisis (Seccombe, 2002). When a community as a whole is resilient, the potential for adaptation in physical, social and economic spheres of society increases because “people in communities are resilient together, not merely in similar ways” (Brown and Kulig, 1996/97: 43). A resilient community is likely to be empowered facing disruption while a vulnerable one is not (IFRC, 2014). Moreover, the lessons that are learned from the efforts to face crisis are vital over time and foster self-sufficiency when external aid is limited or delayed (Price-Robertson and Knight, 2012).

When the idea of ‘resilient community’ arises, the National Strategy for Disaster Resilience (NEMC, 2009) finds that the following features are at its core:

• functioning well while under stress; • successful adaptation;

• self reliance; and • social capacity.

Therefore the members of a community that work together are interconnected in order to enable ways to function after facing a traumatic event are to be considered resilient. Maguire and Hagan (2007) find three properties to social resilience (community resilience): resistance, recovery and creativity. The more resilient is a community, the more these properties are manifested. Referring to resistance as a property entails communities’ efforts to withstand a crisis and its consequences without crossing a threshold meaning these would have to undergo long-term changes (2007).

Commonly associated terms are also “bounce back” to pre-disasters level of functioning and “pulling through”, both equating to the recovery property of social entities that are resilient (Kimhi and Shamai, 2004). Very resilient communities not only return to a pre-disaster point of equilibrium, but also adapt to the new

circumstances while learning from their experience, showing a degree of creativity throughout the recovery process (Maguire and Hagan, 2007). The three properties of

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resilience are strongly linked, making resilient communities able not only to prepare and anticipate disruption but also to absorb and recover from the shock afterwards. All in all, community resilience is multifaceted and changes from one social entity to the other, with the possibility of finding more vulnerable groups within an otherwise resilient community. It is essentially the ability to “utilise community resources to transform and respond to change in an adaptive way” (Maguire and Cartwright, 2008: 8), therefore gain strength as a result of dealing with adversity (Brown and Kulig, 1996/97). Studies showed that community resilience is a process (Kulig and Hanson, 1996) overseeing the enhancement of community cohesion when influenced by a number of different components ranging proactive members, a community problem- solving process in place and community leadership (Kulig et al., 2008). As a

theoretical framework, community resilience provides an explanation for how communities operate as collectives, interacting and creating a “sense of belonging” (Kulig et al., 2008) which leads to expressing a “sense of community”, contributing to problem-solving and the ability to deal with disruption (2008).

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2.4 Community resilience and healthcare, resilient healthcare for communities

After exploring resilience as a concept, associating it with crisis, reviewing the relationship between bottom up and top down approaches and understanding the qualities of communities resilience, it is necessary to delve into what facilitates the development of community resilience. As previously mentioned, Castelden et al. (2011) found that several components are proper to the concept whether they are communication, good governance or economic capacity. This section looks into healthcare as a component of resilience. The choice of this component over others derives from the fact that healthcare availability is an agent of change, especially for developing countries and/or communities in crisis. A community can be resilient and provide for itself in many ways, but certain needs such as health provision demand for more than just a community effort, they demand available and functioning services. Moreover the promotion of resilient healthcare for communities brings scientific knowledge to the realm of decision-making, which can make its best decision when it has the most cunning data available.

The health status of a community undoubtedly factors into its overall resilience and vulnerability (2011). According to the European Union (2014) it is vital for modern health systems to always be accessible and effective, especially in times of crisis. To remain sustainable and build resilience, they have to be fiscally responsible and to pay attention to non-fiscal factors such as environmental change, lack of expertise in certain areas, surges in demand, even with limited resources (2014). To meet

authorities and their crisis management plans, communities can become more resilient by using the resources in place. If a healthcare system is in place, communities can contribute in managing a crisis, if there is no system or it is not prepared, it is

necessary to identify the issue for planners to match external resources. According to Keim (2008: 515) “community-based risk-reduction activities lessen human

vulnerability to the vagaries of natural disasters, especially those activities that integrate public health”. To address and increase disaster resilience in communities, local public health is a key agent able to build and maintain human resilience when facing hazard and vulnerability. Adaptation after a disaster starts at the community level, therefore public health is essential in the resilience of the community itself. In providing health services, local healthcare systems reduce burdens such as disease

