The COVID-19 System Shock Framework: Capturing Health System Innovation During the COVID-19 Pandemic

Document Type : Original Article


1 University of New South Wales, Sydney, NSW, Australia

2 Sydney Children’s Hospitals Network, Sydney, NSW, Australia

3 Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia

4 Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK

5 Institute for Women and Children’s Health, King’s College London, London, UK

6 Integrated Care Project, Sydney Children’s Hospitals Network, Sydney, NSW, Australia


Coronavirus disease 2019 (COVID-19) has resulted in over 2 million deaths globally. The experience in Australia presents an opportunity to study contrasting responses to the COVID-19 health system shock. We adapted the Hanefeld et al framework for health systems shocks to create the COVID-19 System Shock Framework (CSSF). This framework enabled us to assess innovations and changes created through COVID-19 at the Sydney Children’s Hospitals Network (SCHN), the largest provider of children’s health services in the Southern hemisphere.

We used ethnographic methods, guided by the CSSF, to map innovations and initiatives implemented across SCHN during the pandemic. An embedded field researcher shadowed members of the emergency operations centre (EOC) for nine months. We also reviewed clinic and policy documents pertinent to SCHN’s response to COVID-19 and conducted interviews and focus groups with stakeholders, including clinical directors, project managers, frontline clinicians, and other personnel involved in implementing innovations across SCHN.

The CSSF captured SCHN’s complex response to the pandemic. Responses included a COVID-19 assessment clinic, inpatient and infectious disease management services, redeploying and managing a workforce working from home, cohesive communication initiatives, and remote delivery of care, all enabled by a dedicated COVID-19 fund. The health system values that shaped SCHN’s response to the pandemic included principles of equity of healthcare delivery, holistic and integrated models of care, and supporting workforce wellbeing. SCHN’s resilience was enabled by innovation fostered through a non-hierarchical governance structure and responsiveness to emerging challenges balanced with a singular vision.

Using the CSSF, we found that SCHN’s ability to innovate was key to ensuring its resilience during the pandemic.



Commentaries Published on this Paper


  •  Health System Shock Frameworks Between Theory, Application, and Assessment; Comment on “The COVID-19 System Shock Framework: Capturing Health System Innovation During the COVID-19 Pandemic”

        Abstract | PDF


  •  Health System Resilience as the Basis for Explanation Versus Evaluation; Comment on “The COVID-19 System Shock Framework: Capturing Health System Innovation During the COVID-19 Pandemic”

        Abstract | PDF


  • The Fentanyl System Shock – Are There Lessons to Learn From the COVID-19 System Shock Framework?; Comment on “The COVID-19 System Shock Framework: Capturing Health System Innovation During the COVID-19 Pandemic”

