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Local Health Systems Resilience in Managing the COVID-19 Pandemic: Lessons from Mexico

ABSTRACT The concept of resilience was applied to the public health field to investigate the way health systems are impacted by health crises, what conditions allow them to mitigate the blow, and how they reorganize once the crisis is over. In 2020, the COVID-19 pandemic caused by the SARS-CoV-2 virus represented a global challenge demanding immediate response to an unprecedented health crisis. Various voices drew attention to the intensity of the crisis in countries with greater inequalities, where the pandemic converged with other social emergencies. We documented the experiences of health personnel who faced the pandemic at the primary care level while simultaneously maintaining the functioning of other areas of medical care. Our results derived from a qualitative study comprising 103 participants from five states of Mexico. We aimed to show through inferential analysis their perspective on what we call “the resilience of local health systems.” We observed three stages of experience during the crisis: (a) Preparation (official guidelines received to organize care, training, and planning of epidemiological surveillance); (b) Adaptation (performance of community-based prevention activities, infrastructure modifications, telehealth); (c) Learning (participatory governance with city councils, business sector, and organized population). The study suggests that the local health systems analyzed benefited from the initiatives of health personnel that in some cases positively exceeded their duties. In terms of the resilience analysis, they were able to handle the impact of the crisis and cope with it. Their transformative capacity came from the strategies implemented to adapt health services by managing institutional resources. Their experience represents a lesson on the strengthening of the essential functions of health systems and shows a way to address successfully the increasingly complex health challenges of the present and future times.

the crisis in countries with greater inequalities, where the pandemic converged with other social emergencies. We documented the experiences of health personnel who faced the pandemic at the primary care level while simultaneously maintaining the functioning of other areas of medical care. Our results derived from a qualitative study comprising 103 participants from five states of Mexico. We aimed to show through inferential analysis their perspective on what we call "the resilience of local health systems." We observed three stages of experience during the crisis: (a) Preparation (official guidelines received to organize care, training, and planning of epidemiological surveillance); (b) Adaptation (performance of community-based prevention activities, infrastructure modifications, telehealth); (c) Learning (participatory governance with city councils, business sector, and organized population). The study suggests that the local health systems analyzed benefited from the initiatives of health personnel that in some cases positively exceeded their duties.
In terms of the resilience analysis, they were able to handle the impact of the crisis and cope with it. Their transformative capacity came from the strategies implemented to adapt health services by managing institutional resources. Their experience represents a lesson on the strengthening of the essential functions of health systems and shows a way to address successfully the increasingly complex health challenges of the present and future times.

