health system resilience a literature review of empirical research

Health system resilience: a literature review of empirical research

Affiliations.

• 1 Social Determinants, Equity and Migration Working Group, Department of General Practice & Health Services Research, University Hospital Heidelberg, Marsilius Arkaden, Turm West, Heidelberg 69120, Germany.
• 2 Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, 33501 Bielefeld, Germany.
• PMID: 32529253
• PMCID: PMC7553761
• DOI: 10.1093/heapol/czaa032

The concept of health system resilience has gained popularity in the global health discourse, featuring in UN policies, academic articles and conferences. While substantial effort has gone into the conceptualization of health system resilience, there has been no review of how the concept has been operationalized in empirical studies. We conducted an empirical review in three databases using systematic methods. Findings were synthesized using descriptive quantitative analysis and by mapping aims, findings, underlying concepts and measurement approaches according to the resilience definition by Blanchet et al. We identified 71 empirical studies on health system resilience from 2008 to 2019, with an increase in literature in recent years (62% of studies published since 2017). Most studies addressed a specific crisis or challenge (82%), most notably infectious disease outbreaks (20%), natural disasters (15%) and climate change (11%). A large proportion of studies focused on service delivery (48%), while other health system building blocks were side-lined. The studies differed in terms of their disciplinary tradition and conceptual background, which was reflected in the variety of concepts and measurement approaches used. Despite extensive theoretical work on the domains which constitute health system resilience, we found that most of the empirical literature only addressed particular aspects related to absorptive and adaptive capacities, with legitimacy of institutions and transformative resilience seldom addressed. Qualitative and mixed methods research captured a broader range of resilience domains than quantitative research. The review shows that the way in which resilience is currently applied in the empirical literature does not match its theoretical foundations. In order to do justice to the complexities of the resilience concept, knowledge from both quantitative and qualitative research traditions should be integrated in a comprehensive assessment framework. Only then will the theoretical 'resilience idea' be able to prove its usefulness for the research community.

Keywords: Health system resilience; health system research; resilience; responsiveness.

© The Author(s) 2020. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.

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• Volume 6, Issue 8
• A health systems resilience research agenda: moving from concept to practice
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• http://orcid.org/0000-0001-7761-0737 Dell D Saulnier 1 ,
• http://orcid.org/0000-0003-0498-8020 Karl Blanchet 2 ,
• Carmelita Canila 3 ,
• Daniel Cobos Muñoz 4 , 5 ,
• Livia Dal Zennaro 6 ,
• Don de Savigny 4 , 5 ,
• http://orcid.org/0000-0003-1456-626X Kara N Durski 7 , 8 ,
• Fernando Garcia 3 ,
• Pauline Yongeun Grimm 4 ,
• Aku Kwamie 9 ,
• Daniel Maceira 10 , 11 ,
• http://orcid.org/0000-0002-2416-2309 Robert Marten 6 ,
• Isabelle Peytremann-Bridevaux 12 ,
• Camille Poroes 12 ,
• http://orcid.org/0000-0001-9299-8266 Valery Ridde 13 ,
• Laurence Seematter 12 ,
• Barbara Stern 11 ,
• Patricia Suarez 11 ,
• Gina Teddy 14 ,
• http://orcid.org/0000-0002-1751-1961 Didier Wernli 15 ,
• Kaspar Wyss 4 , 5 ,
• http://orcid.org/0000-0001-8671-9400 Fabrizio Tediosi 4 , 5
• 1 Department of Global Public Health , Karolinska Institute , Stockholm , Sweden
• 2 Geneva Centre of Humanitarian Studies , Faculty of Medicine, University of Geneva and Graduate Institute of International and Development Studies , Geneva , Switzerland
• 3 Department of Health Policy and Administration , University of the Philippines Manila , Manila , Philippines
• 4 Swiss Tropical and Public Health Institute , Basel , Switzerland
• 5 University of Basel , Basel , Switzerland
• 6 Alliance for Health Policy and Systems Research , World Health Organization , Geneva , Switzerland
• 7 World Health Organization , Geneva , Switzerland
• 8 Center for Emerging Infectious Diseases Policy and Research , Boston University , Boston , Massachusetts , USA
• 9 Alliance For Health Policy and System Research , Geneva , Switzerland
• 10 Department of Economics , University of Buenos Aires , Buenos Aires , Argentina
• 11 Center for the Study of State and Society (CEDES) , Buenos Aires , Argentina
• 12 Unisanté, Center for Primary Care and Public Health , University of Lausanne , Lausanne , Switzerland
• 13 CEPED, Institute for Research on Sustainable Development , IRD-Université de Paris, ERL INSERM SAGESUD , Paris , France
• 14 Centre for Health Systems and Policy Research , Ghana Institute of Management and Public Administration , Accra , Ghana
• 15 Global Studies Institute , University of Geneva , Geneva , Switzerland
• Correspondence to Dr Fabrizio Tediosi; fabrizio.tediosi{at}unibas.ch

Health system resilience, known as the ability for health systems to absorb, adapt or transform to maintain essential functions when stressed or shocked, has quickly gained popularity following shocks like COVID-19. The concept is relatively new in health policy and systems research and the existing research remains mostly theoretical. Research to date has viewed resilience as an outcome that can be measured through performance outcomes, as an ability of complex adaptive systems that is derived from dynamic behaviour and interactions, or as both. However, there is little congruence on the theory and the existing frameworks have not been widely used, which as diluted the research applications for health system resilience. A global group of health system researchers were convened in March 2021 to discuss and identify priorities for health system resilience research and implementation based on lessons from COVID-19 and other health emergencies. Five research priority areas were identified: (1) measuring and managing systems dynamic performance, (2) the linkages between societal resilience and health system resilience, (3) the effect of governance on the capacity for resilience, (4) creating legitimacy and (5) the influence of the private sector on health system resilience. A key to filling these research gaps will be longitudinal and comparative case studies that use cocreation and coproduction approaches that go beyond researchers to include policy-makers, practitioners and the public.

• health systems
• health policy
• health policies and all other topics

Data availability statement

Data sharing is not applicable as no data was generated or analysed for this manuscript.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjgh-2021-006779

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Summary box

Improving resilience could help health system responses to shocks like COVID-19, but the research has so far remained primarily theoretical. In order to develop and implement strategies to strengthen systems, we need to conduct applied research towards a cohesive set of goals.

Resilience can be critiqued for its potential for political misuse, returning to vulnerability and putting burden to cope with shocks back on the community. If these issues are correctly addressed during research and interpretation of findings, resilience can be an innovative way to look at and strengthen health systems during the pandemic and future shocks and stresses.

To identify where to invest future research time and resources for the greatest payoff, we established five priority areas for health system resilience research from discussion with global experts: (1) measuring and managing dynamic performance, (2) linking societal and health system resilience, (3) governing for resilience, (4) legitimacy and (5) the influence of private and voluntary sectors on resilience.

A key to filling these research gaps will be longitudinal and comparative case studies that use cocreation and coproduction approaches that go beyond researchers to include policy-makers, practitioners and the public.

Introduction

In the last decade, resilience has emerged as a key concept for health systems in global health. 1 Building on work from other disciplines, health systems resilience is generally understood as the capacity of a system to absorb, adapt or transform in order to maintain essential functions when faced with shocks and stresses. 2–4 The COVID-19 pandemic and ongoing conflicts have only heightened recognition of the importance of resilience, by profoundly challenging health systems worldwide to cope with and adapt to new circumstances. 5 Resilience has ushered in a new perspective on how health systems can adjust to shocks and maintain essential services. Yet to date, research and discussions around health systems resilience have focused on theory and principles; the concept is still nascent in health policy and system research. 6 Although research methodologies are recognised, applied research on how resilience is created or strengthened in health systems—a crucial step to developing strategies to promote resilience—remains limited. 7 As we have seen with COVID-19, strong debates continue around the most effective, equitable and efficient way for health systems to be prepared for and respond to such a public health shock, from testing strategies, vaccination approaches, to regulation of medical products and devices, to restructuring health service delivery, to the depth and breadth of lockdown measures. While health system responses to COVID-19 must be relevant to their specific context, the pandemic has made it clear that health system stakeholders are searching for and trying to adopt informed strategies, ideas and plans that can guide their decision making. How do we move health systems resilience research from the concept to practice?

Resilience as an ability

The jump from conceptual to research with operational implications requires considering different starting points of health systems resilience and the critiques of resilience. The complexity of conceptual differences has been well covered, 6 but a fundamental distinction remains: is resilience viewed as an outcome, an ability or both? Biddle et al 8 found that research that views resilience as an outcome is predominantly quantitative, working under the assumption that resilience can be measured and indexed, and that measuring variation in such outcomes will identify inputs that can improve the system. 8 In complement, Topp 9 notes that one implication of expressing resilience capability as an outcome is that resilience is seen as ‘an uncomplicated, even monolithic ‘good’: a goal synonymous with optimised performance’. 9 If resilience is only seen as a performance objective and absorptive, adaptive and transformative change are seen as inherently positive, we are prone to overlook the broader economic, historical, sociocultural and political contextual realities within which health systems are embedded. It risks enacting—or declining to enact—change as its own goal, without greater consideration of whether equity, effectiveness, efficiency and sustainability will follow. 10 11 Resilience requires the ability to adapt; change is partial to the underlying objectives, values, and inequalities that exist in a health system and its context. Health systems resilience has already been criticised for ignoring issues of responsibility, politics and power. Reducing resilience to indicators only favours a ‘return to normality’, one which can sustain a state of vulnerability without addressing the underlying causes that created the vulnerability in the first place. 9 12 It can also fail to recognise the dynamics of health systems, the absorption, adaptation, and transformation constantly taking place within patient, management and clinical regulation and practice and other interlinked systems, pushing the responsibility to cope and adapt back solely onto populations, increasing their vulnerability. 13 14

Acknowledging a system’s local context, interconnectedness and circumstances requires reframing resilience as an ability as well. This second perspective is in line with the idea of health systems as complex adaptive systems constantly emerging, self-organising and adapting to change. 15 Considering health systems as complex adaptive systems is useful for understanding what gives systems the capacity to absorb, react, adapt or transform to different kinds of shocks, rather than what attributes the system has. 2 Health systems are shaped by the variety of interactions and decisions that various actors, such as patients, carers, community health workers, general public, healthcare professionals, managers, policy-makers and private companies, are able or willing to take, governed by implicit and explicit rules. 3 These interactions and rules hinge on the people, their mindsets, interests and agency, as well as the power structures within a health system’s context; resilience as an ability depends on these interdependent relationships. In addition, resilient people and communities are a foundation for resilient systems to function optimally. Resilience from this point of view enables consideration of how to strengthen health systems and deliver equitable, efficient, responsive and sustainable health services and outcomes for both everyday benefits and when faced with shocks such as the COVID-19 pandemic, climate crises and future, unforeseen emergencies. However, this perspective has so far primarily been the domain of qualitative methods, used to make sense of capacities, relationships between actors of the system and dynamics in a given context. 8 Describing resilience as both an outcome and an ability allows for resilient systems to be viewed with a broader scope and recognises the additional dynamics and complexities that need to be understood and researched.

