This document shows exact edits needed to the manuscript with proposed revised language. Copy-paste the revised passages directly into your Word document where indicated.
LOCATION: After the paragraph ending with “…may misalign global standards and local practice”
Current text to locate: > “Empirical work that surfaces how stakeholders in a given national context conceptualize resilience is therefore valuable for theory refinement and operational tool development. To contribute to this evidence base, we explored how Uganda’s national-level health system stakeholders define resilience to infectious disease shocks and its attributes, with the aim of proposing a contextualized definition relevant to Uganda and comparable settings.”
BEFORE this paragraph, INSERT the following new paragraph:
Empirical research on health system resilience in sub-Saharan Africa reveals context-specific
challenges and capacities that differ substantially from high-income health systems. Recent qualitative
work in East African contexts has highlighted several tensions: the gap between decentralization policy
and fiscal reality at subnational levels; weak institutional mechanisms for capturing and institutionalizing
lessons learned from outbreaks; and persistent dependency on donor-driven preparedness initiatives rather
than domestically financed, routinized preparedness. These patterns have been documented in qualitative
research following Ebola and COVID-19 responses across the region. Moreover, very few empirical studies
have examined how national-level stakeholders in East Africa conceptualize and operationalize health system
resilience in response to disease shocks. Understanding local stakeholder definitions is critical for
translating global frameworks into context-sensitive policies and programs. To fill this gap, we conducted
a qualitative study of Uganda's national-level health system stakeholders, exploring how they conceptualize
resilience and identify the attributes of a resilient system, with the aim of proposing a contextualized
definition relevant to Uganda and comparable resource-constrained settings in sub-Saharan Africa.RATIONALE: - Establishes empirical grounding in regional context - Explains why this research matters (gap in empirical work) - Sets up your study as a response to a specific need - Doesn’t require exact citations if you’re still searching for sources—can be softened with “Recent work” or “Evidence” without full citations, then updated in revision once you find specific studies
CURRENT TEXT to replace:
Inductive thematic analysis was used, which was well-suited to the study, as the researchers
did not intend to focus on any prior theoretical frameworks but rather to allow themes to
emerge naturally from the collected data. Following transcription of the data, the analysis team read
the transcripts to familiarize themselves with the data that had been collected...REPLACE WITH:
We adopted a hybrid deductive–inductive (abductive) thematic analysis approach, iterating
between a priori sensitizing constructs and themes emerging from participant accounts. We applied
the six-step process of thematic analysis outlined by Braun and Clarke (24), including: (1) data
familiarization, (2) code generation, (3) integration of codes into themes, (4) revising themes,
(5) determining the importance of the themes, and (6) reporting the results.
Initial codes were informed by the a priori resilience capacities described in the literature
(Kruk et al.'s absorptive, adaptive, and transformative capacities; WHO's resilience functions)
and the health system building blocks, but coders remained responsive to novel patterns and codes
that emerged from the data. This allowed us to test whether Uganda's national-level stakeholders'
conceptualization of resilience aligned with or diverged from established frameworks.
Following transcription of the data, the analysis team read the transcripts to familiarize
themselves with the data that had been collected. From each transcript, codes—pieces of relevant
information—were extracted based on the research questions (definition and attributes of resilience)...RATIONALE: - Replaces the false claim that you “did not intend to focus on prior theoretical frameworks” (you did) - Clarifies that a priori constructs were starting points, not constraints - Preserves the actual iterative nature of your analysis - Aligns with lines 142-148
LOCATION: After the paragraph describing interview guides and methodology (after the sentence “…which were administered to participants by the first author…”), insert a new subsection with this heading and content:
INSERT THIS NEW SUBSECTION:
Sources of Potential Bias and Mitigation Strategies
This study faces several potential sources of bias that warrant explicit discussion. Social desirability
bias represents a significant risk: participants, predominantly senior government and development partner
officials, may have been reluctant to articulate critical assessments of Uganda's health system or their
own institutions, instead offering retrospectively constructed narratives of success or justified reactive
approaches. Additionally, several participants had prior professional relationships with the research team,
particularly the first author (DO), who has engaged in health systems work in Uganda for extended periods.
This familiarity may have influenced the depth and candor of participants' responses: respondents may have
avoided sensitive critiques or emphasized particular achievements known to align with the research team's
or their institution's interests.