INTRODUCTION
Resilience is the ability of any material to recover its original shape or state after being subjected to deformation by an external force. In Psychology (Werner, 1989;Cyrulnik, 2001), this concept has been used metaphorically to study the processes whereby people who have endured extremely adverse experiences can return to their normal lives. The experiences lived by those people can be divided into three stages: Impact (a shock that causes a crisis), adaptation, and learning (Brand and Jax, 2007). The concept of resilience has been applied to the field of public health to study how health systems receive the shock of health crises, what conditions allow them to absorb the blow, and how they reorganize once the crisis is over; all this while maintaining the same characteristics of care provision (Giarelli, 2020;Davis, 2021). Though there are some variations in the definition of resilience within the public health field, it is generally understood as the ability of health actors, institutions, and the population to prepare and respond effectively to crises, while the health system maintains its essential care functions during the crisis and from the lessons learned reorganize itself to obtain favorable health results (Kruk et al., 2015).
In the public health context, the concept of resilience has been used to study some epidemics that emerged during the first two decades of the twenty-first century, namely severe acute respiratory syndrome (SARS), Ebola, and Zika, which tested health systems in some regions of the world and showed the fragility of some countries to cope with public health emergencies. In 2020, the COVID-19 pandemic caused by SARS-CoV-2 virus represented a global challenge that demanded immediate response to an unprecedented health crisis through public policies particular to each country according to its context and resources. In 2020, the World Health Organization (WHO) stated that "building resilience is a key factor in promoting and protecting health and well-being at both the individual and community levels." (WHO, 2021). Highly effective strategies aimed at keeping the essential functions of health systems have been developed, mainly based on four components linked to the concept of resilience, which are (a) activation of governance mechanisms, (b) adaptation of existing resources both on health personnel and on medical products and technology, (c) offering of health services, and (d) actions on public health to reduce the vulnerability derived from infection risks (Haldane et al., 2021).
In 2005, the WHO established the International Health Regulations (IHR) as "a legal framework for the management of acute public health events of potential or actual national and international concern." (WHO, 2008) The IHR are pertinent as a tool to identify the strengths and weaknesses of a health system response to the COVID-19 pandemic. The IHR have been a reference for the development of evaluation proposals aimed to assess the capacity of health systems to prepare for and respond to health emergencies. One of these regulations is the resilience index, which consists of five requirements: (1) recognition of the strengths and weaknesses of the health system itself with respect to its population context, (2) diversity to respond effectively and with financial protection to the health needs of the population, (3) self-regulation to coordinate between services and adapt care models according to the moment of crisis, (4) integration with a governance approach to achieve social commitment, and (5) adaptation for an organized and timely response (Kruk et al., 2017).
Several authors, however, have pointed to the deeper crisis represented by the COVID-19 pandemic in countries with greater social inequalities, such as those in the Latin American region (Etienne et al., 2020;The Lancet, 2020). There, the pandemic converged with other social emergencies, putting additional pressure to health systems to address complex health issues because of population dynamics, inadequate infrastructure, and diversity of epidemiological contexts.
Mexico has suffered the impact of the COVID-19 crisis with a high cost in human lives.
The high prevalence of non-communicable diseases (NCDs) in the country has caused a syndemic rather than a pandemic (Hernández, 2020). From the beginning of the pandemic up to April 2022, more than 400,000 deaths and more than 5 million cumulative cases had been reported, with a mortality rate of 2.2 deaths per thousand inhabitants (National Institute of Public Health, 2022). Furthermore, the percentage increase in total deaths (compared with the average of 2015-2019) represented more than 50% of excess mortality, the highest among the countries from the Organization for Economic Co-operation and Development (OECD, 2021). In Latin America and the Caribbean Region, the case-fatality rate has been averaged at 3.4%, whereas Mexico has reported a lethality of 16.6% (Schwalb et al., 2022).
The emerging response had to be activated from a fragmented health system model in a country with 126 million inhabitants in conditions of socioeconomic disparity. In Mexico's public health system, the population affiliated to social security, represented by formal workers and their families, receive health care services without restriction, funded by employers, employees, and the government. On the other hand, the population without this benefit, who constitute almost half of the population with lower income, are served by state and federal government institutions or must resort to private services and bear out-ofpocket expenses (Shamah et al., 2020). In this context, since the beginning of the COVID-19 pandemic, the Ministry of Health implemented response strategies, which were adapted throughout 2020 and 2021, and based on scientific evidence, international guidelines, and weekly epidemiological information on national cases and deaths. Yet, flaws in the decision-making process and in the model for emergency management have been documented, such as inaccuracies of the surveillance system and low rates of proactive testing, case identification, and contact tracing (Institute for Global Health Sciences, 2021).
One of the main objectives stated in the COVID-19 response guidelines of the public health system was not to exceed the hospital capacity for the care of cases, given the serious difficulties represented by weak infrastructure and a lack of health personnel. This situation worsened in public services for the population without social security-vulnerable in economic and demographic terms-, mainly for residents of marginalized rural communities. In a centralized context of public health policies, the State Health Services (SHS), responsible in each of the 32 states of the country for the care of this population, but with little decision-making capacity to participate in the planning of health programs, implemented the guidelines established at the federal level. Nevertheless, they designed some local care strategies to address the needs of the population with fewer resources. In this context, health personnel carried out prevention activities, detected and cared for cases of COVID-19, and at the same time kept essential health services working, which represented a great challenge.
Health personnel are the backbone of health systems and are key to achieve service delivery, yet there is a knowledge gap on how they coped with the pandemic while performing at the same time their daily work. This article presents partial results of an extensive study aimed to recover the experience of different types of health personnel who faced the challenge of providing community and ambulatory care during the COVID-19 health crisis. Here we present only findings on the "resilience" category that emerged from the data inferential analysis. We are interested in contributing to the debate proposed by Saulnier (Saulnier et al., 2021) about the need to build a research agenda on the resilience of post-pandemic health systems, recovering evidence on how the impact of crises is absorbed at the microsocial level, and health systems adapt and transform.