A health systems resilience research agenda to promote action

We believe health systems resilience research has today reached a crucial point. The weak convergence on clear, comprehensive health system resilience definitions, plus limited operationalisation of the existing frameworks, has diluted research applications and inhibited the development of a common understanding. If these differences remain fractured without a clear common goal, we risk losing the momentum to follow the conceptual inroads with concrete applications. This echoes the case of systems thinking for health systems strengthening. Calls to move towards systems thinking approaches for health system interventions have only partly been followed by empirical research and concrete applications. 16 The crux of the issue is this: if we ultimately want to create more resilient health systems, where, when and how do we invest our research resources for the greatest impact?

In March 2021, we convened a global group of health system researchers to address this fundamental question and initiate a research agenda for health system resilience. Prior to meeting, the authors Saulnier et al conducted a scoping review and analysis of the health system resilience literature, with two focus points: (1) to assess our current understanding of resilience by examining published discussions and debates on resilience and COVID-19 and (2) to summarise the current state of methods used for empirical health systems research and gaps in application. 17 With that review as a starting point, we discussed as a group the following questions in the workshop: Using what we have learnt from COVID-19 and other health emergencies, what are the priorities for health system resilience research? How should research on health systems resilience be implemented?

Based on the workshop discussions and the diverse experiences of the participants, we propose a research agenda for health system resilience that embraces complexity and recognises the embedding of health intrarelated systems in the broader sociocultural, economic and political environment. 18 Below, we offer five key research areas for health systems resilience and discuss approaches to implementing resilience research.

How should systems dynamic performance be managed and measured?

Resilience requires seeing health systems as complex adaptive systems fundamentally embedded within and linked to multiple other systems. Health systems both influence and are influenced by the global markets, ethics and values, political systems, and social protection systems, among others, all of which shape people’s health. COVID-19 is an illustrative example: the health system’s ability to manage health needs has had a clear impact on other systems (eg, labour, economy, the environment), while the ability of other systems to protect health has in turn altered the health system’s capacity to manage. Ignoring these interlinkages will lead to simplistic, short-term solutions that may be costly, ineffective or inappropriate when implemented across contexts, at differing levels, or in the wake of societal shifts like COVID-19. If we want to develop systems capable of continuous change and adaptation, we need to recognise and incorporate other systems and contexts as determinants of resilience.

To connect health system resilience to other systems, our measures of resilience need to move beyond health service delivery functions in response to shocks. Alternative measures of multi-system performance for health during crises, such as financial and health equity-related outcomes, should be explored. Assessing how the health system influences and is influenced by other sectors like travel and trade, food security, education, social protection can generate knowledge on ‘what works’ in a given context. If we can identify measures of resilience that address dynamism (eg, change in social networks, fluidity of information circulation within the system), we can begin to distinguish cross-system resilience capacities. There is potential to learn by documenting local experiences to different risks and their effects on health and other systems, which can reduce traditional biases around contextual factors like managerial skills and power.

To what degree and in what ways does societal resilience support health system resilience? What are the key leverage points?

Health systems do not stop at formal systems; they include communities, families, lay workers and informal providers who manage their own health and provide care during shocks and stresses. They are valuable sources of resilience capacity, coping strategies, resources and knowledge. Considering individuals, communities and societies as key drivers of resilience—from community driven ideas to research to cocreated systems strengthening initiatives—has the potential to increase the system’s resilience capacity. The findings from the 2014 Ebola outbreak in West Africa are clear about the key role played by communities in responding to and containing the outbreak 19–22 ; despite this, the empirical research conducted since is scarce. Research needs to further investigate how individual and community resilience contributes to and potentially hinders health systems resilience to identify joint capacities, limits and solutions.

How does governance affect the capacity for resilience?

Resilience relies on the system’s ability to perform and to change when needed. Governance aims to drive the behaviour, priorities, interactions, participation, accountability and decisions of system actors; power influences the ways in which actors can participate in and contribute to governance. For instance, the most comprehensive surveillance system—necessary for preparedness, awareness of, and response to shocks—will only function if the people who make public health decisions collectively use it and respond to its warnings. While each shock or stress to a health system will be different, and each health system’s context is unique, understanding the details of cross-cutting areas of governance and power can lead to practical ideas for changing practice and influencing leadership.

Although governance has been repeatedly noted in resilience research, we need to better understand the nuances of governance and resilience. 23 This includes the influence of differing power, leadership dynamics and governance contexts (eg, highly bureaucratic, hierarchical, autocratic) on the system’s ability to absorb, adapt or transform. Resilience may improve governance capacity to react to unforeseen risks and to lead processes that require systemic response. As systems change, it is increasingly important to understand how the changes that do occur feed back into governance practices, as this will have implications for the system’s ability to continue absorbing, adapting and transforming.

How is legitimacy created?

Legitimate health systems are accepted through de facto and de jure processes and trusted by communities, who have the power to influence the system. 3 After COVID-19, health systems need to create consistent and institutionalised channels to incorporate the political and socioeconomic context. The power of competing actors and interests within the health system and between technical and political decision makers are all likely to affect legitimacy. With COVID-19, health system actors, politicians, other decision-makers and the general public are receiving an ever-changing flow of information and evidence as COVID-19 circumstances change. This unprecedented global awareness and general knowledge of COVID-19 has shaped political actions and population beliefs in health expertise, bringing the health system’s response to COVID-19 into sharp relief for communities. Community experiences with corruption and accountability and their perceptions of actors with power who are outside of the health system are also likely to influence trust in the health system. 24 25 Their trust in the system and actors can directly impact the system’s ability to respond to shocks. At present, mistrust is at the root of COVID-19 vaccine hesitancy, a barrier which will force health systems to adapt if countries are to reach herd immunity. The pandemic highlights the importance of clear communication to build and maintain trust in the population and the role of information and evidence in shaping legitimacy. Health systems will need to understand the internal and external mechanisms that generate legitimacy and will need to adapt to changing levels of trust if they are to effectively respond to shocks like COVID-19. For example, sound communication strategies could reinforce legitimacy and could constitute an important space for collaboration between public and private sectors and the community, while reinforcing systems thinking for resilience in social systems like health systems.

In what ways do the private and voluntary sectors influence health system resilience?

Existing health system resilience research has focused on the public sector, yet the private and voluntary sectors are likely to play vital roles in the system’s capacity for resilience and its preparedness and response to shocks and stresses. This requires understanding how the public, private and voluntary sectors of the health system interact during shocks, as well as the influence on resilience of the different governance structures between the public and private sector of the system, such as the need for increased coordination in highly segmented health systems. The private sector should not be limited to private for-profit providers and healthcare services but extended to corporate services and interventions for health. The COVID-19 pandemic has shown the far-reaching influence of broader structures like global markets on health system capacities, like the supply chain failures leading to personal protective equipment shortages. Future research should include not-for-profit and faith-based organisations, the biomedical industry, the supply chain and logistics, the tech industry, regional markets and other private sector actors, as they all are likely to help or hinder the health system’s capacity to overcome adaptive challenges and manage resilience.

Approaches to researching health systems resilience

Longitudinal studies, comparative case studies and forward-looking learning sites are essential to answering the questions above. We must consider innovative ways of approaching resilience research to understand how a health system can respond to a crisis and the processes and behaviour enabling change to happen. This entails also combining public health and social sciences research methods. Although difficult to measure, approaches will need to better include soft-issues like power, trust and social capital. Research will also need to explore how health systems have developed and changed over time if we are to understand the dynamics of health systems and explain the reasons for changes within the system. Understanding changes over time can illuminate the factors, processes and pathways that have led to a system’s capacity for resilience, show the short- and long-term consequences of change in the system, and further clarify the boundaries between absorptive, adaptive and transformative capacities.

It is time to reconsider how health system resilience research is produced. We acknowledge the difficulty in funding, conducting, and disseminating independent research on processes and systems over time. Still, we believe that a bottom-up, cocreation and coproduction approach to embedded research, associating researchers, policy-makers, politicians, practitioners and the public from various settings can advance health systems resilience research is key. 26 Research and researchers need to be closer to the health system’s response structures and closer to people in power, such as national, multilateral and bilateral funding bodies and policy-makers, while maintaining independence. 27 Coproduction approaches inherently create spaces for mutual knowledge exchange across researchers and policy-makers throughout the entire research process, starting at study design. In these ways, research can provide workable solutions to policy and practice questions that are most relevant and impactful. By using a more inclusive approach to how we develop and conduct research, we can begin to build the strategies and concrete findings that can support local and national health system practitioners, the ultimate end users of resilience research and help to develop resilience thinking capacity across regions.

The COVID-19 pandemic has been a stark reminder of the risks that health systems and populations face. It has shown the limitations of existing systems, such as the scale up of emergency health service systems, maintaining services for routine and chronic health needs, incorporating wide-scale diagnostic testing into health services, failing supply chain systems to source supplies like reagents for diagnostic tests, personal protective equipment and sanitiser and the roll-out of large-scale vaccination programmes. It has highlighted the importance of tying systems research and the complexity of the environment in which health systems operate with public health practice. 28 Developing research on resilience as a health system ability that is methodologically sound and policy relevant is crucial to strengthen health systems.

