Introduction : Fragile contexts are characterized by multiple simultaneous shocks combined with limited resources and inadequate institutional capacity to manage and respond effectively. These contexts account for 25% of the world population and are home to 72% of those living in extreme poverty, making resilient health systems essential to respond to the health needs of more than 2 billion people. This study aimed to develop a framework for the appraisal of health system resilience and subsequently inform the design of resilience building activities in fragile contexts.

Method : The study applied a Best Fit Framework Synthesis (BFFS) approach to adapt WHO health system building blocks framework for appraising resilience in fragile contexts. A two-stage synthesis was undertaken: a scoping review identified how health system performance and resilience have been assessed and measured in fragile, low-income contexts, and a desk review examined normative guidance and operational tools from global health agencies. An iterative, mixed deductive–inductive process was used to refine the framework and generate resilience domains, subdomains, and standards.

Results : The framework, the Resilient Health Systems Appraisal Model (ReHSAM), was developed through the identification and analysis of 918 indicators from peer-reviewed and normative sources. It comprises 17 domains, 45 subdomains, and 69 standards. Of the 69 resilience standards, 15 are newly introduced, meaning they were not articulated in existing frameworks and tools, and 30 are essential but under-studied. ReHSAM standards focus on the operational capacities that underpin health system resilience and guide context-specific, dynamic actions across the different administrative levels. ReHSAM articulated 69 attainable actions within each building block, bridging the gap between conceptual and operational aspects of health system resilience. ReHSAM provides a whole-of-system appraisal tool applicable across fragile and stable settings.

Conclusions : This study introduces the Resilient Health Systems Appraisal Model (ReHSAM), a whole-of-system approach for appraising health-system resilience. ReHSAM enables comprehensive assessment, cross-context comparison, and integration of resilience-building actions into health system operations. By translating resilience into universal yet context-adaptable standards, it provides a practical basis for bolstering health system resilience in both fragile and stable settings.