MATERIAL AND METHODS
Study design and population. This is a qualitative, exploratory study (Denzin and Lincoln, 2011).
For this study, a "local health system" is understood as a health-focused organization of the state government working within a territorial delimitation (states) with its own health service infrastructure and organizational structure. In Mexico, this structure is divided into Health Jurisdictions (HJs), which are technical-administrative departments varying in complexity; they are responsible for the operation of health care programs at district level.
A HJ can territorially group one or several municipalities in rural and urban areas. The local health system also manages regulations for the provision of public and private health services. It coordinates and allocates health resources for their best use, which are own resources-human, material, financial, information systems-and those coming from the federation.
Initially, seven states from Northern, Central, and Southern Mexico were selected because of their diversity of social, environmental, and populational contexts (border, sea, and mountain regions, including migrant population, indigenous population, and itinerant day laborers). Of these, five states agreed to participate in the study, two in the North region, one in the Southeast region, one in the Gulf of Mexico, and one in the Yucatan Peninsula (National Institute of Statistics, Geography, and Informatics, 2021). Afterward, a sample of different types of health personnel who worked in public health services and provided care to population not affiliated to social security was selected.
(Insert Figure 1) Sample selection. SHS management was contacted to explain to them the objectives of the study and the interest of analyzing a variety of health personnel's experiences in both urban and rural areas. Data from the states were reviewed and three HJs from each state were chosen for a total of 15 HJs. Next, a purposive sample of state managers and health workers responsible for HJs was chosen. Likewise, medical units of ambulatory care were selected in rural and urban areas (39 in total; urban area 21, rural 18). In these medical units, different types of health personnel were chosen to have sufficient variety of viewpoints regarding the care provided to the population during the health emergency. The main inclusion criterion was to be a health worker performing community activities focused on prevention of COVID-19 infection risk, detection of cases (COVID-19 home screening), remote care for uncomplicated cases staying at home, and referral of complicated cases to designated hospitals. The sample totaled 103 participants and consisted of health managers, medical staff (responsible for clinical care), nursing personnel (in charge of preventive actions), and health promoters (who carried out community-based health promotion). (Table 1). Table 1) Data collection and instrumentation. Data were collected between December 2020 and August 2021. The main technique used to gather information was the semi-structured qualitative interview. Guides were elaborated by type of health worker (health managers, medical personnel, nursing personnel, health promoters), designation (HJs, community health brigades, health centers), and interviewees' place of work (rural or urban area). The guides were organized into two thematic axes. The first axis explored aspects of the reorganization of health care services from the start of the pandemic and included the following topics: coordination for medical care, infrastructure adaptations, prevention activities to avoid the risk of COVID-19 infection, referral of cases, protection equipment for health personnel (masks, sanitation measures), support for health personnel, human resources situation, and coordination with other government and civil society sectors to address the pandemic. The second axis explored barriers and challenges to face the pandemic and was disaggregated into the following themes: continuity of priority health care programs (immunization for children under 5 years of age, care for chronic diseases, reproductive health), challenges for care during the pandemic, and recommendations to keep coping with the pandemic. All interviews were conducted by video calls due to sanitary restrictions in the states to carry out face-to-face activities. This facilitated the access to very remote rural areas that under normal conditions are difficult to reach, though there were also connectivity limitations. The interviews lasted on average 30 to 90 minutes; all of them were audiorecorded and transcribed verbatim.

(Insert
Data analysis. The perspective of the Constructivist Grounded Theory was used for the analysis of the data (Charmaz, 2006). From the interview guides, first, two types of information concentrates were elaborated according to the thematic axes, i.e., by interviewee's type of health work and by topic explored. Later, content analysis of the interview transcripts was performed manually. The transcripts were coded by analyzing line by line (Glaser and Strauss, 1967;Strauss and Corbin, 1997). Six categories (initial codes) were constructed, from which 19 sub-categories (focused coding) derived (See description of each thematic category in code tree SM-1). Subsequently, the interconnections between the codes were analyzed to construct categories that grouped the experiences narrated by the interviewees according to the coincidences between the situations. In this way, the theoretical category "resilience" was constructed, which analyzes the capacity of the interviewed health care actors to prepare, adapt, and respond in a coordinated manner to the challenge of prevention and care for cases of SARS-Cov-2. This category consisted of three codes (theoretical codes): Preparation for the health crisis; Adaptation and Management of the pandemic; and Learning, to which some of the above subcategories were integrated (See description of each thematic category in code tree SM-2).
Ethical aspects: The interviews were conducted after prior verbal informed consent. The principles of research ethics stated in the Declaration of Helsinki (World Medical Association, 2013) were followed. As this is a sensitive matter, the names of the states and villages where the fieldwork was carried out and of the health personnel who agreed to be interviewed have been removed.