We believe a cohesive agenda and cocreated and coproduced approach to health system resilience research that builds on existing findings and bridges conceptual gaps, and associates researchers, policy-makers and practitioners from various settings, can advance health systems resilience research. This paper is a starting point for a more comprehensive agenda and action on cocreation and coproduction.

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Handling editor Seye Abimbola

Twitter @BlanchetKarl, @Daniel_Cobos_PH, @KaraDurski, @martenrobert, @ValeryRidde, @fabrizio2570

Contributors DDS, KB and FT designed and led the workshop and wrote the first draft of the manuscript. All authors contributed to the workshop and to revisions of the manuscript. All authors gave final approval of the manuscript.

Funding The work was supported by the initiative “Foster Inter-University Initiatives and Collaborations” of the Swiss School of Public Health https://ssphplus.ch/ .

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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• Published: 06 March 2024

Practical strategies to achieve resilient health systems: results from a scoping review

• David Bishai 1 ,
• Basma M. Saleh 2 ,
• Maryam Huda 3 ,
• Eman Mohammed Aly 2 ,
• Marwa Hafiz 2 ,
• Ali Ardalan 4 &
• Awad Mataria 4  

BMC Health Services Research volume  24 , Article number:  297 ( 2024 ) Cite this article

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This paper presents the results of a systematic review to identify practical strategies to create the institutions, skills, values, and norms that will improve health systems resilience.

A PRISMA 2020 compliant systematic review identified peer-reviewed and gray literature on practical strategies to make health systems more resilient. Investigators screened 970 papers to identify 65 English language papers published since 2015.

Practical strategies focus efforts on system changes to improve a health system’s resilience components of collective knowing, collective thinking, and collaborative doing. The most helpful studies identified potential lead organizations to serve as the stewards of resilience improvement, and these were commonly in national and local departments of public health. Papers on practical strategies suggested possible measurement tools to benchmark resilience components in efforts to focus on performance improvement and ways to sustain their use. Essential Public Health Function (EPHF) measurement and improvement tools are well-aligned to the resilience agenda. The field of health systems resilience lacks empirical trials linking resilience improvement interventions to outcomes.

Conclusions

The rigorous assessment of practical strategies to improve resilience based on cycles of measurement should be a high priority.

Peer Review reports

COVID-19 highlighted overconfidence in health system resilience [ 1 ]. Resilience includes efforts to learn from a crisis and transform the health system on an ongoing basis [ 2 ]. Several sources have converged to recommend that achieving resilience in health security requires better governance, leadership, financing, and equity [ 3 ].

WHO has outlined a vision placing primary health care as the foundation for dual goals of health security and universal health coverage [ 3 , 4 ]. WHO’s “resilience toolkit” has assembled close to 100 products to support efforts to build resilience [ 5 ]. It remains unclear how resilience tools can actually be applied and how to sustain the use of these tools. The resilience agenda needs an evidence base of well-defined actions. There is a window of attentiveness among citizens and leaders inside and outside the health sector adding urgency to what was already a strong rationale to accelerate the implementation of resilience strategies [ 6 ].

A recent systematic review of empirical work on resilience noted an imbalance between theoretical understanding of resilience and practical efforts to apply these concepts [ 7 ]. Many policy makers and health system leaders face obstacles in designing policies, programs, and budget allocations that increase resilience. The rationale for this systematic review is to examine current knowledge about how to put the concept of resilience into practice in health systems.

Health systems are complex collections of agents and units governed by institutions. They have variable success in adapting coherently towards an ultimate goal of better health. Sub-systems focus on canonical building blocks like financing, service delivery, supplies, etc. Health systems operate from micro, meso, to macro levels. Despite the sprawling landscape, the concept of resilience can be applied at all levels and in all subsystems. The resilience literature we review can be expected to come from practical efforts in various domains of the health system, and as long as it sheds light on how to implement resilience, it will be in scope.

This paper addresses the following question: How does an increase in health system resilience get put into practice? The objective is to gather answers to questions of who, what, where, when, why and how to improve resilience. The paper applies a systematic literature review about the implementation of resilience strategies to achieve health security in low- and middle-income countries.

Answers to “how to?” are circular and unhelpful if they end up using verbs like “strengthen”, “empower” or “invest in”. Planners and implementers need verbs like, “hire”, “purchase”, “legislate”, “measure”, “inform” and “meet with”. Meaningful contributions in the literature need to name who is to do what with whom, how, when, why, with a plan for accountability. We benefited from the Foroughi et al. (2022) framework to ask that resilience actions be classified according to their intermediate objectives, phases, and requirements [ 8 ].

Literature Review

A systematic literature review was conducted following PRISMA 2020 guidelines [ 9 ]. The search strategy was developed by starting with the term “resilience” and circumscribing it to the area of “health systems”. Because neither term is recognized by PubMed as a medical subject heading (MeSH), both terms were put in as field searches for title or abstract. Attempts to circumscribe this two-term search with other AND terms like “universal health coverage” or “health security” or “policy” became unacceptably restrictive. The final search terms used were: <(resilien*[Title/Abstract]) AND (“health syste*“[Title/Abstract])>. This search was confined to English language publications with publication dates after January 1, 2015. Literature databases included PubMed, Web of Science, and OAIster. The search was completed on October 25, 2022. Additionally, the project has examined the websites of relevant public health-related organizations (WHO Headquarters, WHO EMRO, Alliance for Health Policy and Systems Research, Health Systems Global, UNICEF, World Bank and CDC) in an attempt to identify articles and frameworks not indexed in the other databases.

The PubMed search produced 956 papers with 2 duplicates. Oaister and Web of Science contributed 1 paper each not identified by PubMed. Bibliographies in papers by Fridell (2020), Kuhlmannn (2021), WHO Toolkit (2022), and Alilio (2022), yielded an additional 16 citations that were not identified in the search databases [ 5 , 10 , 11 , 12 ].

Rapid title screening was conducted by a single investigator to reduce the list to 136 titles which then underwent a second round of title screening by three investigators who narrowed the list to 87. Title-based screening excluded papers because they described resilience concepts that were outside the aims of this research, (e.g., resilience properties of whole mechanical systems or resilience of single organizations that did not extend to the health system). For example, articles were excluded if the article described resilience in contexts outside of the health systems context (e.g., armed conflict situations). We included documents if they described attempts to implement health system resilience or link it to universal health coverage or health security.

The 87 that passed the title screening were then classified and further screened by a single investigator based on the abstract leading to an additional 22 exclusions. These abstract-based exclusions occurred when abstract review showed that they were editorials (e.g. introducing a special issue) or not about resilience, or not related to practical implementation of resilience. Finally, 65 papers were forwarded to the extraction stage. (See Fig.  1 PRISMA Diagram.)

PRISMA diagram

All articles deemed relevant after title and abstract review were then read in their entirety by at least two members of the study team. A database was maintained in DistillerSR™ for each article’s contribution to the four key questions of the project: (1) Defining practical aspects of resilience; (2) Links to health security and UHC; (3) Resilience in practice; (4) Implementation. Extracted data were reviewed for recurrent themes related to the main question of practical strategies that can improve resilience. Despite the effort to screen out editorials based on abstract review, upon examining the full documents, it emerged that 16 papers were opinion, commentary, and expert advice and flagged as such.

The research themes in the extracted summaries were coded inductively using codes that emerged from the extracted texts (See Table  1 ).

We found fourteen papers specifying resilience strategies in terms of “who does what”. Other common themes pointed out the overlap between everyday resilience and crisis resilience (nine papers) and laid out approaches to measure resilience as a way to improve the governance, workforce capability, and cross-system coherence (eight papers).

Other important themes were about how community trust, multisectoral engagement and social capital could be leveraged to improve resilience (See Table  1 ). The categories of included studies are shown in Fig.  2 .

Categories of included studies

Features of the resilience concept that affect implementation

Several recent literature reviews have focused on conceptual definitions [ 10 , 13 , 14 , 15 , 7 ]. Biddle et al. reviewed 71 papers on the topic from 2008 to 2019, but over half of the papers were published from 2017 to 2019 [ 7 ]. Ten of the papers reviewed by Biddle et al. have “Ebola” in the title, reflecting how the 2014 outbreak had triggered interest. However, resilience had earlier become a major focus of the Rockefeller Foundation during the presidency of Dr. Judith Rodin whose 2014 book The Resilience Dividend sparked popular attention through narrative case studies of community resilience under a variety of crisis situations [ 16 ]. Rodin’s book popularized a set of five pillars of community resilience as Awareness, Diversity, Self-Regulation, Integration, and Adaptation (A, D, SR, I, A) that figure heavily in later conceptual maps of resilient health systems [ 17 , 18 ].

As more scholarship on the concept of health system resilience developed, related definitions echoed Rodin’s contribution that the concept of resilience was highlighted during times of crisis and that resilience involved an anticipatory practice of drawing together diverse strands of situational knowledge to deliberately build institutions that were responsive. One can see a refinement from Rodin’s original 5 pillars (A, D, SR, I, A) to the three most conserved elements of the resilience concept: Awareness, Self-Regulation, and Adaptation (A, SR, A). It is not that diversity and integration are unnecessary, but that they are subsumed if there is to be any true success with awareness, self-regulation, and adaptation. The refinement from five resilience elements to three is most obvious when Blanchet and co-authors note that resilience of a health system is, “its capacity to absorb, adapt and transform when exposed to a shock such as a pandemic, natural disaster or armed conflict and still retain the same control over its structure and functions.” [ 2 ] One synthesis of the three preserved elements of resilience that we found in the concept papers is an agreement that resilience is a form of intelligence. Intelligence implies that information is taken in, processed, and acted on [ 16 , 17 , 19 , 22 ]. (And as per Rodin, to do this well, one would do it with respect to diversity and the ability to integrate). Intelligent systems -living or artificial- adapt to their situations by starting with afferent “sensing”, followed by “deliberating” either by unitary or social deliberation, and finally launch efferent “actions” that act upon the internal or external state.