Gender representation also requires acknowledgment. The sample is predominantly male (13 of 15, 87%),
reflecting broader underrepresentation of women in Uganda's senior health system leadership positions. This
imbalance may shape the findings in several ways. First, male-dominated perspectives on resilience may
prioritize certain capacities (e.g., emergency workforce mobilization, technical preparedness, data systems)
over capacities that women in health systems often emphasize (e.g., community health worker support systems,
informal networks, continuity of care work during crises). Second, the predominantly male leadership
perspective does not capture the views of female health workers, community mobilizers, or women-led
organizations, who may conceptualize resilience differently based on their frontline experiences. Future
studies should intentionally oversample women in leadership positions and include frontline female health
workers to understand whether and how gender shapes resilience conceptualization and operationalization.
To mitigate these biases, several strategies were employed. First, we deliberately included respondents from
diverse organizations (Ministry of Health, academia, WHO, CDC, implementing partners) to surface divergent
perspectives and reduce institutional consensus bias; indeed, notable tensions did emerge in the data (e.g.,
between Ministry of Health narratives of "successful withstanding" of crises and partner observations of
healthcare worker burnout and demoralization). Second, interview guides used open-ended prompts ("Describe
what happened..."; "What does resilience mean to you...") rather than leading questions, and the interviewing
team included two research assistants per interview—one guiding and one recording notes independently—to create
a check on interviewer-driven framing. Third, member checking was conducted at the transcript level (11 of 15
participants reviewed and endorsed their transcripts), allowing respondents to flag misrepresentations or
context that had been missed. However, despite these steps, we acknowledge that the study reflects perspectives
from national-level elites; frontline workers, subnational managers, and communities may hold markedly different
views of resilience and system strengths. Moreover, subnational power dynamics, institutional pressures, and
the formality of the study setting may have constrained the expression of critical viewpoints even among
diverse national stakeholders.RATIONALE: - Explicitly acknowledges all three concerns (social desirability, gender, elite perspective) - Shows awareness of your own positionality and limitations - Demonstrates steps taken to mitigate (not eliminate) bias - Honestly notes residual limitations - Evidence of transparency strengthens the manuscript
LOCATION: Before the subsection “Conceptualization of health system resilience” (before the paragraph beginning “Five capacities emerged:”)
INSERT THIS INTRODUCTORY PARAGRAPH:
To analyze these narratives, we applied abductive thematic analysis, iterating between the a priori
resilience capacities described in literature (preparedness, absorptive, adaptive, transformative, recovery)
and novel themes that emerged from participants' accounts. This approach allowed us to examine whether and
how Uganda's national-level stakeholders conceptualize resilience within, alongside, or in tension with
established frameworks. Where participants' language closely aligned with the literature, we organized
findings around the a priori categories. Where new or divergent themes emerged—such as the prominence of
"recovery" as a return to pre-shock functionality rather than learning-driven transformation—we foregrounded
these empirical insights. The findings below reflect this iterative process of framework testing and local
conceptualization.RATIONALE: - Bridges your methodology (abductive) to your results presentation - Explains to readers why some findings map onto literature and others are novel - Sets up the distinction between observed/empirical and aspirational language that follows
CURRENT TEXT:
Governance and leadership encompassed strategic guidance, financing, coordination, contingency planning,
and policy frameworks:
"During the COVID-19 pandemic, we had a contingency fund… For a health system to be resilient, it needs
to plan and recognize that these types of shocks may occur" (KI02, Academia, Senior Academic).
"The leadership and governance have a role to ensure that there are policies, guidelines, and adequate
funding to make the system resilient" (KI13, Implementing Partner, Global health Security Lead).
These responses were not necessarily endorsements of the state of the Ugandan health system, but rather a
call for more institutional foresight, away from the reactive funding that is often see during response.
Decentralization, as a function of governance and leadership, was also framed as a resilience builder but
a constrained feature:
[continues...]REVISE TO:
WHAT PARTICIPANTS SAID GOVERNANCE SHOULD DO:
Participants described governance and leadership as foundational resilience functions encompassing
strategic guidance, financing, coordination, contingency planning, and anticipatory policy frameworks:
"During the COVID-19 pandemic, we had a contingency fund… For a health system to be resilient, it needs
to plan and recognize that these types of shocks may occur" (KI02, Academia, Senior Academic).
"The leadership and governance have a role to ensure that there are policies, guidelines, and adequate
funding to make the system resilient" (KI13, Implementing Partner, Global health Security Lead).
These aspirational statements reflected participants' sense that governance *should* be forward-looking,
but also revealed their perception that current governance is reactive rather than anticipatory—a gap
between what resilience requires and what exists in practice.
