Note: This abstract has been summarized to meet the portal submission requirements while preserving the study’s key messages;
Background: Despite substantial evidence on how health systems respond to crises, practical approaches for measuring and strengthening health system resilience remain limited. In fragile contexts, health systems face increased risk exposure alongside constrained capacities of states and communities to respond. These vulnerabilities disrupt health service delivery for an estimated 2.1 billion people. In the absence of standardized measures of resilience, governments, Ministries of Health, and their partners have limited capacity to identify gaps, target investments, monitor progress, and evaluate the effectiveness of resilience-building interventions over time. Closing this gap requires creating resilience standards and a tool to operationalize them.
Research Design: Grounded in critical realism and systems thinking, this three-phase study applied systems thinking to operationalize health system resilience. Phase I identified gaps in existing measures through a scoping review. Phase II developed a resilience appraisal framework using Logic Models, Theories of Change, and Best-Fit Framework Synthesis, followed by a Causal Loop Diagram; Phase III translated the framework into a measurement tool using implementation science and the Balanced Scorecard approach, then applied it in Sudan to measure the resilience of the national health system as of December 2022 and December 2024.
Key Findings: The thesis moved from identifying a measurement gap to testing a tool to measure and monitor health system resilience. The scoping review identified 466 indicators across 18 studies, but only 61 (13%) were relevant to resilience, feasible to measure, and comparable across contexts. Most existing measures focused on inputs and outputs rather than on the capacities that allow systems to absorb, adapt, and transform. A subsequent synthesis of 918 indicators from 23 documents informed the Resilient Health Systems Appraisal Model (ReHSAM), comprising 17 domains, 45 subdomains, and 69 resilience standards. Using implementation science and the Balanced Scorecard, each standard was translated into an indicator with four resilience levels, applicable across national, subnational, and local levels. ReHSAM is not organized by shock type. Instead, it measures capacities and functions relevant across different types of shocks. Political economy, fiscal constraints, donor dependency, reform history, conflict dynamics, and epidemiological conditions are considered in interpretation and reporting, rather than scored as separate components in the tool. The causal loop diagram identified leverage points where targeted investment could benefit several building blocks. Application in Sudan during active conflict showed declining resilience between December 2022 and December 2024, although some capacities were maintained or improved. Further testing is ongoing in Ghana, with future research focused on validation, predictive validity, and routine decision-making.