RESULTS
The health crisis has not ended. As of the time of closing our study, adjustments were still being made to deal with the pandemic. The health personnel interviewed had the experience of the first wave of infections and the beginning of the second. It has been a heterogeneous learning process that overlaps according to the context of their place of work (rural or urban) and the human and material resources available.
We organized the results of the study into three stages: Preparation, Adaptation, and Learning. Tables 2 and 3 show in more detail how the pandemic was addressed and how the situations presented in the rural and urban scenarios were solved, according to the level of responsibility of the actors interviewed. Figure 2 illustrates the dynamic interaction between the three stages, i.e., the circumstances of uncertainty, disruptions, and feedback through the flow and movement of the system.

(a) Preparation for the health crisis
The HJs are organized as follows: the care areas and the number of health staff working in each medical unit of primary care level depend on the population served in a determined territory and the size of the unit. In rural units, there is a single basic nucleus (BN) consisting of a doctor and one or two nurses. In urban units, in cities with a large population, the medical services consist of three and up to 14 NB. Additionally, they may have personnel of health promotion, nutrition, dentistry, psychology, or laboratory services, including social service staff for each of these care areas, distributed at different working hours. This is important to note because the planning of services at the managerial level responded to the needs of health personnel in those terms.
(i) The process followed: For explanatory purposes, we defined three stages of preparation according to the narrative of the interviewees at the managerial level to show a part of the process followed. In practice, however, these stages overlapped since the emergency response measures were not taken in all the states at the same time. First stage: It was characterized by surprise once the national epidemiological system gave the alert. The states began designing local guidelines to organize care using the existing scientific evidence, but there was no glimpse of what the impact of the virus might be. This occurred around the world during the first months of the pandemic. Second stage: From the arrival of the first case to Mexico and the increase in infections, the pandemic was formally recognized in the country. In the states, training for teams of health professionals was intensified, preventive measures were disseminated to the population, and medical facilities were prepared. Actions diversified as more evidence-based information was available.
Third stage: It began in March 2020, when severe cases and deaths from COVID-19 increased. The situation led to lockdown (closure of non-essential economic activities and schools) and made medical care more difficult. (iii) Planning for epidemiological surveillance: States with virtual platforms for epidemiological registration adapted them for the control of COVID-19 cases (State 4); otherwise, they used paper formats and reported via telephone or email (State 2). In both circumstances, responsibilities were appointed to report results daily more efficiently at national level. Call centers were established; staff were assigned to answer calls and guide people on identification of symptoms and referral to hospitals (State 1, State 3). In all states, mobile health teams were set up to take samples. At the state level, health promoters were assigned to integrate community COVID-19 screening teams during the stage when more infections were detected.

