From inherent capacities to resilient systems: a multi-dimensional framework for assessing health system resilience

BACKGROUND: The concept of health system resilience has gained increasing importance as countries seek to improve their preparedness for unexpected events, ensuring both effective response and the continuity of essential health services. However, assessing resilience remains challenging due to the complex and interconnected nature of health systems. This study proposes a Health System Resilience Assessment Framework (HSRAF) to conceptualize and evaluate resilience through a systems-thinking approach. The framework is structured around the system’s inherent capacities, which constitute the foundational resources, structures, and characteristics that enable normal functioning and, when challenged, trigger the activation of adaptive capacities. Inherent capacities refer to the conditions that support regular Service Delivery, whereas adaptive capacities enable the system to reorganize and maintain essential functions during crises. The framework incorporates nine key indicators: Human Resources, Physical Resources, Medical Products, Information, Financing, Service Delivery, Health Status, Health Risks and Governance. To examine the interconnections among these indicators, Key Informant Interviews (KIIs) were conducted. The Decision-Making Trial and Evaluation Laboratory (DEMATEL) method was applied to identify causal relationships and influence levels among indicators. RESULTS: The DEMATEL analysis revealed that Service Delivery (0.128) is the most critical indicator for health system resilience, followed by Financing (0.124), Governance (0.116), Health Status (0.110), Human Resources (0.108), Information (0.106), Health Risks (0.104), Physical Resources (0.102), and Medical Products (0.100). The results also identified Governance, Financing, and Information as the most influential dimensions on health systems resilience. CONCLUSION: The findings highlight the pivotal role of Service Delivery, Financing, and Governance in strengthening health system resilience. The DEMATEL-based framework captures both the relative weights and directional influences among indicators. This provides policy makers with an analytical tool to explore alternative scenarios and enhance the preparedness, response, and recovery capacities of health systems.