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that increase vulnerability and enhance safety in strengthening the resilience of the community against crisis (2008). In promoting “healthy people, healthy homes and healthy communities” (Shobha et al., 2003) vulnerability can decrease since healthier individuals are more likely to ‘bounce back’ from disasters and disaster morbidity. With healthy homes there is a lower risk of structural damage and increased safety, therefore healthy communities become sustainable and have overall minimalized exposure to crisis and its consequences. Enhancing healthcare resilience from both an institutional and a community’s perspectives equates to enhancing adequate

preparedness to hazard, especially in regions were climate change-related events are frequent. Ultimately “resilience fits the complexities of healthcare more effectively than principles of high reliability. In essence, resilience represents a shift from seeing humans as a pathological feature of a healthcare system to one where they contribute actively to ‘safe’ work and greater patient safety” (Jeffcott et al., 2009).

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2.6 Chapter Conclusion

How does resilient healthcare place within the academic discussion on resilience? This chapter has answered the question by exploring general knowledge on resilience, resilience within crisis management, the top-down and bottom-up approaches to the concept and finally studying community resilience and a most vital component of it: healthcare. Nonetheless, further questions have to be asked in order to understand the topic and the case. Moreover, the complexity of the notion, paired with crisis and resilient healthcare require for an in-depth research on indicators capable of linking the theory to the case and conduct the analysis appropriately. The literature does not find a complete set of indicators for this subject as it can do with food security for example. For this reason in Chapter 3 indicators developed ad-hoc will be described starting from an exploration of the theoretical understanding of resilience and complementing the search for indicators through an initial expert interview. A healthcare system is to be understood in general, from its achievements and its pitfalls, therefore it is important to question every aspect of it. Moreover, in pairing resilience with crisis we have to delve deep into the practical matters of the problem, and in the case of healthcare, ask whether the sector, in the given country, can face disruption. With a sector unable to work under stress, community resilience is hindered. Lastly, communities have to be able to respond to the healthcare system, access it, engage with it, otherwise they may not turn to it when crisis hits. All in all, resilience is “an ideological project that is informed by political and economic rationalities which offer very particular accounts of life as an ontological problem” (Evans and Reid, 2013: 92). Whether from a grass-roots or a top-down point of view, the key to security is in the resilience of people (Toulmin, 2009). It does not

automatically mean protection but it entails adaptation to disruption, not helplessness in front of it. Insecurity must be accepted as permanent and the concept of resilience promotes the adaptability of the actors that do not politically strive for a world free from danger, because they know it is utopic. To some extent, resilience in general and healthcare in community resilience in particular force us to question what it means to live when “crisis is the mother of history” (Lilla, 2007).

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3. Research Design and Methodology

In the following chapter there is going to be a presentation of the research design and methodology employed in this thesis. The research question and sub-questions will be introduced together with a brief description of the case. Finally, the methodology used in the case study analysis is going to be explained before proceeding in using it

throughout the next chapter.

3.1 Research questions

This research was developed through a guiding research question:

To what extent is Peru’s healthcare system resilient and how can this degree of resilience be explained?

Furthermore, the following sub-questions were also formulated in order to better answer the main research question:

1. How does resilient healthcare place within the academic discussion on resilience?

2. What is Peru’s healthcare situation?

3. What are Peru’s healthcare system’s achievements and pitfalls?

4. How resilient is Peru’s healthcare system from both a top-down and a bottom-up perspective?

The following section is designed to further explain the main research question and sub-questions, but especially, to show how they are going to be answered. Each one will be presented in how it relates to the research and with the indicators that were assigned to it. In order to increase the understanding of the questions, an

operationalization of terminology will be offered, so that the main themes of the thesis will be explained clearly. There will be no operationalization of sub-question 1, how does resilient healthcare place within the academic discussion on resilience? due to the fact that it is a theoretical matter that was covered in the theoretical framework.