        Abstract | PDF



Main Subjects

  1. Australian Government Department of Health. Coronavirus (COVID-19) current situation and case numbers. Accessed April 26, 2020.
  2. Australia: Coronavirus Pandemic Country Profile. Global Change Data Lab; 2020. Accessed November 23, 2020.
  3. McAnulty JM, Ward K. Suppressing the epidemic in New South Wales. N Engl J Med. 2020;382(21):e74. doi:1056/NEJMc2011592
  4. Tartaglia R, La Regina M, Tanzini M, et al. International survey of COVID-19 management strategies. Int J Qual Health Care. 2021;33(1). doi:1093/intqhc/mzaa139
  5. Mann DM, Chen J, Chunara R, Testa PA, Nov O. COVID-19 transforms health care through telemedicine: Evidence from the field. J Am Med Inform Assoc. 2020;27(7):1132-1135. doi:1093/jamia/ocaa072
  6. Ripp J, Peccoralo L, Charney D. Attending to the emotional well-being of the health care workforce in a New York City health system during the COVID-19 pandemic. Acad Med. 2020;95(8):1136-1139. doi:1097/acm.0000000000003414
  7. Diez Roux AV. Population health in the time of COVID-19: confirmations and revelations. Milbank Q. 2020;98(3):629-640. doi:1111/1468-0009.12474
  8. Hollnagel E, Braithwaite J, Wears RL. Delivering Resilient Health Care. Routledge; 2018.
  9. Hollnagel E, Braithwaite J. Resilient Health Care. CRC Press; 2019.
  10. Wears RL, Hollnagel E, Braithwaite J. Resilient Health Care, Volume 2: The Resilience of Everyday Clinical Work. Ashgate Publishing Ltd; 2015.
  11. Braithwaite J, Wears RL, Hollnagel E. Resilient Health Care, Volume 3: Reconciling Work-as-Imagined and Work-as-Done. CRC Press; 2016.
  12. Braithwaite J, Hollnagel E, Hunte GS. Working Across Boundaries: Resilient Health Care, Volume 5. CRC Press; 2019.
  13. 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:1093/heapol/czx183
  14. Hollnagel E, Woods DD, Leveson N. Resilience Engineering: Concepts and Precepts. Ashgate Publishing Ltd; 2006.
  15. Elmqvist T, Folke C, Nyström M, et al. Response diversity, ecosystem change, and resilience. Front Ecol Environ. 2003;1(9):488-494. doi:1890/1540-9295(2003)001[0488:rdecar];2
  16. Walker B, Holling CS, Carpenter SR, Kinzig A. Resilience, adaptability and transformability in social–ecological systems. Ecol Soc. 2004;9(2):5. doi:5751/es-00650-090205
  17. Blanchet K. Thinking shift on health systems: from blueprint health programmes towards resilience of health systems comment on "constraints to applying systems thinking concepts in health systems: a regional perspective from surveying stakeholders in Eastern Mediterranean countries". Int J Health Policy Manag. 2015;4(5):307-309. doi:15171/ijhpm.2015.49
  18. Sydney Children’s Hospitals Network. 2019 Annual review: Working Together for Children. Sydney Children’s Hospitals Network; 2019.
  19. Nichols T. The Death of Expertise: The Campaign Against Established Knowledge and Why it Matters. Oxford: Oxford University Press; 2017.
  20. Churruca K, Ludlow K, Taylor N, Long JC, Best S, Braithwaite J. The time has come: embedded implementation research for health care improvement. J Eval Clin Pract. 2019;25(3):373-380. doi:1111/jep.13100
  21. Hodgins MJ. An introduction and overview of research and knowledge translation practices in a pan-Canadian art-based health research study. J Appl Arts Health. 2017;8(2):225-239. doi:1386/jaah.8.2.225_1
  22. Dadich A, Collier A, Hodgins M. Navigating and understanding organisational complexity in health services: the value of POSH-VRE. J Manag Organ. 2020;26(3):375-390. doi:1017/jmo.2019.82
  23. Braithwaite J, Plumb J. Exposing hidden aspects of resilience and brittleness in everyday clinical practice using network theories. In: Resilient Health Care, Volume 2: The Resilience of Everyday Clinical Work. Ashgate; 2015:115-127.
  24. Fusch PI, Ness LR. Are we there yet? data saturation in qualitative research. Qual Rep. 2015;20(9):1408-1416.
  25. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. doi:1191/1478088706qp063oa
  26. Yang Y, Li W, Zhang Q, Zhang L, Cheung T, Xiang YT. Mental health services for older adults in China during the COVID-19 outbreak. Lancet Psychiatry. 2020;7(4):e19. doi:1016/s2215-0366(20)30079-1
  27. Armocida B, Formenti B, Ussai S, Palestra F, Missoni E. The Italian health system and the COVID-19 challenge. Lancet Public Health. 2020;5(5):e253. doi:1016/s2468-2667(20)30074-8
  28. Kim H, Kim D, Paul C, Lee CK. The spatial allocation of hospitals with negative pressure isolation rooms in Korea: are we prepared for new outbreaks? Int J Health Policy Manag. 2020;9(11):475-483. doi:34172/ijhpm.2020.118