) (b) Adoption of measures and adaptation against adversity: "making more with less"
(i) Supplies for care. At the start of the pandemic, one of the biggest concerns of health personnel was protection from infection. During the first few months, personal protective equipment (PPE) was slow to reach medical units, especially in rural areas. Health personnel reported using their own resources to buy PPE and disinfectant products. Later, PPE was supplied from the state level. For nursing personnel and health promoters, the equipment received consisted of masks and disinfectant products. Doctors, due to close contact with patients, received gowns, goggles, or face shields. As cases increased, more PPE was needed, and shortage occurred in rural areas. Health personnel spent their own money to buy more protective equipment, such as three-layer masks.
(ii) Community prevention activities for COVID-19. Several actions were carried out depending on the stage of the pandemic. As a first action, educational material was prepared and information on how to prevent infection (handwashing, use of masks and alcoholic gel) was distributed. Health teams were integrated to give prevention information in key places, such as markets, schools, shopping centers, and transport hubs. Social networks were also used for dissemination of information on the pandemic. With the increase in cases, other strategies were added. COVID-19 screening stations were installed at state and municipal borders and in bus stations and airports; test samples were taken in some places. After lockdown, health teams reduced the number of prevention activities to avoid infection. In some medical units these activities continued only inside the facilities.
The role of health promoters and nursing personnel was key to COVID-19 prevention and care activities in urban and rural areas. Overall, preventive activities were carried out in urban areas without great difficulty. In rural areas, however, where most of the medical units are small and have few health personnel, the prevention actions underwent some adjustments. For example, administrative staff had to participate in some units. In states with indigenous population, nurses who spoke the indigenous language distributed prevention information. Also, some states prepared educational materials on prevention measures in indigenous languages. In the northern states of the country, prevention work extended to the migrant population, agricultural day laborers, and textile factory workers.
(iii) Care of COVID-19 cases in outpatient medical units. Once training was received, infrastructure adaptation in medical facilities was the following step. Screening stations were set up to measure body temperature and provide hand sanitizer to each person upon entering the facilities. Entry and exit routes were drawn and spaces were marked to maintain the appropriate distance. The medical units that were able to, allocated an exclusive office for the detection of COVID-19 cases and adapted spaces for the taking of PCR tests. All available spaces were used, and some administrative offices were transformed into consultation rooms. In rural areas, warehouses for cleaning supplies were used by heath workers as dressing rooms and places to sanitize themselves; patios became waiting rooms. COVID-19 management followed a three-step process depending on the stage of the pandemic: (1) The medical unit informed patients of positive COVID-19 results. The nursing personnel recommended home care measures to both infected persons and their families. Patients were to be isolated at home and symptoms were monitored via telephone; when necessary, patients were referred to hospital. (2) With the increase in cases, mobile teams were integrated to search for COVID-19 cases; the work of nursing personnel and promoters was essential due to their acquaintance of the population. (3) The states with the greatest human resources (State 4) extended the work of the mobile teams (health brigades) to carry out home visits, assess possible cases, take samples with the aid of epidemiological teams, and prepare censuses. The positive cases were given information for home care; some of them received an aid kit including an oximeter that later had to be handed back to the health personnel.
Some states allocated ambulatory care facilities of greater capacity as "COVID centers" to exclusively perform diagnostic tests on suspected cases, inform on results, monitor positive cases at home via telephone, and give information for referral to hospital. Other states reassigned health workers from other care departments to cover services lacking staff, who were in leave because of occupational risks. In rural areas, some medical units temporarily closed while staff infected with COVID-19 recovered or substitutes were sent. Table 3) (iv) Medical care for other diseases. Owing to the lockdown and the limited access of nonurgent cases to medical facilities, continuous care delivery was challenging, mainly for population needing regular care or supplies, such as pregnant women, children under five years of age in need of immunization, patients with pulmonary tuberculosis, and people with chronic diseases. These cases were monitored remotely by telephone and social media platforms. An example is the follow-up of patients with chronic diseases. Self-monitoring patients with hypertension or diabetes were followed remotely (telephone messages); when necessary, home appointments were made, and medicine supplies for up to three months were sent over to them. Other relevant aspect of the participation of health personnel was the continuation of preventive programs, such as vector eradication campaigns and health promotion activities. In the voice of an interviewee:

DISCUSSION
According to the WHO, understanding how resilience is built in health systems is a key factor in promoting and protecting health (WHO, 2021). Nevertheless, as Saulnier remarks, a lot has been talked about resilience in conceptual terms, but little is shown in a practical way on how it is built on a day-to-day basis, which is essential for health system recovery in the post-pandemic era. The findings of this study offer a view of how decisions are made daily, both at the managerial planning level and at the health personnel level, in prevention and care activities. It was the social actors interviewed who built the resilience of the local health systems. From this approach, as the authors above mentioned point out, it is necessary to understand that resilience is simultaneously a result and a skill, both aspects occurring at the same time and feedbacking each other. This idea broadens the classic definition of resilience that equates it with health system efficiency. Analyzed from a complex systems approach, resilience should thus be understood as a process that enhances the experience of the health system through the interconnections generated at different participant levels, which facilitates the planning of more focused responses.
In the stage of Preparedness for the health crisis, local actions were organized as part of the strategies implemented by the Mexican health system for the response to the pandemic before vaccine availability. Actions included containment and mitigation of infections through home confinement, closure of non-essential school and work activities, general hygiene measures, and adaptation or conversion of services for the care of cases Mendoza and Suárez, 2020). The centralized governance also defined national policies, which narrowed the response according to regional and local needs (Díaz et al., 2021;Knaul et al., 2021).
The training of health personnel was the main action carried out during this stage. At the same time, other components of the health system influenced the preparedness for service delivery, but it was the conditions of the context that exerted the greatest influence, with rural areas facing additional challenges. This situation has been reported as well in other countries (Schiff et al., 2020, Peters, 2020, Vázquez and Gandolfi, 2020, Bastos and Fonseca, 2021) that paid less attention to rural areas during the COVID-19 pandemic, to territories inhabited by indigenous population, and to homeless people with fewer social resources and greater susceptibility to COVID-19 infection. The inadequate protection for these population sectors has already been evidenced from the public policy analysis (Lal et al., 2021) as one of the serious pending tasks in the response to the pandemic.
The priority for resource allocation in case of a health emergency has also been analyzed (Senthilingam, 2021, Schiff et al., 2020, O'Sullivan et al., 2020, Etienne et al., 2020. Urban areas represent a greater risk of virus transmission compared with rural areas due to the higher population density of the former. Rural areas, however, present other challenges, such as the difficulty in accessing health services, a situation of structural inequality aggravated by the COVID-19 pandemic. During the Adaptation stage, and in relation to skill, another aspect to consider was the effort of health professionals to reach small villages in remote areas and provide care in conditions of great disadvantage, such as personnel shortage and high demand for care. This enormous effort had costs to their physical and mental health, which has been reported in other contexts as well (Galbraith et al., 2021, Vizheh et al., 2020, Walton, Murray, and D Christian, 2020, O'Sullivan et al., 2020. In Mexico, as in other Latin American countries, the reassignment of personnel to address the health emergency caused a lag in other health services, such as care for NCDs (OPS, 2020). To counter that situation, health personnel was temporally hired, and other strategies were developed, such as greater provision of medication to control chronic illnesses at home (Colchero et al., 2021;Martínez and Gómez, 2022;Tetelboin, Iturrieta and Schor, 2021).
As for learning, the pandemic demonstrated the capacity of health personnel to self-manage (which also refers to skill) in the performance of preventive activities (an area of special relevance for the containment of the pandemic), in the solution of challenges represented by the remote monitoring of people infected with COVID-19, and in the efforts made to give continuity to care for other diseases. In these activities, the use of technologies, specifically the mobile phone, was paramount. The emergence of electronic media as an alternative for care is also highlighted by other studies. The use of videoconferences to provide medical consultations and inform on preventive measures against the pandemic, the so-called "telehealth" (Bhaskar et al., 2020, Meyer et al., 2020Monraz et al., 2021), is identified as an important aid to extend care coverage in rural areas.
Another learning in crisis management was the work of "social intermediaries", as Blanchet (Blanchet, et. al., 2017) calls them. These are actors that form links between users and "build bridges" with health services, provide greater local knowledge, and represent an opportunity to expand the provision of services. These organizational experiences arising spontaneously "from below" as a help offer from the population show the need for the reconceptualization of the term "participatory governance" from the experience of the pandemic. They represent a way of integrating the decision-making spaces generated on a day-to-day basis with different social actors who usually were not considered in the traditional concept of governance, as they did not have a formal participation in the decision-making process (Pyone, Smith andvan den Broek, 2017, Kickbusch andGleicher, 2012). It is important not to lose these initiatives by setting up mechanisms to integrate them.

CONCLUSIONS
The local health services analyzed in this study benefited from the initiatives of health personnel that in some cases positively exceeded their duties. In terms of the resilience analysis, their effort was key in the ability to handle the impact of the crisis and cope with it; their capacity came from their strategies to adapt health services by managing the resources available. From this perspective, our study shows the need to set up response plans for public health emergencies that allow implementing timely and effective care strategies, considering the diversity of contexts as well as the social actors that activate local support networks. The case of Mexico illustrates the way local health services responded effectively to care demand generated by the COVID-19 pandemic making do with the existing infrastructure, personnel, and supplies, in coordination with communities.
Yet, the limitation of resources and the heterogeneity of the responses of each region according to its capacity resulted in the delayed care of other pressing health conditions.
The results of this study point thus to the need for the implementation of public health policies that consider the health conditions of a population and the capacity of services specifically by region and local contexts as the basis to strengthen the essential functions of a health system to successfully face increasingly complex health challenges of the present and future times.

LIMITATIONS
The above analysis derived from the inference of health personnel's narratives obtained by interview, which portrays their own outlook. Our aim was to know how they coped with the pandemic from their local frontline as part of the Mexican health system; therefore, the results are not intended to be generalized. Also, the stages for the assessment of resilience overlapped and did not follow a linear process. They were not homogeneous; even within the states there were variations because of very vast areas to cover and great population diversity. The information about the beginning of the health crisis reached the states at different moments, so there was not specifically a phase of Preparation to deal with the impact/shock, as the crisis and the subsequent stages affected the states unevenly. Lastly, a thorough analysis of the health system resilience would require information on details on the public policy developed to deal with the pandemic, financial resources aimed at the different levels of care and the different health care sectors, details on intersectoral participation and consensus agreements, among others. These aspects exceeded the objectives of the present study.     supplies and personal protective equipment.  When necessary, they bought personal protective equipment with their own resources.
Source: Authors' elaboration from the collected data.