Part of the attraction of the term “resilience” comes from its ambiguity. Its lack of clarity invites people from both politics and science to a crossroads area where the term “resilience” can be stretched to fit divergent goals and diverse perspectives [ 2 ]. Those who write about resilience typically feel free to adapt the term in various ways. Having a “big tent” word for what is desired from a health system is a gateway for the necessary multi-stakeholder, multi-perspective conversations that enable progress. Usefully ambiguous buzzwords can play an important galvanizing and unifying role. This is the case for the concepts of “sustainability” and “capacity development” [ 19 , 20 , 21 ]. After all, as per Judith Rodin (2014) and most other successive writers, resilience comes from integrating diverse concerns and strengths of a community. Turenne et al. comment on how presently, most writers do not share a consensus on the definitions, clarity, preconditions, or limits of the use of the term “health system resilience”. Turenne et al. see the hallmarks of a term that is not mature, not stable [ 13 ]. Biddle et al. also note that the term “resilience” is dynamic, complex, and in its infancy [ 7 ].

Resilience for crises, for social reform, and for every day

Because of its elasticity, “resilience” has been pulled in multiple directions when it is used to guide thinking about health systems. There are three overlapping principal applications of resilience to health systems: 1 ) Crisis resilience refers to health system properties of high value during a crisis [ 13 ]; (2) Social resilience also known as “transilience” refers to health systems efforts to engage with broader social circles and wider environmental issues that affect health like differential access to power, knowledge, and resources [ 22 ] as well as community norms and social cohesion that can enable health and other systems to function and adapt in a crisis [ 23 ]. (3) Everyday resilience is the ability to handle the serious chronic challenges routinely facing health system managers [ 15 , 24 , 25 ]. There is still no consensus about whether these three types of resilience can or should focus on homeostasis—on restoring a system to an ideal baseline, or whether resilience refers to a healthy embrace of adaptation, transformation, and learning. Fridell et al. see a growing emphasis on a more adaptive understanding of resilience that embraces change and adapts to it [ 10 ].

To briefly summarize: the current consensus is that the concept of “resilience” refers to properties of health systems that are universally desired because they ease adaptation to change, but the specific properties and pathways to develop them are not fully agreed upon.

Practical strategies to improve resilience

Defining agency over resilience, contextualizing it, and benchmarking it emerged as common themes. For a strategy to be practical, there has to be clarity over who is assigned what role and how they are to be accountable. Practicality demands that a feasible strategy be adapted to a particular context. For both implementation and evaluation, each strategy needs to have a system for making and using measurements.

Who implements resilience strategies?

Health system resilience can be advanced or impeded by people inside and outside the health sector. A few papers saw resilience in broad whole of society terms that they called “community resilience” [ 23 , 26 ]. The measures for community resilience addressed broad features of development, livelihoods, and social cohesion that were not bounded by the health system [ 23 , 26 ], and hence difficult for health sector leaders to make practical.

Most papers focused heavily on strategies to be carried out by leaders from the government and noted the absolute need for top level support by national leadership. Recognizing the role of “whole of government” or “health in all policies”, Mckenzie et al. (2015) caution that entrenched interests outside the health sector can be quite challenging to change. Their case study of resilient responses to Ebola in Northern Nigeria looked specifically at management functions [ 27 ].

Managers at the sub-national or district level of the health system were repeatedly emphasized as being critical for resilient response to crises based on Uganda’s successful response to COVID-19 [ 12 ]. Mustafa et al’s (2022) review of 106 COVID 19 Response plans repeatedly flagged the need to strengthen sub-national capability for multi-sectoral collaboration to deliver services and keep community stakeholders coordinated in maintaining non-emergency services in a crisis [ 28 ]. Fridell et al’s scoping review also noted consensus around leadership with local governance based on a workforce with a mix of skills [ 10 ]. In the Ebola response in 2014, it was local level partnerships with community political leaders, NGOs, faith leaders and facility managers that executed the work of reaching citizens with effective messages about behavioral change that reduced transmission and identified chains of transmission [ 29 , 30 ].

Implicit in identifying the role for managers at the district level was recognizing that mid-level managers participate in, but do not drive the policies that lead to health system change [ 11 , 31 ]. National Public Health Institutes and Health Ministries were able in some cases to set up the structures that would activate sub-national, district public health officials to exercise their stewardship [ 5 , 31 ].

What should be done: the role of essential public health functions

The things that need doing for resilience will revolve around the tasks of sensing, deliberating, and acting. Decades of implementation work on “Essential Public Health Functions” (EPHFs) provide a ready-made to do list to increase sensing, deliberating, and acting [ 6 , 31 ]. The idea of “essential public health functions” emerged in the late 1990s as a set of regional and national consensus-based lists of capabilities that national and sub-national public health departments had to carry out to create the physical and social conditions for large populations to be healthy. WHO convened an international Delphi panel to define a list of these essential functions [ 32 ]. National [ 33 , 34 ] and regional [ 35 , 36 ] initiatives followed to assess and improve the execution of these essential functions. Exercises to define and measure EPHFs have now been applied in over 100 countries [ 37 ]. Tools to define and assess EPHFs have been developed for Latin America, Western Pacific, Europe, Eastern Mediterranean regions as well as USA, Australia, UK, India, New Zealand, Israel, British Columbia [ 38 ], Mozambique, Botswana [ 39 ] and Angola [ 40 ]. Of note, WHO EMRO region developed and initially applied measurement of EPHFs in Qatar and Morocco [ 41 ]. An assessment tool for EMRO is now in the public domain [ 42 ]. EPHF measurement for a national health agency might be a process taking several months, but in a district can be accomplished in a few hours [ 39 ] using a combination of qualitative, quantitative, subjective, and objective responses by district health management teams.

There are variations in the details of EPHFs across regions, but all share a three-part structure with functions to support: (1) Sensing the current health, health threats, and health system assets; (2) Deliberation about what to do that is engaged with local stakeholders and aligned with local laws and culture; (3) Assurance that solutions are executed effectively. See Supplement 1 for a representative list of EPHFs from the WHO EMRO region that highlights the three-fold structure. The confluence of the EPHF construct with the resilience consensus is shown in Table  2 . The WHO’s recognition that the EPHFs tools are a strategic pathway to resilience can leverage decades of progress in using EPHF tools to improve system performance [ 6 , 31 ].

Applications of the EPHF tools to improve the resilience of health systems show contextual variability [ 38 ]. The absence of a universal consensus on what is included and excluded as an “essential” public health function reflects a recognition that context matters. The most common approach has been a national measurement of EPHFs leading to a national report or in some cases a regional set of national reports [ 36 , 38 ]. Most of the time the evaluation cycle has stopped at evaluation without consequent intervention. Often the evaluation is restricted to national level omitting public health actors at the sub-national districts.

Our literature review found no evidence that there has ever been a prospective assessment of a national or district level project tying EPHF or resilience interventions to health system outputs or population health outcomes. The best explanation for the lack of field-level evaluations of EPHF improvement initiatives relates to the fragmented structure of health system financing where the bulk of funding goes to clinical services [ 27 ]. There is a window of hope that the COVID-19 pandemic has revealed the need for a better approach [ 6 ].

How to implement practical strategies: the role of measurement

Kruk and co-authors were one of the earliest groups to conceptualize a resilience index composed of 25 elements that embody elements of the original Judith Rodin Rockefeller Foundation resilience formula (Aware/Diverse/Self-regulating/Integrated/Adaptive) [ 43 ]. A national adaptation of this index was prepared with the participation of national stakeholders from Bangladesh [ 18 ] and a second adaptation made for Pakistan was pilot-tested in 2021 [ 44 ].

The limitations of measurements have been noted. National measurements of compliance with International Health Regulations like the Joint External Evaluations have been faulted for their lack of follow up [ 37 ]. National measurements like the Global Health Security (GHS) Index which draws on these measurements have been found questionable after the USA scored extremely high on the GHS in 2019, but in practice had a disappointing performance in delivering health security during its COVID-19 epidemic [ 45 ].

For practical implementation that leads to change, measurements of resilience have to be integrated into a quality improvement cycle [ 46 , 47 , 48 ]. A pilot project in Botswana and Mozambique was able to develop stakeholder-endorsed measures of EPHFs suitable for the sub-national performance improvement cycles, but application and scale up of these cycles never occurred [ 39 ]. Measurement is not a panacea. Measurement divorced from a system of accountability to regularly revisit locally owned and generated EPHF-based assessments of resilience for public health performance improvement has repeatedly failed to trigger reform [ 38 ]. On the other hand, the complete absence of any evaluation of programs where resilience or EPHF measures were applied in a quality improvement cycle leaves a major gap in what is known about the impact of measurement [ 48 ]. A community-based trial of district level public health functions measurement to improve objective measures of resilience is a high priority for next steps. Other promising approaches that did not come up in our search strategy include social accountability that can be approached with community scorecards [ 49 ].

Mechanisms for how actions alter resilience

People’s behaviors, performance, and trust-building are properties that adhere to all building blocks of a health system [ 50 ]. The interlinkage of health system components means governance improvements that alter health workforce capability and improve the information used in the system spillover to improve service delivery, finance, and medicine supply chains.

Social features of resilience

The social aspects of resilience are well demonstrated in case studies like an analysis of Lebanon’s handling of the Syrian refugee crisis that was built on pre-existing social networks with diverse stakeholders [ 51 ]. Strong relationships between the public health officials and private health providers, school systems, faith communities, transport, law enforcement, agriculture etc. are a way to have off-budget surge capacity. A case study of Liberia’s Ebola response pointed out how pre-existing communications platforms with the community relied on treating community members as active participants and not passive recipients of health response efforts [ 52 ]. This facilitated Ebola response efforts and led to a fortuitous cycle of increased trust, improved communication and even more engagement. The Liberian case study stresses that the health system actors have to build public trust before a crisis. The Ebola response in Nigeria and Uganda also relied on previous social connections to partners [ 29 ].

This need to build social connections and networks before a crisis is the basis for synergy between everyday resilience and crisis resilience. One has to build a people-centered health system every day in order to have the social networks and trust that are critical for a resilient response to a crisis [ 24 ]. Gilson and co-authors’ list of resilience capacities stresses proactive efforts to build social capital by diffusing power and inclusion throughout an organization and outside it. To engage in this type of everyday resilience the organization will need to master skills in shared narrative and sense-making to align the diverse partners that have to work together [ 24 ]. Barasa et al. call these everyday resilience investments the “software” of resilience and note that this approach is inherently adaptive and uncommitted to preserving past structures in order to bounce back to them [ 15 ].