  29. Fauci AS. Ebola--underscoring the global disparities in health care resources. N Engl J Med. 2014;371(12):1084-1086. doi:1056/NEJMp1409494
  30. Gostin LO, Friedman EA. A retrospective and prospective analysis of the west African Ebola virus disease epidemic: robust national health systems at the foundation and an empowered WHO at the apex. Lancet. 2015;385(9980):1902-1909. doi:1016/s0140-6736(15)60644-4
  31. Nagesh S, Chakraborty S. Saving the frontline health workforce amidst the COVID-19 crisis: challenges and recommendations. J Glob Health. 2020;10(1):010345. doi:7189/jogh-10-010345
  32. Kruk ME. Emergency preparedness and public health systems lessons for developing countries. Am J Prev Med. 2008;34(6):529-534. doi:1016/j.amepre.2008.02.012
  33. Karanikolos M, Heino P, McKee M, Stuckler D, Legido-Quigley H. Effects of the global financial crisis on health in high-income OECD countries: A Narrative Review. Int J Health Serv. 2016;46(2):208-240. doi:1177/0020731416637160
  34. Legido-Quigley H, Otero L, la Parra D, Alvarez-Dardet C, Martin-Moreno JM, McKee M. Will austerity cuts dismantle the Spanish healthcare system? BMJ. 2013;346:f2363. doi:1136/bmj.f2363
  35. Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. Effects of the 2008 recession on health: a first look at European data. Lancet. 2011;378(9786):124-125. doi:1016/s0140-6736(11)61079-9
  36. Wolf LJ, Haddock G, Manstead ASR, Maio GR. The importance of (shared) human values for containing the COVID-19 pandemic. Br J Soc Psychol. 2020;59(3):618-627. doi:1111/bjso.12401
  37. Pfattheicher S, Nockur L, Böhm R, Sassenrath C, Petersen MB. The emotional path to action: empathy promotes physical distancing and wearing of face masks during the COVID-19 pandemic. Psychol Sci. 2020;31(11):1363-1373. doi:1177/0956797620964422
  38. Legido-Quigley H, Asgari N, Teo YY, et al. Are high-performing health systems resilient against the COVID-19 epidemic? Lancet. 2020;395(10227):848-850. doi:1016/s0140-6736(20)30551-1
  39. Liu Q, Luo D, Haase JE, et al. The experiences of health-care providers during the COVID-19 crisis in China: a qualitative study. Lancet Glob Health. 2020;8(6):e790-e798. doi:1016/s2214-109x(20)30204-7
  40. van Olmen J, Marchal B, Van Damme W, Kegels G, Hill PS. Health systems frameworks in their political context: framing divergent agendas. BMC Public Health. 2012;12:774. doi:1186/1471-2458-12-774
  41. Barbazza E, Tello JE. A review of health governance: definitions, dimensions and tools to govern. Health Policy. 2014;116(1):1-11. doi:1016/j.healthpol.2014.01.007
  42. Abimbola S, Negin J, Jan S, Martiniuk A. Towards people-centred health systems: a multi-level framework for analysing primary health care governance in low- and middle-income countries. Health Policy Plan. 2014;29(Suppl 2):ii29-39. doi:1093/heapol/czu069
  43. Bigiani L, Bigiani S, Bigiani A. How to minimize the impact of pandemic events: lessons from the COVID-19 crisis. Int J Health Policy Manag. 2020;9(11):469-474. doi:34172/ijhpm.2020.115
  44. Topp SM. Power and politics: the case for linking resilience to health system governance. BMJ Glob Health. 2020;5(6):e002891. doi:1136/bmjgh-2020-002891
  45. 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:15171/ijhpm.2017.36
  46. Saulnier DD, Hean H, Thol D, et al. Staying afloat: community perspectives on health system resilience in the management of pregnancy and childbirth care during floods in Cambodia. BMJ Glob Health. 2020;5(4):e002272. doi:1136/bmjgh-2019-002272
  47. 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:1136/bmjgh-2018-000758
  48. Blecher GE, Blashki GA, Judkins S. Crisis as opportunity: how COVID-19 can reshape the Australian health system. Med J Aust. 2020;213(5):196-198.e1. doi:5694/mja2.50730
  49. Chamberland-Rowe C, Chiocchio F, Bourgeault IL. Harnessing instability as an opportunity for health system strengthening: a review of health system resilience. Healthc Manage Forum. 2019;32(3):128-135. doi:1177/0840470419830105
  50. Lee BY, Wedlock PT, Mitgang EA, et al. How coping can hide larger systems problems: the routine immunisation supply chain in Bihar, India. BMJ Glob Health. 2019;4(5):e001609. doi:1136/bmjgh-2019-001609
Volume 11, Issue 10
October 2022
Pages 2155-2165
  • Receive Date: 01 April 2021
  • Revise Date: 14 August 2021
  • Accept Date: 07 September 2021
  • First Publish Date: 08 September 2021