Overview

Key messages:

• Health system resilience is about the ability to withstand complex crises.
  • Resilience involves responding to shocks but also preparing for (or preventing) them; managing during the “acute” phase; recovery; learning; and acting on legacy issues.
  • Resilient health systems can respond to acute shocks (pandemics, economic crises, conflicts) but also to chronic stressors (ageing, multimorbidity).
  • Crises are increasingly global, making resilience an international concern, but, despite the scope for shared learning, specific context is key.
• Communication, collaboration and coordination across sectors and multiple systems are essential because resilience is not just about protecting the health system and its performance but is embedded in broader contexts – societal, political, cultural, environmental and economic.
• Core capacities matter across the shock cycle and at particular stages of a shock.
  • “Hardware” capacities – like infrastructure, resources and finances – have overarching relevance.
  • “Software” capacities, such as governance, communication and collaboration – are also cross‑cutting.
  • The ability to take proactive steps to protect from shocks (for example, by investing in cybersecurity or climate-resilient infrastructure) is central to exercising foresight and prevention.
  • Capabilities to identify and act on lessons – from a shock or the interaction of overlapping shocks – and to tackle any suboptimal responses are critical in the learning and legacy stages and in addressing long‑lasting challenges (such as staff burnout or waiting lists).
• Strengthening resilience means improving governance and implementing integrated approaches in practice. Coordinated action is needed within and beyond the health system and across three interconnected areas:
  • Strengthening governance so that it consolidates an understanding of past shocks and intersectoral power dynamics to advocate for adequate funding, mobilize capacities and shape strategic action.
  • Making power structures accountable and building relationships that involve multiple stakeholders in decision-making so as to protect vulnerable groups and guard against mismanagement.
  • Fostering long-term and broad perspectives, particularly a whole-of-society approach and a focus on international cooperation, rules and investment to address big picture issues like the climate crisis.
• Equity must be a key consideration in resilience efforts because shocks disproportionately affect vulnerable and underserved populations and there is a risk that existing inequalities are reinforced.
• Resilience must be supported by robust assessment tools, including resilience testing. Tests need to involve a mix of stakeholders (from education, social care, emergency services, etc.). They also need real-world scenarios. System dynamics modelling clarifies factors affecting performance; realist reviews of the underlying mechanisms that shape resilience support optimal strategies; and scenario-based testing using hypothetical shocks uncovers system vulnerabilities and prompts pre‑emptive improvement.
• Resilient health system responses can (and should) aim to transform health systems so that they do more than preserving existing functioning and improve access, quality and efficiency.
  • Resilience is not a fixed outcome but a dynamic process.
  • Chronic challenges like natural disasters can encourage complex (and dynamic) adaptive systems. However, these may mask systemic weakness and encourage short-term coping (a kind of “malign resilience”) over long-term change.
  • Countries benefit from a dual approach that combines complex adaptive systems thinking with more long-term consideration of how to challenge resource constraints and protect vulnerable groups.