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3.1.1 Main research question

In order to answer the main research question, “to what extent is Peru’s healthcare system resilient and how can this degree of resilience be explained?” it is necessary to use the aforementioned sub-questions. Nonetheless, it is useful to adopt a unique definition for resilience that encapsulates the themes of this analysis - healthcare system and community resilience. The United Nations’ International Strategy for Disaster Risk Reduction then, will serve the purpose, as it states that resilience is “the ability of a system, community or society exposed to hazards to resist, absorb,

accommodate to 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” (2005).

3.1.2 Sub-question 2

Sub-question two, ‘what is Peru’s healthcare situation’ is going to be answered throughout Chapter 4. The chapter is going to present the context of the case, Peru’s healthcare system, and provide data in order to understand the background of the overall analysis. This favors the discussion that is going to permeate the answer to the following sub-questions.

The third sub-question, ‘what are Peru’s healthcare system’s achievements and pitfalls?’ furthers the investigation launched by the first. Continuing Chapter 4, ‘Problem situation’, the question will open to a discussion where the ‘achievements’ and ‘pitfalls’ presented in the case description are going to be examined objectively according to WHO rules and regulations (found in the IHR). The indicators used are going to be reflecting the level of access to healthcare for all and the availability of blood donations.

The fourth and final question is a complete analysis on the resilience of healthcare in Peru. It is composed by a main sub-question: ‘how resilient is Peru’s healthcare system from both a top-down and a bottom-up perspective?’

This sub-question demands for us to look deep into any policy or technical issues that a crisis may present: are there plans to tackle it in the healthcare system? Are facilities capable of withstanding it? Is the nation sufficiently covered? Are all types of

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communities able to access healthcare services when in need?

Because of this, in Chapter 5 ‘Results’ it will be possible to understand the reasoning behind the answer to the sub-question through the use of the following indicators: Equal Access to healthcare, Emergency Response Plans in Health Emergencies, Critical infrastructure protection and “safe hospitals”, Cooperation with non-state healthcare providers and healthcare-oriented NGOs, Sustainability in blood donations and Citizens’ engagement in healthcare.

The analysis will be developed over two chapters. The first describes the case and the ‘problem situation’ offering a familiarization to the first and second sub-questions and providing in-depth information to use in order to understand the complex situation of Peru’s healthcare system. The situation of the system, its pitfalls and achievements are embedded into social, economic and historical happenings that have to be explained to the reader. The second, more analytical, chapter uses indicators to

answer the third and fourth question thoroughly and provide further perspective to the first two. The indicators will be described in this chapter and associated to one or more sub-questions.

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3.2 Research design: single case study

Every thesis requires a research design in order to conceptualize the problem and understand how far the findings can reach (Grinnell and Stothers, 1988: 219). The problem of healthcare resilience is multifaceted and differs from region to region, if not from state to state, therefore this specific research concentrates on a single case in which the unit of analysis is the healthcare system in Peru.

The choice of a single case study is due to the specificity of the phenomenon itself. As Goode and Hatt (1952) state, “the case study … is a way of organizing social data so as to preserve the unitary character of the social object being studied”. A case study, according to Swanborn (2010), entails the manifestation of the social subject in its natural surroundings, within an established time period. It focuses on details (indicators) attached to the social process and finds the researcher starting from a broad research question and using theories and data analysis to find an answer through several data sources, some or which may be engaged with confronting the case itself (Swanborn). In order to collect information, the process requires a theory to guide it, even the most primitive. In this research, the primitive theory that opens the collection of data and its subsequent analysis is the aforementioned United Nations’ International Strategy for Disaster Risk Reduction’s definition of resilience and the belief that in community resilience, healthcare is substantial in order to ‘bounce back’ from a disaster.

