Enhancing the Understanding of Resilience in Health Systems of Low- and Middle-income Countries: A Qualitative Evidence Synthesis

Document Type : Review Article


1 Swiss Tropical and Public Health Institute, Basel, Switzerland

2 University of Basel, Basel, Switzerland

3 Social Science Research Unit, University College London, London, UK

4 Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa

5 Department of Medical Research, Ministry of Health and Sports, Yangon, Myanmar


A country’s health system faces pressure when hit by an unexpected shock, such as what we observe in the midst of the coronavirus disease 2019 (COVID-19) pandemic. The concept of resilience is highly relevant in this context and is a prerequisite for a health system capable of withstanding future shocks. By exploring how the key dimensions of the resilient health system framework are applied, the present systematic review synthesizes the vital features of resilient health systems in low- and middle-income countries. The aim of this review is to ascertain the relevance of health system resilience in the context of a major shock, through better understanding its dimensions, uses and implications.
The review uses the best-fit framework synthesis approach. An a priori conceptual framework was selected and a coding framework created. A systematic search identified 4284 unique citations from electronic databases and reports by non-governmental organisations, 12 of which met the inclusion criteria. Data were extracted and coded against the pre-existing themes. Themes outside of the a priori framework were collated to form a refined list of themes. Then, all twelve studies were revisited using the new list of themes in the context of each study.
Ten themes were generated from the analysis. Five confirmed the a priori conceptual framework that capture the dynamic attributes of a resilient system. Five new themes were identified as foundational for achieving resilience: realigned relationships, foresight and motivation as drivers, and emergency preparedness and change management as organisational mechanisms.
The refined conceptual model shows how the themes inter-connect. The foundations of resilience appear to be critical especially in resource-constrained settings to unlock the dynamic attributes of resilience. This review prompts countries to consider building the foundations of resilience described here as a priority to better prepare for future shocks.