Every day investments in social connections for the health system build resilience, but so do every day investments in reaching groups who have been historically excluded or socially vulnerable. Haldane and Morgan (2020) point out that addressing the social and environmental concerns of marginalized groups is not only core to public health, but it pays a resilience dividend [ 22 ]. During a crisis reaching these groups with services and trusted messages becomes critical, because historically they have experienced, and in the future, they will continue to experience the highest losses in a crisis.

Multisectoral linkages for resilience

Ensuring that the health sector is connected to other sectors of government has been termed, “health in all policies” [ 53 ]. Having functional relations among leaders of non-health government agencies (e.g., education, law enforcement, transportation, social services, environment, etc.) is not just an essential public health function [ 31 ], but also critical for resilience during a crisis [ 48 ]. Crisis response teams will draw on multiple government agencies and the teams will work better if they have worked together in other capacities for everyday tasks that they share for community well-being. There is a tendency for vertical “preparedness” planning to only see these multi-sectoral collaborations as useful in crisis response. But in fact, multisectoral work is basic to all of public health [ 31 ]. Another way that pre-crisis relations build linkage for resilience is their ability to assist with regional and global efforts in procurement of supplies and assistance during a crisis [ 54 ].

The role of trust

Multiple papers emphasized that the health system has to build trust before a crisis [ 55 , 17 ]. Crises will require collective coordinated activities by diverse elements of society that do not ordinarily collaborate [ 17 ]. The health system has a special role of being a bridge, but can only be such a bridge if it embraces this role and the call for repeated empathetic interaction with all members of a community [ 56 ]. Everyday resilience builds crisis resilience through inclusive provision of public health services with empathy and integrity to all members of a community [ 15 , 51 , 57 ].

Sustaining resilience improvements by defragmentation

Fragmentation of health system financing and organization was cited as the key barrier to resilience. The funding streams in both high income and low income health systems come from multiple levels of government and multiple programs [ 58 ]. Public health agencies at national and sub-national level face verticalized sequestered budgets with funds that are earmarked to specific diseases, treatment programs or technologies. Campbell and co-authors who shared a particular interest in Perinatal Maternal, Newborn, and Child health (PMNCH) recognized that fragmentation was blocking their own particular agenda and called for integration of their vertical efforts into primary health care [ 59 ]. Ordinary people want clinics that can take care of their whole body and their whole family, but fragmentation induces care options that focus on single problems or sub-populations. PMNCH could reach more people if it could be part of a person-centered system rather than a problem-centered one.

Fragmentation’s root cause stems from the practice of budgeting and organizing health systems around separate strategic objectives. As Ramalingam notes, top-down, blueprint planning approaches have been integral to government and business since the early 20th century [ 60 ]. The units that make up the building blocks of a health system are given their objectives and task lists independently. The hard work of connecting and integrating the units to each other or to make them able to sense and respond to emerging problems together is seldom a pre-specified top-down task. Defragmentation does not call for abandonment of the top-down approach, but the augmentation of these multiple units by forging linkages across fragmented programs. The workforce that can do this linking would naturally be part of governmental public health departments. The tools they need would be the ability to observe the assets present in the system as well as their relevance to emerging health problems. The integrative work of coordinating multiple siloed projects in a system is inherent in efforts to improve capacity in essential public health functions. The EPHF make it essential to deliberate together based on data on assets and problems about how to respond to emerging health problems. Hence adding EPHF capability to all members of the public health workforce can bring coherence to a siloed and fragmented system.

Summary and Conclusion

Improving resilience will not look like a standard implementable project with a sequence of step 1, step 2, and step 3. Resilience emerges from doing many things to nudge a system towards the sentient action state outlined in Table  2 . Lack of resilience is a systems problem rooted in fragmentation whose origin was management by strategic objectives. The cure for narrow, segmented strategies is broad cross-cutting strategies. Yes, one can implement practical strategies to counteract an emergent systemic weakness brought on by too much strategic focus. Ultimately, the pathway to resilience must include integrative sensing, deliberating, and doing throughout a health system.

Assign a unit of the health system that will be explicitly responsible for resilience, specified as bringing out sensing, deliberating, and doing as a system-wide responsibility. Context will decide, but in most cases the national and sub-national public health workforce will need to lead resilience building efforts [ 24 , 30 ]. Public health institutes at national and sub-national level are an obvious choice [ 5 , 31 ]. In applications of the viable system model community stakeholders are engaged for advice on how a local system can be adapted [ 61 ].

Set up policies and legislation that assign the resilience responsibility to national and sub-national teams [ 62 ]. There is a danger that this will be mis-interpreted as one more fragmented unit, i.e. “a resilience squad” or a “public health preparedness office’. However, noting the homology of resilience to the more frequently operationalized efforts to improve essential public health functions throughout a health system can defend against this pitfall.

Convene broad stakeholders in a conversation about context-relevant resilience indicators [ 56 , 63 ]. Drawing on EPHF checklists will accelerate this effort [ 42 ]. Resilience indicators coming from EPHF checklists would naturally show their relevance to everyday concerns in service delivery for vertical programs and vulnerable groups [ 14 , 18 ].

Embed annual or quarterly cycles of measurement of contextualized resilience indicators into a total quality management cycle where the resilience scores drive local performance improvement plans that can be costed and met with financing [ 39 ].

Assist with technical support in the areas of social science, inclusion, quality improvement, coaching and workforce development [ 12 , 30 ].

Accompany resilience improvement with evaluation to assess impact and lead to modification and learning in the effort [ 64 ].

Invest in lateral learning [ 65 ]. By benchmarking performance, one can learn which sub-national units are doing well in resilience improvement, and they can become catalysts for change in units that are slightly lagging.

The review identified zero empirical prospective field trials that have showed longitudinal changes in a quantitative or qualitative assessment of resilience. The chief obstacle to implementing resilience interventions that emerged was fragmented silo-based organization of the work of many public health systems. When health systems become organized around specific-diseases and sub-populations they and those who govern them use specific key service performance indicators. Since these indicators rarely call on a worker to help their workplace or community become aware of emerging health threats or to cultivate connections to community resources that could help respond in a crisis, these key resilience capabilities and EPHFs stay out of sight and off the agenda.

Our review revealed many practical opportunities that can put resilience into practice. The elements of resilience (sensing, deliberating, doing) look exactly the same as EPHFs. The extensive toolkit of EPHF measures for accountability can accelerate local contextualization of benchmarks for resilience. Importantly these resilience and EPHF benchmarking measures can be applied longitudinally and reacted to with resourced improvement plans. Although benchmarking and improvement plans are tools of health system governance their effect spills over to affect all components (e.g. building blocks) of the health system.

There is enough known right now to support pilot interventions that could be implemented to improve resilience. Future work in this area needs to capitalize on the open window of the current high prioritization of resilience at the highest level [ 6 ]. The next big step in resilience will be field implementations of resilience projects that are prospectively evaluated with mixed methods.

Data availability

All papers reviewed in the systematic review are listed in the bibliography and can be accessed publicly.

Abbreviations

Regional Office for the Eastern Mediterranean (of the WHO)

Essential public health functions

Emergency preparedness and response

Global health security

health emergency and disaster risk management

Health extension worker

Medical subject heading

Non communicable disease

National public health institute

Primary health care

Prenatal maternal neonatal child health

United Nations Children’s Fund

World Health Organization

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Acknowledgements

Helpful comments were obtained from participants at a meeting on Primary Health Care for Universal Health Coverage and Health Security in the Eastern Mediterranean Region in Cairo on December 11, 2022.

Research support from the World Health Organization is gratefully acknowledged.

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David Bishai designed and conceived the study. Basma M. Saleh and Maryam Huda screened and reviewed literature. David Bishai wrote the main text with assistance from Basma M. Saleh, Maryam Huda, Marwa Hafiz, Awad Mataria, Ali Ardalan, and Eman Mohammed Aly. All authors reviewed and approved the manuscript.

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Bishai, D., Saleh, B.M., Huda, M. et al. Practical strategies to achieve resilient health systems: results from a scoping review. BMC Health Serv Res 24 , 297 (2024). https://doi.org/10.1186/s12913-024-10650-8

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Health system resilience: a literature review of empirical research

Louise biddle.

c1 Social Determinants, Equity and Migration Working Group, Department of General Practice & Health Services Research, University Hospital Heidelberg, Marsilius Arkaden, Turm West, Heidelberg 69120, Germany

Katharina Wahedi

Kayvan bozorgmehr.

c2 Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, 33501 Bielefeld, Germany

Associated Data

The concept of health system resilience has gained popularity in the global health discourse, featuring in UN policies, academic articles and conferences. While substantial effort has gone into the conceptualization of health system resilience, there has been no review of how the concept has been operationalized in empirical studies. We conducted an empirical review in three databases using systematic methods. Findings were synthesized using descriptive quantitative analysis and by mapping aims, findings, underlying concepts and measurement approaches according to the resilience definition by Blanchet et al . We identified 71 empirical studies on health system resilience from 2008 to 2019, with an increase in literature in recent years (62% of studies published since 2017). Most studies addressed a specific crisis or challenge (82%), most notably infectious disease outbreaks (20%), natural disasters (15%) and climate change (11%). A large proportion of studies focused on service delivery (48%), while other health system building blocks were side-lined. The studies differed in terms of their disciplinary tradition and conceptual background, which was reflected in the variety of concepts and measurement approaches used. Despite extensive theoretical work on the domains which constitute health system resilience, we found that most of the empirical literature only addressed particular aspects related to absorptive and adaptive capacities, with legitimacy of institutions and transformative resilience seldom addressed. Qualitative and mixed methods research captured a broader range of resilience domains than quantitative research. The review shows that the way in which resilience is currently applied in the empirical literature does not match its theoretical foundations. In order to do justice to the complexities of the resilience concept, knowledge from both quantitative and qualitative research traditions should be integrated in a comprehensive assessment framework. Only then will the theoretical ‘resilience idea’ be able to prove its usefulness for the research community.