Peru was picked as a case because it is the third country most vulnerable to the impact of climate change (UNDPLAC, 2015) it experiences climate variations due to El Niño and overall has unique geographic peculiarities. Moreover its society is multi-ethnic and presents differences in the socioeconomic sphere, with extreme poverty levels still high in the most rural areas of the country. The development of the nation is also going at a fast pace but government spending is not always focused on areas of welfare. The country is matchless in matters of resilient healthcare in the Latin

American region, therefore its complexity serves the topic as much as the topic serves its complexity.

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3.3 Operationalization

3.2.1 Indicators

The process of finding the correct indicators was one of trail and error. At first literature addressed concerns over what aspect of healthcare was the most important to tackle, whether it was disease prevention, first aid healthcare or general guidelines for medical safety in a country. Eventually the focus shifted on the fact that the focus healthcare provision used in this thesis is a component of community resilience, leading to the development of public administration and crisis management-related indicators. Although these tackle different aspects of the healthcare system, they are to be portrayed as all part of a system that is in place to provide to communities. For this reason, the first indicator at the basis of this research is the subscription to International Health Regulations. As it will be explained in the following paragraphs these Regulations are in place to safeguard public health from disease outbreak – and what better than a resilient health system to do so? Resilience is a practical

application of the regulations in the healthcare environment, especially to tackle any outbreak and/or crisis to prevent dramatic spread of disease. On the other hand indicators such as emergency response plans in health emergencies and critical infrastructure protection and “safe hospitals” were distilled after an examination of WHO, PAHO, Red Cross and UN guidelines on health management and crisis management. As a matter of fact these are the most technical indicators that directly address the substantial role of coordination and infrastructure preparedness for crisis scenarios. The following paragraphs will go in depth on the peculiarities of the chosen technical indicators. The remaining four indicators, equal access to healthcare,

cooperation with non-state healthcare agencies, sustainability in blood donations and citizens’ engagement in healthcare were developed after an expert interview focused on exploring aspects of healthcare in Peru that were not as highlighted on official text. Luigina Prosocco of COMIVIS was very kind in answering this thesis sub-questions for an initial interview and provided insight in the state of healthcare in the country which lead to confirming some indicators (equal access to healthcare, cooperation with non-state healthcare agencies, citizens’ engagement in healthcare) that had already been approached and adding a seventh to the list, sustainability in blood donations, which is also technical and related to crisis management.

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Once again, the indicators used in this analysis are: - Adhesion to International Health Regulations - Equal Access to healthcare

- Emergency response plans in health emergencies - Critical infrastructure protection and “safe hospitals”

- Cooperation with non-state healthcare providers and healthcare-oriented NGOs

- Sustainability in blood donations - Citizens’ engagement in healthcare

In the following section indicators are going to be explained through literature, information provided by datasets and expert interviews.

Adhesion International Health Regulations

The International Health Regulations are a framework to govern the response to public health emergencies posing an international threat (Wilson et al., 2008). The first International Health Regulations were drafted in 1851 as the International Sanitary Regulations, after cholera epidemics around Europe showed the need for international cooperation in matters concerning health. After the World Health Organization was born in 1948, a new series of Regulations were drafted as the International Health Regulations in 1969. These concerned notifiable diseases such as cholera, plague and yellow fever and presented a series of limitations in the

cooperation among countries that caused the 1995 World Health Assembly to revise them. By 2005, a new and more organic set of Regulations was proposed and it became binding in June 2007 in 194 State Parties.

In introducing the concept of “public health emergency of international concern” (WHO, 2005), the revised Regulations provide guidance to protect travel and trade in the international community from the spread of health emergencies. They also require from each state the development of health surveillance and response systems (Wilson et al., 2008). To implement the IHR (WHO, 2005), State Parties are required to fully respect human rights, dignity and fundamental freedoms through the guidance of the WHO Constitution and aiming at universal application to protect all from disease. State Parties have the right to legislate and implement legislation in upholding the