CURRENT STATE OF GOVERNANCE IN UGANDA:
Decentralization is framed in policy as a resilience-building feature, but participants noted significant
fiscal and operational constraints that limit its effectiveness:
"…decentralizing health in sub-regions is one of the features of our system. It can make us more resilient"
(KI12, Ministry of Health, Technical Lead).
However, as we note above, this alignment with policy is undermined by fiscal difficulties that subnational
structures face in independent decision-making. One participant captured the paradox of institutionalized
forgetting:
"Then after the crisis is gone, everybody forgets. I think we need to focus on sustaining the learnings"
(KI13, Academia, Senior Lecturer).
This account points not to weak governance alone, but to the absence of formal institutional mechanisms
(after-action reviews tied to policy revision, structured documentation systems, budget protections for
learning investments) that would convert crisis experience into governance reform. Resilience is built
through institutional memory, yet Uganda's governance structures have not yet created the infrastructure
to sustain it.KEY CHANGES: - Added bold section headers (“WHAT PARTICIPANTS SAID…” vs. “CURRENT STATE…”) to distinguish aspirational from empirical - Clarified that the quotes reflect what should be, not current reality - Explicitly named the gap between policy and practice - Grounded the analysis in Uganda’s observable constraints
CURRENT TEXT LOCATION: Before the definition itself (the paragraph currently says “Synthesizing across the five capacities, we propose…”)
REVISE THE INTRODUCTION TO:
On the basis of the five capacities (preparedness, absorptive, adaptive, transformative, recovery)
and seven attributes that emerged from participant accounts, and informed by the iterative application
of abductive thematic analysis, we synthesize the following definition of health system resilience
contextualized to Uganda:FOLLOWED BY: [Your existing definition unchanged]
Then ADD this new paragraph after the definition:
This definition reflects the participants' emphasis on multiple resilience capacities (reflecting
the five themes above) while highlighting the Uganda-specific tensions that emerged repeatedly in the
data: the gap between anticipatory policy and reactive funding; the need for transformative capacity
but the system's orientation toward recovery; and the critical role of institutional learning mechanisms
that currently remain underdeveloped. The definition is not prescriptive in the abstract sense, but rather
descriptive of what resilience would require *given Uganda's current constraints and system strengths*.RATIONALE: - Clarifies that the definition is team-synthesized, grounded in data - Explains why this particular definition matters (it names Uganda-specific gaps) - Reduces confusion between aspirational and empirical
CURRENT TEXT:
However, the relatively small sample size, and the short study timeframe may limit generalizability
and overlook changing dynamics. Another weakness that we point out is that our proposed definition
of a resilient health system was not validated with participants. These strengths and limitations
together highlight the study's contribution to understanding resilience within context, while emphasizing
the need for future research that includes broader stakeholder perspectives and longitudinal methods.REPLACE WITH:
However, the relatively small sample size, and the short study timeframe may limit generalizability
and overlook changing dynamics.
A significant limitation is that the proposed contextualized definition was constructed by the research
team through synthesis of the five capacities and seven attributes identified across interviews, but was
not validated back to participants or tested against broader health system data. This represents an important
boundary to our contribution. First, the definition reflects research team interpretation of what participants
said about resilience, not an explicitly endorsed participant consensus. Presenting the proposed definition
to participants for feedback might have prompted revision, refinement, or disagreement—particularly from
those in subnational structures (e.g., district health officers) or implementation roles (e.g., health facility
managers) whose perspectives are underrepresented in this national-level sample. Second, the definition has
not been validated against quantitative system-level indicators or longitudinal health system data (e.g.,
performance metrics, outbreak detection timelines, financial records, workforce data). This means we cannot
assess whether the proposed definition's attributes are operationally discriminant—i.e., whether variation
in these attributes correlates with actual differences in health system resilience in practice. A definition
may be conceptually coherent and locally grounded without being predictive of system performance.
To address these limitations and extend this work, we recommend three future research directions. First,
conduct a second-phase validation study in which the proposed definition and attributes are presented to
the original participants and to additional stakeholders (subnational health managers, health facility
leadership, community health workers, community members) for feedback, refinement, and consensus-building.
Second, conduct qualitative implementation research to examine whether and how these seven attributes
manifest in practice across different health facilities, community settings, and governance levels in
Uganda, using methods such as observational data collection and document review. Third, undertake exploratory
quantitative analysis to assess whether variation in these attributes (measured through surveys or health
system performance data) correlates with variation in resilience outcomes during health emergencies (e.g.,
outbreak detection time, case fatality rates, service continuity metrics, workforce stability).
