Health System Resilience: What Are We Talking About? A Scoping Review Mapping Characteristics and Keywords

Document Type : Review Article


Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden


Health systems are based on 6 functions that need to work together at all times to effectively deliver safe and quality health services. These functions are vulnerable to shocks and changes; if a health system is unable to withstand the pressure from a shock, it may cease to function or collapse. The concept of resilience has been introduced with the goal of strengthening health systems to avoid disruption or collapse. The concept is new within health systems research, and no common description exists to describe its meaning. The aim of this study is to summarize and characterize the existing descriptions of health system resilience to improve understanding of the concept.
Methods and Analysis
A scoping review was undertaken to identify the descriptions and characteristics of health system resilience. Four databases and gray literature were searched using the keywords “health system” and “resilience” for published documents that included descriptions, frameworks or characteristics of health system resilience. Additional documents were identified from reference lists. Four expert consultations were conducted to gain a broader perspective. Descriptions were analysed by studying the frequency of key terms and were characterized by using the World Health Organization (WHO) health system framework. The scoping review identified eleven sources with descriptions and 24 sources that presented characteristics of health system resilience. Frequently used terms that were identified in the literature were shock, adapt, maintain, absorb and respond. Change and learning were also identified when combining the findings from the descriptions, characteristics and expert consultations. Leadership and governance were recognized as the most important building block for creating health system resilience.
No single description of health system resilience was used consistently. A variation was observed on how resilience is described and to what depth it was explained in the existing literature. The descriptions of health system resilience primarily focus on major shocks. Adjustments to long-term changes and the element of learning should be considered for a better understating of health system resilience.