Key Messages

• The way in which resilience is currently applied in the empirical literature does not match its theoretical foundations.
• In order to do justice to the complexities of the resilience concept, knowledge from both quantitative and qualitative research traditions should be integrated in a comprehensive assessment framework.

Introduction

The word ‘resilience’ origins from the Latin prefix ‘re-’ (back) and the verb ‘salire’ (to jump, leap). In science, it has long been used by engineering and material science to describe the ability of a material to absorb energy without losing its original form or characteristics ( Hollnagel 2009 ). Over time, different disciplines adopted and adapted the term, adding different interpretations and facets to it: In ecology, resilience describes the persistence of ecological systems and measures a system’s ability to absorb changes of variables and maintain relationships between different populations ( Holling 1973 ). In psychology, resilience is understood as the individual human capability to cope with crises, losses or hardships without negative consequences ( Tugade and Fredrickson 2004 ).

In the last decade, the concept of resilience has also gained popularity in global public health. This development is reflected by major UN frameworks adopted in the last decade: The 2005–15 Hyogo Framework for Action ( UNISDR, 2005 ) was subtitled ‘Building the Resilience of Nations and Communities to Disasters’. Its successor, the 2015–30 Sendai Framework for Disaster Risk Reduction ( UNISDR, 2015 ), increases the focus on health in the disaster preparedness discourse and correspondingly calls for health resilience. Various sustainable development goals point to resilience as a target (1.5: ‘resilience of the poor’, 2.4 ‘resilient agricultural practices’, 11b ‘resilience to disasters’; Bahadur et al. 2015 ; UNISDR 2015 ) In a 2016 editorial of Bulletin of the World Health Organisation (WHO), health system resilience is named as a critical concept for global health, in the same vein as health system strengthening, universal health coverage and health security ( Kutzin and Sparkes 2016 ).

The shifting conceptualization of health system resilience

While definitions and concepts of health systems resilience differ substantially throughout the literature, all have a common core: they regard resilience as the degree of change a system can undergo while maintaining its functionality. The concept of resilience was introduced to the health systems literature from the ecological sciences through an increased understanding of health systems as complex adaptive systems ( Blanchet and James 2013 ). In this context, the idea of resilience, defined as ‘a measure of the amount of change a system can experience while maintaining the same controls on structure and function’ ( Blanchet and James 2013 ), can act as a useful tool to help us understand health system dynamics. The ecological idea that strategies to enhance resilience can be absorptive, adaptive or transformative depending on the impact and intensity of the crisis has been particularly impactful in the health system resilience discourse.

Popularized further during the Ebola crisis, health system resilience underwent a conceptual shift; from a mere ‘system’ capacity to recognizing the contribution of individuals and their agency within that system and acknowledging the wider social, economic and political context in which responses occur. Critics argued that the application of the resilience concept—as a ‘top-down’ approach—obscured important factors which prevented an adequate response to the Ebola crisis. They emphasized instead the importance of ‘understanding and reducing local power disparities, building the trustworthiness of health actors […] both between and during crisis’ which improves the ‘everyday functioning of the health system’ ( Martineau 2016 ). In response to these criticisms, Barasa et al. (2017) proposed the idea of ‘everyday resilience’, emphasizing in particular the importance of the capacities and resources available to individuals faced with delivering health services every day. Everyday resilience may especially be of relevance, they argued, in low- and middle-income countries where managers may ‘routinely face structural and policy instability, such as changes in governance structures, payment delays, abrupt and imposed policy directives […], unstable authority delegations, unpredictable staff and […] changing patient and community expectations’ ( Barasa et al. 2017 ).

Similarly, Blanchet et al. (2017) proposed a new model of understanding health systems resilience which focuses not just on the outcome of the resilience process (i.e. absorptive, adaptive and transformative capacities), but also on the underlying management capacities of the system and its actors to response to change: knowledge, uncertainties, interdependence and legitimacy ( Box 1 ). These operational dimensions are interlinked with each other and together characterize the management of resilience in health systems ( Figure 1 ). While these two more recent conceptualizations of resilience can be understood as different in terms of taking a ‘top-down’ ( Blanchet et al. 2017 ) and ‘bottom-up’ ( Barasa et al. 2017 ) approach, they both acknowledge the importance of the context in which the resilience process takes place and the agency of actors involved, and thus represent two sides of the same coin.

Box 1 Resilience domains used in conceptual analysis of studies, as defined by Blanchet et al. (2017)

Management capacities:

Knowledge—‘Capacity to collect, integrate and analyse different forms of knowledge and information’

Uncertainties—‘Ability to anticipate and cope with uncertainties and surprises’

Interdependence—‘Capacity to manage interdependence: to engage effectively with and handle multiple- and cross-scale dynamics’

Legitimacy—‘Capacity to build or develop legitimate institutions that are socially accepted and contextually adapted’

Three levels of resilience:

Absorptive capacity—‘capacity of a health system to continue to deliver the same level (quantity, quality and equity) of basic healthcare services and protection to populations despite the shock using the same level of resources and capacities’

Adaptive capacity—‘capacity of the health system actors to deliver the same level of healthcare services with fewer and/ or different resources, which requires making organisational adaptations’

Transformative capacity—‘the ability of health system actors to transform the functions and structure of the health system to respond to a changing environment’

Conceptual overview of health system resilience, adapted from Blanchet et al. (2017) .

Conceptual influences from other fields

In addition to the conceptualization of resilience outlined above, other disciplinary fields have influenced the discourse on health system resilience, most notably the disaster management and healthcare quality literature.

In the disaster management sciences, resilience discussions were initially focused on the maintenance of infrastructure, functionality of health care facilities and continued service delivery ( Crowe et al. 2014 ; Balbus et al. 2016 ; Cimellaro et al. 2017 ) operationalizing resilience as ‘capability of a health system to mitigate the impact of major external disruptions on its ability to meet the needs of the population during the disaster’ ( Crowe et al. 2014 ). However, experiences of Hurricane Catrina in the USA shifted the dominant discourse in the disaster management literature to the concept of community resilience ( Wulff et al. 2015 ; Olu 2017 ). Community resilience proposes that the key to a good disaster response lies in communities, and their ability to ‘prepare, respond, and recover’ from major events through a range of measures including increased social connectedness, adaptive health and social systems and emergency preparedness planning ( Wulff et al. 2015 ).

A further prominent influence on the health system resilience discussions has been the concept of ‘resilience engineering’ or ‘health care resilience’, emerging from the healthcare quality literature. This approach, developed as a critique to traditional views of healthcare safety as an ‘absence of failures’, defines safety as the ‘ability to succeed under varying conditions’ ( Hollnagel et al. 2006 ). It thus focuses on nurturing the everyday functioning of healthcare teams and facilities to strengthen resilience and reduce clinical mistakes. A recent review on the topic has found that this approach has garnered significant attention in both the primary and secondary literature since its emergence around 2012 ( Ellis et al. 2019 ).

The need for a review of the empirical literature

Existing literature reviews have been conducted on the theoretical conceptualization of health system resilience ( Turenne et al. 2019 ) and the factors contributing to resilient health systems ( Barasa et al. 2018 ). The concept of resilience has also been extensively discussed outside the health sector ( Tanner et al. 2017 ). While grasping the theoretical background of the concept is certainly crucial, understanding how theory is translated into evidence is equally important for assessing the usefulness of the ‘resilience idea’ for the research community. However, so far there has been no critical appraisal of how the concept of health system resilience has been operationalized and applied in the empirical literature.

We thus conducted an empirical review of health system literature in order to better understand how the resilience concept has been operationalized in empirical studies. Within this research aim, we address three specific sub-questions: (1) What are the key aspects (methodological approach, geographic focus, health system building block addressed and crisis/challenge discussed) of research on health system resilience and how have these changed over time? (2) What concepts and frameworks on health system resilience have been used to operationalize resilience in the health systems literature? (3) What is the scope of empirical research on health system resilience within current definitions of the concept? We thus provide an overview of the existing empirical literature on health systems research which can be used to further develop the concept and inform its operationalization in future studies.

Methodology

We conducted a review of empirical literature, following systematic review methodology in line with the understanding brought forward by Moher et al . (2015) . This included a systematic literature search, and a rigorous and systematic data screening and extraction process ( Peters et al. 2015 ).

Searches were conducted in Medline, Social Science Citation Index and CINAHL (Cumulative Index to Nursing and Allied Health Literature) using Resilien* AND a health system related terms (see Box 2 ).

Box 2 Search terms

Search terms:

((((((((secondary health care [mh]) OR primary health care [mh]) OR health services [mh]) OR delivery of health care [mh]) OR health services research [mh])) OR ((((((((((((““health system””) OR ““health systems””) OR ““health care system””) OR ““health care systems””) OR ““health care””) OR ““health care sector””) OR ““health care sectors””) OR ““health service””) OR ““health services””) OR ““service delivery””) OR ““health care service””) OR ““health care services””))) AND Resilien*

The searches were conducted on 18 October 2019 and were limited to articles published since 2008 in English or German language to keep the extent of the review feasible. The search produced 6136 publications for screening after the removal of 794 duplicates [see Figure 2 for the PRISMA flow diagram in line with Moher et al. (2009) ].

Prisma flow diagram.

Due to the high number of items, we used a three-stage screening process, eliminating non-relevant articles at the stage of title-, abstract- and full text-screening. Items were excluded if they did not report primary data, or were concerned with individual/psychological resilience including resilience of healthcare providers (e.g. nurses, physicians), resilience in the non-health space (e.g. social resilience, resilience of urban environments and resilience of biological systems), community resilience without link to health systems or articles that were concerned neither with health systems nor resilience. We also excluded articles which were concerned with health system resilience, but only used the term as a ‘buzzword’, without further definition, discussion or operationalization of the concept. As the research objective was to understand the application and use of resilience in health system research, items with any research design, geographic scope and health system focus were included.