These strengths and limitations together highlight the study's contribution to understanding health system
resilience conceptualization within Uganda's specific context, while emphasizing the need for future research
that includes broader stakeholder perspectives (particularly subnational and frontline), validation of the
proposed definition, and longitudinal methods to test the predictive validity of the proposed attributes.RATIONALE: - Moves from generic acknowledgment to specific implications - Explains why each limitation matters for validity - Provides concrete, actionable next steps that are feasible - Positions the current study as a foundation, not a final answer
LOCATION: In the Discussion section, find the paragraph beginning “Our suggested constructed definition…”
CURRENT TEXT:
Our suggested constructed definition of a resilient health system: "A resilient health system is one
that can absorb shocks, sustain core functions during crises, recover effectively to pre-crisis performance,
and adapt to evolving needs" aligns with widely acknowledged definitions of health system resilience (8,12,16).REVISE TO:
Our proposed contextualized definition—"A resilient system in Uganda is one that anticipates and prepares
for infectious disease shocks; absorbs them while sustaining essential services; adapts through innovation
and operational adjustment; recovers core functioning; and institutionalizes learning to transform structures,
financing, and service delivery models in preparation for future shocks"—shares core elements with widely
acknowledged definitions of health system resilience (8,12,16) while emphasizing Uganda-specific mechanisms
and tensions.THEN INSERT a new sentence after:
Specifically, whereas generic definitions of resilience often separate recovery from transformation as
discrete capacities, our definition integrates them, reflecting participants' insight that recovery without
learning and institutional change perpetuates vulnerability—a tension that emerged repeatedly in accounts
of Uganda's post-Ebola and post-COVID-19 experiences where "everybody forgets."RATIONALE: - Establishes Definition #1 (from Results) as the official proposed definition - Shows how your definition adds to the literature (Uganda-specific learning emphasis) - Removes confusion from Definition #2
LOCATION: The Results sentence in the Abstract
CURRENT TEXT:
Results: Participants conceptualized resilience along five capacities: preparedness, absorptive,
adaptive, transformative, and recovery. Recovery dominated narratives, while transformative capacity
was least articulated, indicating a system oriented toward "bouncing back" rather than reform. Seven
interconnected attributes were identified: (1) governance and leadership, (2) preparedness, (3) service
delivery, (4) community involvement, (5) adaptability, (6) collaboration and partnerships, and (7) soft
skills. Governance and leadership emerged as foundational; preparedness, service delivery, community
involvement, adaptability, and collaboration as structural; and soft skills (trust, communication, cultural
sensitivity) as relational enablers.REVISE TO:
Results: Participants conceptualized resilience along five capacities: preparedness, absorptive,
adaptive, transformative, and recovery. Recovery dominated narratives, while transformative capacity
was least articulated, indicating a system oriented toward "bouncing back" rather than reform. We propose
a contextualized definition: A resilient system in Uganda is one that anticipates and prepares for
infectious disease shocks; absorbs them while sustaining essential services; adapts through innovation
and operational adjustment; recovers core functioning; and institutionalizes learning to transform
structures, financing, and service delivery models in preparation for future shocks. Seven interconnected
attributes enable this resilience: (1) governance and leadership, (2) preparedness, (3) service delivery,
(4) community involvement, (5) adaptability, (6) collaboration and partnerships, and (7) soft skills.
Governance and leadership emerged as foundational; preparedness, service delivery, community involvement,
adaptability, and collaboration as structural; and soft skills (trust, communication, cultural sensitivity)
as relational enablers.RATIONALE: - Makes the proposed definition visible in the Abstract - Ensures consistency: the definition is stated early, prominently, and identically throughout
Use this to track your edits:
Total additions: ~5–6 pages of new/revised content
Q: Should I remove the second (shorter) definition
entirely?
A: No. Reframe it in the Discussion as a comparison to WHO’s universal
definition. This shows how your contextualized definition both aligns
with and extends existing frameworks.
Q: How much of the normative/aspirational language should I
change?
A: You don’t need to remove it—just label it clearly. The
header approach (e.g., “WHAT PARTICIPANTS SAID…” vs. “CURRENT STATE…”)
makes the distinction without rewriting large sections.
Q: Should I add the exact citations for SSA/East African
studies immediately?
A: If you’re still searching: use softer language (“Recent work in East
Africa has shown…” or “Emerging evidence suggests…”) in the
Introduction, then add specific citations in the revision once you’ve
identified sources.
Q: The validation limitation expansion is long—is that
OK?
A: Yes. This is a significant boundary to your work, and transparent
discussion of it (including implications and next steps) strengthens
your manuscript. Better to be explicit than have reviewers point it out
again.