Main Subjects

Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes: WHO’s Framework for Action. Geneva: World Health Organization; 2007.
Musgrove P, Creese A, Preker A, et al. World Health Report. Improving Health System Performance. Geneva: WHO; 2000.
Haimes YY. On the Definition of Resilience in Systems. Risk Anal. 2009;29(4).
Kruk ME, Myers M, Varpilah ST, Dahn BT. What is a resilient health system? Lessons from Ebola. Lancet. 2015;385(9980):1910-1912. doi:10.1016/S0140-6736(15)60755-3
Focosi D, Maggi F, Pistello M. Zika Virus: Implications for Public Health. Clin Infect Dis. 2016;63(2):227-233. doi:10.1093/cid/ciw210
Castro MC. Zika Virus and Health Systems in Brazil: From Unknown to a Menace. Health Syst Reform. 2016;2(2):119-122. doi:10.1080/23288604.2016.1179085
Olafsdottir AE, Allotey P, Reidpath DD. A health system in economic crises: a case study from Iceland. Scand J Public Health. 2013;41(2):198-205. doi:10.1177/1403494812470038
Thomas S, Keegan C, Barry S, Layte R, Jowett M, Normand C. A framework for assessing health system resilience in an economic crisis: Ireland as a test case. BMC Health Serv Res. 2013;13:450. doi:10.1186/1472-6963-13-450
Viens AM, Littmann J. Is antimicrobial resistance a slowly emerging disaster? Public Health Ethics. 2015;8(3):255-265. doi:10.1093/phe/phv015
Fletcher D, Sarkar M. Psychological Resilience. Eur Psychol. 2013;18(1):12-23. doi:10.1027/1016-9040/a000124
Hallegatte S. Economic Resilience: Definition and Measurement. The World Bank; 2014. doi:10.1596/1813-9450-6852
Walker B, Holling CS, Carpenter SR, Kinzig AP. Resilience, Adaptability and Transformability in Social-ecological Systems. Ecol Soc. 2004;9(2):15. doi:10.5751/ES-00650-090205
Holling CS. Resilience and stability of ecological systems. Annu Rev Ecol Syst. 1973;4:1-23.
Baggio JA, Brown K, Hellebrandt D. Boundary object or bridging concept? A citation network analysis of resilience. Ecol Soc. 2015;20(2):2.
Alexander DE. Resilience and disaster risk reduction: an etymological journey. Nat Hazards Earth Syst Sci. 2013;13(11):2707-2716. doi:10.5194/nhess-13-2707-2013
Folke C. Resilience: The emergence of a perspective for social–ecological systems analyses. Glob Environ Change. 2006;16(3):253-267.
van de Pas R, Ashour M, Kapilashrami A, Fustukian S. Interrogating resilience in health systems development. Health Policy Plan. 2017;32(suppl 3):iii88-iii90. doi:10.1093/heapol/czx110
Folke C, Carpenter SR, Walker B, Scheffer M, Chapin T, Rockström J. Resilience Thinking: Integrating Resilience, Adaptability and Transformability. Ecol Soc. 2010;15(4):20. doi:10.5751/ES-03610-150420
Hanefeld J, Mayhew S, Legido-Quigley H, et al. Towards an understanding of resilience: responding to health systems shocks. Health Policy Plan. 2018;33(3):355-367. doi:10.1093/heapol/czx183
Barasa E, Mbau R, Gilson L. What is resilience and how can it be nurtured? A systematic review of empirical literature on organizational resilience. Int J Health Policy Manag. 2018;7(6):491-503. doi:10.15171/ijhpm.2018.06
Blanchet K. Governance and capacity to manage resilience of health systems: towards a new conceptual framework. 2017;6(8):431-435. doi:10.15171/ijhpm.2017.36
Arksey H OL. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19-32. doi:10.1080/1364557032000119616
Levac D, Colquhoun H, O’Brien KK. Scoping studies: Advancing the methodology. Implement Sci. 2010;5(1):1-9. doi:10.1186/1748-5908-5-69
Godin K, Stapleton J, Kirkpatrick SI, Hanning RM, Leatherdale ST. Applying systematic review search methods to the grey literature: a case study examining guidelines for school-based breakfast programs in Canada. Syst Rev. 2015;4(1):1-10. doi:10.1186/s13643-015-0125-0
Intelligent verbatim transcription. Academic Transcription Services.  Accessed January 28, 2018. Published June 2016.
Moore JE, Mascarenhas A, Bain J, Straus SE. Developing a comprehensive definition of sustainability. Implement Sci. 2017;12(1):110. doi:10.1186/s13012-017-0637-1
World Health Organization. Operational Framework for Building Climate Resilient Health Systems. Geneva, Switzerland: World Health Organization; 2015.
Campbell J, Cometto G, Rasanathan K, et al. Improving the resilience and workforce of health systems for women’s, children’s, and adolescents’ health. BMJ. 2015:h4148. doi:10.1136/bmj.h4148
Ozawa S, Paina L, Qiu M. Exploring pathways for building trust in vaccination and strengthening health system resilience. BMC Health Serv Res. 2016;16:639. doi:10.1186/s12913-016-1867-7
Ammar W, Kdouh O, Hammoud R, et al. Health system resilience: Lebanon and the Syrian refugee crisis. J Glob Health. 2016;6(2):020704. doi:10.7189/jogh.06.020704
Kieny MP, Dovlo D. Beyond Ebola: a new agenda for resilient health systems. Lancet. 2015;385(9963):91-92. doi:10.1016/S0140-6736(14)62479-X
Barasa EW, Cloete K, Gilson L. From bouncing back, to nurturing emergence: reframing the concept of resilience in health systems strengthening. Health Policy Plan. 2017;32(suppl 3):iii91-iii94. doi:10.1093/heapol/czx118
Kamal-Yanni M. Never Again: Building resilient health systems and learning from the Ebola crisis. OXFAM Brief Pap. 2015:38.