After the abstract-screening stage, 517 references remained, with another 444 references excluded after screening full texts (see Figure 2 ). Both abstract- and full text-screening were carried out by the first and second author with joint synthesis until consensus was reached. Two further articles were from the reference lists of the literature reviews by Barasa et al. (2018) and Turenne et al. (2019) met the inclusion criteria for the present study and were included in the review. The remaining articles were divided into two categories: (1) those papers which specifically assessed health system resilience by including this as a specific research objective or applying a framework allowing for the operationalization of health system resilience (‘key papers’) and (2) articles reporting research which led to a discussion of health system resilience or how to achieve health system resilience.

Data extraction was carried out by the first and second author using Microsoft Excel. To answer the first research question on key aspects of the empirical health systems literature, data on type of research (primary/secondary research), discipline of the first author, the health system building block studied [according to World Health Organization (2010) ], the type of crisis or conflict studied, study location (country, continent, low-/middle-/high-income country), the organizational level being studied (e.g. global, national or regional) and type of data used were extracted from all identified studies.

To answer the second and third research objectives, only those studies directly measuring or assessing health system resilience (‘key papers’) were analysed. In order to evaluate the use of existing empirical frameworks in the empirical literature (second objective), information on frameworks used was extracted if these guided either the data collection or analysis process, or both. To further extract the scope of empirical research in terms of aspects or elements of the concept being addressed (third objective), we were guided by the conceptual framework of Blanchet et al. (2017) . We used this framework because it captures the various ways in which resilience is used in the empirical literature: it describes both the management capacities essential for a resilient system (management capacities: knowledge, uncertainties, interdependence, legitimacy) as well as those describing the outcome (three levels of resilience: absorptive, adaptive and transformative capacities). It thus is able to capture a broad range of research on post ex ante and ex post ( Béné et al. 2015 ) aspects of the resilience process. Research articles were classified within this framework using the definitions listed in Box 2.

We synthesized the findings by combining a narrative synthesis with descriptive quantitative analysis of key aspects addressed. We further tabulated and mapped aims, findings, underlying concepts and measurement approaches according to the resilience definition by Blanchet et al. (2017) . Indicators used to measure aspects of resilience in quantitative and mixed methods studies were also extracted and mapped according to their respective resilience domain and the level of data collection (national, organizational, staff or population/patient level).

A total of 71 articles met our inclusion criteria, comprising 40 research papers specifically measuring or addressing health system resilience and 31 discussing health system resilience using empirical research ( Figure 2 , see Supplementary file for full list of studies).

Quantitative synthesis and mapping of empirical literature in health system resilience

The literature was found to be fairly evenly distributed across continents: Africa ( n  = 18; 25%), Europe ( n  = 18; 25%), Asia ( n  = 15; 21%), North America ( n  = 15; 21%) and Australia ( n  = 2; 3%), with four studies reporting data across continents. The exception was South America, where no empirical papers were found. The majority of research was conducted in high-income countries ( n  = 37; 52%), with 18 studies (25%) in middle-income countries and 13 studies (18%) in low-income countries. We found an increase in literature in recent years (62% of studies published since 2017).

The majority of research ( n  = 58; 82%) addressed a specific crisis or challenge. Overall, infectious disease outbreaks was the most frequently addressed challenge ( n  = 14; 20%), followed by natural disasters ( n  = 11; 15%) and climate change ( n  = 8; 11%). Other challenges were conflicts ( n  = 4; 6%), migration ( n  = 4; 6%), financial crises ( n  = 2; 3%) and terrorist attacks ( n  = 1; 1%). Several articles addressed chronic, non-crisis-related challenges ( n  = 12; 17%): changes in team composition ( n  = 1; 1%), human error ( n  = 5; 7%), everyday resilience ( n  = 3; 4%) and structural change ( n  = 2; 3%). While non-crisis-related challenges and climate-related studies dominated the early records from 2008 to 2014, over time, the diversity of addressed challenges has grown embracing financial crises from 2013, infectious disease outbreaks from 2015 triggered by the Ebola epidemic and migration from 2017 (see Figure 3 ).

Identified literature on health system resilience ( N  = 71) organized by type of challenge and year (2008–19).

In terms of health system building blocks addressed, a large proportion of studies ( n  = 34; 48%) focused on service delivery, while 14 (20%) did not focus on a particular health system building block but took a general perspective. Other building blocks addressed frequently include leadership and governance ( n  = 9; 13%) and health workforce ( n  = 8; 11%), while health information systems ( n  = 4; 6%), medicines and access to medicines ( n  = 2; 3%) and health system financing ( n  = 1; 1%) are addressed less frequently.

Overall, the empirical studies identified differed in terms of their disciplinary tradition or conceptual background. Studies from the public health sciences tended to converge in three groups: (1) quantitative studies focusing on service delivery, making use of service utilization indicators provide an easily accessible measure to assess resilience before, during and after a crisis ( Paterson et al. 2014 ; Gizelis et al. 2017 ; Sochas et al. 2017 ; Kozuki et al. 2018 ; Ray-Bennett et al. 2019 ), (2) qualitative studies focusing on the health workforce, influenced by ideas of ‘everyday resilience’ and addressing the contributions of social connectedness and leadership on health system resilience ( Mash et al. 2008 ; Witter et al. 2017 ; Raven et al. 2018 ; Brooke-Sumner et al. 2019 ; Thude et al. 2019 ), and (3) studies taking a broad perspective of health system resilience, looking at multiple health system building blocks or aspects of a health system to assess resiliency ( Ager et al. 2015 ; Ammar et al. 2016 ; Fukuma et al. 2017 ; Ling et al. 2017 ; Meyer et al. 2018 ; Watts et al. 2018 ).

However, influences from outside the public health sciences could also be identified in the empirical health system resilience literature. As a relatively distinct influence, the disciplines of engineering and architecture have contributed empirical research assessing the infrastructure and thermal resilience of healthcare facilities and structures ( Lomas et al. 2012 ; Iddon et al. 2015 ; Short et al. 2015 ; Dippenaar and Bezuidenhout 2019 ). A further relatively distinct influence has been the contribution of specific checklists to assess facility and organizational resilience from the fields of disaster management and emergency preparedness ( Paterson et al. 2014 ; Zhong et al. 2014a , 2015 ; Dobalian et al. 2016 ; Khan et al. 2018 ; Meyer et al. 2018 ). Also from the field of disaster management, but perhaps more intertwined with resilience in the way it has been conceptualized in the health systems literature, are studies assessing community resilience and its relationship with service delivery during a crisis ( O’Sullivan et al. 2013 ; Andrew et al. 2016 ; Toner et al. 2017 ; Alonge et al. 2019 ; Cohen et al. 2019 ). Finally, hailing from the tradition of medical sciences concerned with patient safety and quality of care, concepts of ‘health care resilience’ or ‘resilience engineering’ have also influenced the empirical literature on health system resilience ( Brattheim et al. , 2011 ; Franklin et al. , 2014 ; Falegnami et al. 2018 ; Merandi et al. , 2018 ; Patriarca et al. , 2018 ). While study object of these studies is also the health workforce, the focus is placed on the analysis of work processes and the avoidance of medical errors to maintain functionality of services.

Methodological analysis of key empirical papers

We identified 40 high-relevance empirical studies specifically assessing health system resilience. Fifteen articles used a quantitative methodology ( Table 1 ), nine articles applied mixed methods ( Table 2 ) and a further 16 used qualitative methods ( Table 3 ). Given the distinction between articles in terms of their thematic focus described above, we present articles in six thematic areas: assessing national-level health system resilience in the context of a specific crisis ( n  = 8; 20%), assessing health service delivery ( n  = 10; 25%), addressing health workforce issues ( n  = 7; 18%), taking a community resilience perspective ( n  = 3; 7%), looking at infrastructure and thermal resilience ( n  = 3; 7%) and developing emergency preparedness checklists and assessment tools ( n  = 9; 23%).

Overview of aims, methods, concepts used and dimensions of resilience addressed by quantitative research papers ( n  = 15)

Overview of aims, methods, concepts used and dimensions of resilience addressed by mixed methods research papers ( n  = 9)

Overview of aims, methods, concepts used and dimensions of resilience addressed by qualitative research papers ( n  = 16)

Assessing national-level health system resilience in context of a specific crisis

Of the eight studies which assessed an entire, national health system in the context of a particular crisis, two studies took a purely quantitative approach: Fukuma et al. (2017) assessed Japan’s health system responsiveness and resilience after the Great East Japan Earthquake and Watts et al. (2018) assessed the resilience of 101 health systems in the context of climate change. Fukuma et al. (2017) operationalized resilience by using composite routine data indicators during the time of crisis, including: service utilization, cause-specific mortality rates incl. suicides, number of hospitals, health expenditures, human resources and immunization coverage. Watts et al. (2018) assessed resilience by surveying for the presence of specific policy efforts and strategies in the context of climate change at a national level.

Three further studies assessed the resilience of a health system at the country level using a mixed methods approach. Ammar et al. (2016) studied the Lebanese health system in the context of the Syrian refugee crisis using a case study approach. Orru et al. (2018) assessed the ways in which the Estonian health system was able to assess and manage the health risks of climate change using a combination of document review, expert interviews and population survey data as applied to the WHO Operational Framework for Building Climate Resilient Health Systems ( World Health Organization 2015 ). Thomas et al. (2013) assessed the performance of the Irish health system in the face of the economic crisis by applying quantitative indicators developed from their own resilience framework to government documents and supplementing these with semi-structured interviews.

Finally, three qualitative studies considered national health system resilience. Ager et al. (2015) assessed key barriers to the provision of responsive service in the context of Boko Haram in Nigeria, Alameddine et al. (2019) assessed the resilience of Lebanon and Jordan’s health systems in the context of the Syrian crisis and Ling et al. (2017) assessed the resilience of Liberia’s health system during the Ebola crisis. All three studies used semi-structured interviews with health professionals and other key health stakeholders for data collection, with Ling et al. (2017) complementing these with focus group discussions.

Out of these eight studies, all studies except one ( Fukuma et al. 2017 ) applied a specific conceptual framework to study resilience. However, the frameworks used in the other studies vary, including frameworks developed by international or development agencies, such as the World Health Organization or the United Kingdom’s Department for International Development ( Ager et al. 2015 ; Orru et al. 2018 ; Watts et al. 2018 ), general health system frameworks ( Ammar et al. 2016 ) and resilience frameworks developed in the academic literature ( Thomas et al. 2013 ; Ling et al. 2017 ; Alameddine et al. 2019 ).

