Sailing between fate and control: Health systems resilience in the Caribbean Netherlands

Small, non-sovereign islands remain largely absent from the health policy and systems research literature, despite facing distinct governance challenges, rooted in logistical challenges, sociogeographical isolation, and post-colonial entanglements. We therefore studied how health system actors on Bonaire, Sint Eustatius, and Saba - three islands and 'special municipalities' of the Netherlands in the Caribbean - enact health systems resilience in everyday practice. We draw on multi-sited ethnographic research conducted between February and December 2024. We collected 44 interviews, 60 h of observations across disaster preparedness and crisis meetings, and analysed 109 policy documents. Our analysis followed an iterative, abductive approach, moving continuously between empirical data and a practice-based sociological health systems resilience framework. Our analysis identified three interrelated practices of health systems resilience: prioritising risks, building and mobilising alliances, and working with(in) double roles. Together, these practices reveal how health systems resilience on small islands works as an active process of mediating the space between managerial control and the recognition of fate; that is: uncertainties beyond full anticipation. We show that practices of health systems resilience may simultaneously reproduce structural vulnerabilities, mask governance deficits, and normalise conditions of persistent precarity. With our analysis, we contribute to theoretical debates about what health systems resilience means in practice and extend the limited empirical literature on health systems in non-sovereign small island geographies. We argue that the health policy and systems literature should engage more systematically with such peripheralised settings, where everyday ingenuity coexists with, and partly compensates for, structural inequalities.