Khan FN, Qazi S, Tanveer K, Raza K. A review on the antagonist Ebola: A prophylactic approach. Biomed Pharmacother. 2017;96:1513-1526. doi:10.1016/j.biopha.2017.11.103
McKenzie A, Abdulwahab A, Sokop E, Mecaskey J. Building a Resilient Health System: Lessons from Northern Nigeria. Published 2015.
Senkubuge F, Modisenyane M, Bishaw T. Strengthening health systems by health sector reforms. Glob Health Action. 2014;7(1):23568. doi:10.3402/gha.v7.23568
Olu O. Resilient health system as conceptual framework for strengthening public health disaster risk management: An african viewpoint. Front Public Health. 2017;5. doi:10.3389/fpubh.2017.00263
Gilson L, Barasa E, Nxumalo N, et al. Everyday resilience in district health systems: emerging insights from the front lines in Kenya and South Africa. BMJ Glob Health. 2017;2(2):e000224. doi:10.1136/bmjgh-2016-000224
Using Intersectionality to better understand health system resilience. RESYST website.  December 2017.
European Commission. Communication from the Commission: On Effective, Accessible and Resilient Health Systems. Published 2014.
Resilient and Innovative Health Systems for Europe. Austria: International Forum Gastein; 2013.
M8 Alliance Kyoto. Meeting Emerging Challenges: Toward Responsive and Resilient Health Systems. Published April 21, 2015.
Kendall H, Najeeb A-S, Ed B, et al. Applying the Resilient Health System Framework for Universal Health Coverage. Stud Health Technol Inform. 2016:54–62. doi:10.3233/978-1-61499-712-2-54
Mfutso-Bengo J, Kalanga N, Mfutso-Bengo EM. Proposing the LEGS framework to complement the WHO building blocks for strengthening health systems: one needs a LEG to run an ethical, resilient system for implementing health rights. Malawi Med J. 2018;29(4):317. doi:10.4314/mmj.v29i4.7
Blanchet K. Governance of health systems: Comment on “A network based theory of health systems and cycles of well-being.” Int J Health Policy Manag. 2013;1(2):177-179. doi: 10.15171/ijhpm.2013.31
Abimbola S, Topp SM. Adaptation with robustness: the case for clarity on the use of ‘resilience’ in health systems and global health. BMJ Glob Health. 2018;3(1):e000758. doi:10.1136/bmjgh-2018-000758
World Health Statistics 2018: Monitoring Health for the SDGs. World Health Organization website.  Accessed May 23, 2019. Published 2018.
Ling EJ, Larson E, Macauley RJ, et al. Beyond the crisis: did the Ebola epidemic improve resilience of Liberia’s health system? Health Policy Plan. 2017;32(suppl 3):iii40-iii47. doi:10.1093/heapol/czx109
Sochas L, Channon AA, Nam S. Counting indirect crisis-related deaths in the context of a low-resilience health system: the case of maternal and neonatal health during the Ebola epidemic in Sierra Leone. Health Policy Plan. 2017;32(suppl 3):iii32-iii39. doi:10.1093/heapol/czx108
Witter S, Wurie H, Chandiwana P, et al. How do health workers experience and cope with shocks? Learning from four fragile and conflict-affected health systems in Uganda, Sierra Leone, Zimbabwe and Cambodia. Health Policy Plan. 2017;32(suppl 3):iii3-iii13. doi:10.1093/heapol/czx112
Global Health Risk Framework: Resilient and Sustainable Health Systems to Respond to Global Infectious Disease Outbreaks. Washington, DC: the national academies press; 2016. doi:10.17226/21856
Olmen JV, Criel B, Bhojani U, et al. The Health System Dynamics Framework: The introduction of an analytical model for health system analysis and its application to two case-studies. Health Cult Soc. 2012;2(1):1-21. doi:10.5195/HCS.2012.71
WHO Adapts Ebola Vaccination Strategy in the Democratic Republic of the Congo to Account for Insecurity and Community Feedback.  Published 2019. Accessed May 22, 2019.
Tomson G, Vlad I. The need to look at antibiotic resistance from a health systems perspective. Ups J Med Sci. 2014;119(2):117-124. doi:10.3109/03009734.2014.902879
Haldane V, Ong S-E, Chuah FL-H, Legido-Quigley H. Health systems resilience: meaningful construct or catchphrase? Lancet. 2017;389(10078):1513 doi:10.1016/S0140-6736(17)30946-7.
Martineau FP. People-centred health systems: building more resilient health systems in the wake of the Ebola crisis. Int Health. 2016;8(5):307-309. doi:10.1093/inthealth/ihw029
Pendall R, Foster KA, Cowell M. Resilience and regions: building understanding of the metaphor. Camb J Reg Econ Soc. 2010;3(1):71-84. doi:10.1093/cjres/rsp028
Lama PD, Becker P, Bergström J. Scrutinizing the relationship between adaptation and resilience: Longitudinal comparative case studies across shocks in two Nepalese villages. Int J Disaster Risk Reduct. 2017;23:193-203. doi:10.1016/j.ijdrr.2017.04.010
Hudson CG, Vissing YM. Sustainability at the edge of chaos: its limits and possibilities in public health. BioMed Res Int. 2013;2013:801614. doi:10.1155/2013/801614
Sharachchandra ML. Sustainable development: a critical review. World Dev. 1991;19(6):607-621.
Du Pisani JA. Sustainable development – historical roots of the concept. Environ Sci. 2006;3(2):83-96. doi:10.1080/15693430600688831
About the Sustainable Development Goals. Sustainable Development Goals.