  1. World Health Organization (WHO). Statement on the 1st meeting of the IHR Emergency Committee on the 2014 Ebola outbreak in West Africa. WHO; 2014.
  2. World Health Organization (WHO). Ebola Virus Disease Democratic Republic of Congo: External Situation Report 48. WHO; 2019.
  3. Hollnagel E, Woods DD, Leveson N. Resilience Engineering: Concepts and Precepts. Ashgate Publishing Ltd; 2007:410.
  4. Bodin P, Wiman B. Resilience and other stability concepts in ecology: notes on their origin, validity, and usefulness. ESS Bulletin. 2004;2(2):33-43.
  5. Folke C. Resilience: the emergence of a perspective for social–ecological systems analyses. Glob Environ Change. 2006;16(3):253-267. doi:10.1016/j.gloenvcha.2006.04.002
  6. 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
  7. Luthar SS. Resilience in development: a synthesis of research across five decades. In: Cicchetti D, Cohen DJ, eds. Developmental Psychopathology: Risk, Disorder, and Adaptation. John Wiley & Sons; 2006:739-795.
  8. Fleming J, Ledogar RJ. Resilience, an evolving concept: a review of literature relevant to Aboriginal research. Pimatisiwin. 2008;6(2):7-23.
  9. Obrist B, Iteba N, Lengeler C, et al. Access to health care in contexts of livelihood insecurity: a framework for analysis and action. PLoS Med. 2007;4(10):1584-1588. doi:10.1371/journal.pmed.0040308
  10. 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
  11. Kruk ME, Ling EJ, Bitton A, et al. Building resilient health systems: a proposal for a resilience index. BMJ. 2017;357:j2323. doi:10.1136/bmj.j2323
  12. 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
  13. Blanchet K, Nam SL, Ramalingam B, Pozo-Martin F. Governance and capacity to manage resilience of health systems: towards a new conceptual framework. Int J Health Policy Manag. 2017;6(8):431-435. doi:10.15171/ijhpm.2017.36
  14. Biddle L, Wahedi K, Bozorgmehr K. Health system resilience: a literature review of empirical research. Health Policy Plan. 2020;35(8):1084-1109. doi:10.1093/heapol/czaa032
  15. 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
  16. Kutzin J, Sparkes SP. Health systems strengthening, universal health coverage, health security and resilience. Bull World Health Organ. 2016;94(1):2. doi:10.2471/blt.15.165050
  17. 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
  18. Kluge H, Martín-Moreno JM, Emiroglu N, et al. Strengthening global health security by embedding the International Health Regulations requirements into national health systems. BMJ Glob Health. 2018;3(Suppl 1):e000656. doi:10.1136/bmjgh-2017-000656
  19. Carroll C, Booth A, Leaviss J, Rick J. "Best fit" framework synthesis: refining the method. BMC Med Res Methodol. 2013;13:37. doi:10.1186/1471-2288-13-37
  20. 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
  21. Barker KM, Ling EJ, Fallah M, et al. Community engagement for health system resilience: evidence from Liberia’s Ebola epidemic. Health Policy Plan. 2020;35(4):416-423. doi:10.1093/heapol/czz174
  22. World Health Organization (WHO). Everybody's Business--Strengthening Health Systems to Improve Health Outcomes: WHO's Framework for Action. WHO; 2007.
  23. CASP Qualitative Checklist. Critical Appraisal Skills Programme; 2018.
  24. Achour N, Pascale F, Price ADF, et al. Learning lessons from the 2011 Van Earthquake to enhance healthcare surge capacity in Turkey. Environ Hazards. 2016;15(1):74-94. doi:10.1080/17477891.2016.1139539
  25. 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
  26. Curran KG, Wells E, Crowe SJ, et al. Systems, supplies, and staff: a mixed-methods study of health care workers' experiences and health facility preparedness during a large national cholera outbreak, Kenya 2015. BMC Public Health. 2018;18(1):723. doi:10.1186/s12889-018-5584-5
  27. Lin L, Ashkenazi I, Dorn BC, Savoia E. The public health system response to the 2008 Sichuan province earthquake: a literature review and interviews. Disasters. 2014;38(4):753-773. doi:10.1111/disa.12079
  28. Otu A, Ameh S, Osifo-Dawodu E, Alade E, Ekuri S, Idris J. An account of the Ebola virus disease outbreak in Nigeria: implications and lessons learnt. BMC Public Health. 2017;18(1):3. doi:10.1186/s12889-017-4535-x
  29. Purohit V, Kudale A, Sundaram N, Joseph S, Schaetti C, Weiss MG. Public health policy and experience of the 2009 H1N1 influenza pandemic in Pune, India. Int J Health Policy Manag. 2018;7(2):154-166. doi:10.15171/ijhpm.2017.54
  30. Thiam S, Delamou A, Camara S, et al. Challenges in controlling the Ebola outbreak in two prefectures in Guinea: why did communities continue to resist? Pan Afr Med J. 2015;22 Suppl 1:22. doi:10.11694/pamj.supp.2015.22.1.6626
  31. Alameddine M, Fouad FM, Diaconu K, et al. Resilience capacities of health systems: accommodating the needs of Palestinian refugees from Syria. Soc Sci Med. 2019;220:22-30. doi:10.1016/j.socscimed.2018.10.018
  32. Ager AK, Lembani M, Mohammed A, et al. Health service resilience in Yobe state, Nigeria in the context of the Boko Haram insurgency: a systems dynamics analysis using group model building. Confl Health. 2015;9:30. doi:10.1186/s13031-015-0056-3
  33. McPake B, Witter S, Ssali S, Wurie H, Namakula J, Ssengooba F. Ebola in the context of conflict affected states and health systems: case studies of Northern Uganda and Sierra Leone. Confl Health. 2015;9:23. doi:10.1186/s13031-015-0052-7
  34. Nyikuri M, Tsofa B, Barasa E, Okoth P, Molyneux S. Crises and resilience at the frontline-public health facility managers under devolution in a Sub-County on the Kenyan Coast. PLoS One. 2015;10(12):e0144768. doi:10.1371/journal.pone.0144768
  35. Farley JM, Suraweera I, Perera W, Hess J, Ebi KL. Evaluation of flood preparedness in government healthcare facilities in Eastern province, Sri Lanka. Glob Health Action. 2017;10(1):1331539. doi:10.1080/16549716.2017.1331539
  36. Purohit V, Kudale A, Sundaram N, Joseph S, Schaetti C, Weiss MG. Public health policy and experience of the 2009 H1N1 influenza pandemic in Pune, India. Int J Health Policy Manag. 2018;7(2):154-166. doi:10.15171/ijhpm.2017.54
  37. Topp SM. Power and politics: the case for linking resilience to health system governance. BMJ Glob Health. 2020;5(6):e002891. doi:10.1136/bmjgh-2020-002891
  38. Witter S, Palmer N, Balabanova D, et al. Health system strengthening-reflections on its meaning, assessment, and our state of knowledge. Int J Health Plann Manage. 2019;34(4):e1980-e1989. doi:10.1002/hpm.2882
  39. Fridell M, Edwin S, von Schreeb J, Saulnier DD. Health system resilience: what are we talking about? a scoping review mapping characteristics and keywords. Int J Health Policy Manag. 2020;9(1):6-16. doi:10.15171/ijhpm.2019.71
  40. 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
  41. Arnold RD, Wade JP. A definition of systems thinking: a systems approach. Procedia Comput Sci. 2015;44(2015):669-678.
  42. Pronovost PJ, Mathews SC, Chute CG, Rosen A. Creating a purpose-driven learning and improving health system: the Johns Hopkins Medicine quality and safety experience. Learn Health Syst. 2017;1(1):e10018. doi:10.1002/lrh2.10018
  43. 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
  44. 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
Volume 11, Issue 7
July 2022
Pages 899-911
  • Receive Date: 27 May 2020
  • Revise Date: 15 December 2020
  • Accept Date: 19 December 2020
  • First Publish Date: 16 January 2021