Assessing resilience of health service delivery

Ten studies focused on the resilience of health service delivery. Six studies assessed the delivery of emergency services, three focused on the delivery of maternal health services, while one considered the continuity of a community health worker programme.

Two quantitative studies from the USA take a specific look at the delivery of emergency services: Radcliff et al. (2018) analyse ambulatory care measures during and after a storm, while Simonetti et al. (2018) model the potential of the US blood supply system during an emergency. Both make use of available administrative data, with Radcliff et al. (2018) relying in utilization data from Veterans Affairs clinics and Simonetti et al. (2018) using data on the national availability of blood stocks. The provision of emergency services during a crisis is also explored in four qualitative studies. Two of these assess service provision in the context of a particular crisis: Ridde et al. (2016) describe the emergency response to the Ouagadougou Terrorist attack in Burkina Faso, using a mixture of observations and expert interviews as their data source and structuring insights around Kruk et al. ’s (2017) ‘resilience indicators’ framework. Landeg et al. (2019) assess the emergency response to localized flooding in the UK using semi-structured interviews with decision-makers and document analysis. Finally, two qualitative studies explore the functionality of emergency service processes: while Back et al. (2017) use policy analysis and observation to examine escalation policies in UK hospitals, Errett et al. (2019) use semi-structured interviews with key informants to identify the impact of disruption of maritime transportation on the provision of emergency services during a disaster.

Being the only purely quantitative study to do so, Sochas et al. (2017) analysed the utilization of reproductive, maternal and neonatal health services in Sierra Leone in the context of the Ebola crisis using antenatal health service utilisation data. Gizelis et al. (2017) also assessed the impact of the Ebola epidemic on maternity delivery services, using a mixed methods approach by complementing maternity service utilization data from population surveys with semi-structured interviews and focus group discussions. Ray-Bennett et al. (2019) looked at the provision of reproductive health services in the context of flooding in Bangladesh, applying a structured facility assessment tool complemented by structured interviews with patients.

Kozuki et al. (2018) use a process evaluation methodology to document the ability of an integrated community case management programme to continue operation during the active conflict of 2013 and 2014 in South Sudan. The authors use routine programme data, including reporting, supervision, contact, treatment and referral rates, as well as interviews and focus groups with key stakeholders to evaluate the programme’s resiliency.

Only two of these studies ( Ridde et al. 2016 ; Back et al. 2017 ), both using qualitative methodologies, apply a specific framework of health system resilience. All quantitative studies and one mixed methods study focus on the absorptive capacities of service delivery, while the other studies address a more varied set of resilience dimensions.

Health workforce issues

A total of seven studies were identified which address aspects of health workforce resilience. These include studies both from the tradition of ‘resilience engineering’, as well as research influenced by the concept of ‘everyday resilience’.

One quantitative and one mixed methods study were conducted in the field of resilience engineering and safety research. Falegnami et al. (2018) surveyed the resilience of anaesthesia professionals in different work conditions in Italy using the four cornerstones of resilience framework ( Hollnagel 200 9). In the same setting, Patriarca et al. (2018) applied the functional resonance analysis method to explore the potential of the tool in enhancing the resilience of anaesthesia practices, drawing on documentary studies, interviews, observations and patient pathway modelling to do so.

Three studies considered health workforce issues on the context of a specific crisis. Applying a mixed methods approach, Witter et al. (2017) explored the impact of shocks on the health workforce across different contexts in Uganda, Sierra Leone, Zimbabwe and Cambodia, with a particular focus on vulnerabilities and coping strategies employed. The authors employed a mixture of methods for analysis, including surveys, human resource data, document review and qualitative interviews. Also taking a cross-national perspective, Raven et al. (2018) conducted observations and in-depth interviews with healthcare workers and management in Sierra Leone during the time of the Ebola crisis and in Nepal during a major earthquake to explore coping strategies of staff in both settings. In Portugal, Russo et al. (2016) explored physician’s perceptions of the changes in their work environment during the economic crisis in semi-structured interviews.

Finally, two qualitative studies take an ‘everyday resilience’ perspective to understand the ability of health workers in dealing with everyday challenges. Comparing experiences in Kenya and South Africa, Gilson et al. (2017) synthesize information from documents, interviews, group discussions and observations to understand factors influencing everyday resilience of staff. In Denmark, Thude et al. (2019) conducted semi-structured interviews with healthcare staff to explore the resilience of the workforce faced with challenges in their work environment, including changing leadership structures.

Only two of these studies ( Gilson et al. 2017 ; Falegnami et al. 2018 ) make use of an explicit resilience framework in their analysis. The dimensions assessed in individual studies varies: while Gilson et al. (2017) and Raven et al. (2018) explore a broad range of management capacities and resilience outcomes, the other five studies focus on only one of these two aspects, with three studies restricted in their analysis to a single outcome dimension ( Witter et al. 2017 ; Patriarca et al. 2018 ; Thude et al. 2019 ).

Taking a community resilience perspective

Three studies approached health system resilience from a community perspective. Cohen et al. (2019) quantitatively analyse the relationship between community resilience and the public’s confidence in the availability of healthcare services during emergency situations in Israel. Data for this study were conducted using the conjoint community resilience assessment measurement tool ( Leykin et al. 2013 ) in a household survey. Alonge et al. (2019) apply a qualitative approach to understand the relationship between community resilience and health system resilience. Combining information from key informant interviews and a national stakeholder meeting, they look at the contribution of responsible leadership and social capital into the resilience of the health system during the Ebola outbreak in Liberia. Finally, Andrew et al. (2016) take a slightly different approach to the issue of community resilience, by focusing on the resilience of community organizations involved with the relief efforts in the aftermath of the Thailand floods in 2011. Applying Bruneau et al. (2003) framework on the seismic resilience of communities, the authors quantitatively assess whether the bonding or the bridging effect made a larger contribution on the ability of organizations to deliver essential services after the crisis.

Both quantitative community resilience studies made use of an explicit framework for their analysis, while the qualitative study did not. While one study ( Cohen et al. 2019 ) focused entirely on dimensions of resilience management capacities, the other two studies explored a mix of management capacities and outcomes.

Infrastructure and thermal resilience

Three studies assessed the infrastructure and thermal resilience of hospitals, taking a purely quantitative approach. Resilience in this context is understood as the capability of buildings to withstand extreme conditions such as heat or earthquakes. Iddon et al. (2015) , Lomas et al. (2012) and Short et al. (2015) assessed the thermal resilience for specific building styles of wards in the UK in order to ensure climate change resiliency. None of these studies used specific conceptual frameworks for their analysis. In terms of the dimensions of resilience addressed, they focused entirely on dimensions of outcome, rather than management capacities. All three studies considered ways in which hospital infrastructure was able to absorb temperature changes, with two studies additionally assessing the potential for adaptation in response to these changes.

Development of preparedness checklists and assessment tools

A total of nine articles described the development of checklists to prepare for future catastrophic events or tools with which such preparedness can be measured. These have been developed at different levels: six studies focused on healthcare facilities and hospitals, two studies considered communities, while one study developed a conceptual framework at the national level.

Four articles described the quantitative development of checklists or measurement tools for assessing resilience of healthcare facilities. Dobalian et al. (2016) developed a general hospital preparedness tool, while Zhong et al. (2015) developed a framework for measuring hospital resilience and applied it to 41 tertiary care hospitals in a province in China ( Zhong et al. 2014a ). Goncalves et al. (2019) adapted and validated the short-form version of the Benchmark resilience tool for assessing the resilience of healthcare organizations. Using a mixed methods approach, Paterson et al. (2014) developed a toolkit for assessing the resiliency of healthcare facilities in the context of climate change. The methods for development differ: while Zhong et al. (2015) and Paterson et al. (2014) , respectively, used a Delphi consultation and workshops for an expert evaluation of proposed domains, Dobalian et al. (2016) , Goncalves et al. (2019) and Zhong et al. (2014a ) used psychometric assessments to assess validity and reliability. One of the instruments was operationalized as a survey of workers ( Goncalves et al. 2019 ), while the other three carried out assessments at the organizational level—either by external evaluation ( Dobalian et al. 2016 ), as a survey completed by managers of the facility ( Zhong et al. 2014a , 2015 ) or as a toolkit for facilities aiming to improve their climate resiliency ( Paterson et al. 2014 ). Finally, Meyer et al. (2018) conduct semi-structured interviews with key informants involved in the Ebola response in the USA to develop an actionable checklist to enable preparedness for future responses.

Two further papers used a qualitative approach to develop checklist for enhancing community resilience in a health system context. O’Sullivan et al. (2013 ) identify levers to promote community resilience for health during disasters using a community-based participatory research approach. Toner et al. (2017) used experiences from Hurricane Sandy collected through key informant interviews and focus groups to develop a checklist for assessing and strengthening communities’ health sector resilience.

Finally, Khan et al. (2018) conducted focus groups to develop a framework comprising of essential elements of a resilient public health system in during emergencies, using the lens of complex adaptive health systems. They discuss the importance of recognizing the interconnectedness of actors and processes during an emergency response, acknowledging that these dimensions, while crucial, are particularly difficult to measure and quantify.

Many of these studies understandably did not use a specific resilience framework, as part of the research aim was to develop key dimensions of resilience in a particular context. However, three studies did use frameworks to guide the selection of their proposed dimensions ( Zhong et al. 2014a , 2015 ; Goncalves et al. 2019 ) or the development of topics for discussion in focus groups ( O’Sullivan et al. 2013 ). Checklists tended to focus on measuring the management capacities of facilities, organizations and systems, with a noticeable trend towards a more diverse set of dimensions among the qualitative studies. Only two studies ( O’Sullivan et al. 2013 ; Khan et al. 2018 ) considered assessment of the system’s ability for absorption and adaptation.

Conceptual analysis of key empirical studies

Conceptual frameworks used.

Across the empirical studies, a specific framework for assessing resilience was used by four quantitative studies, two mixed methods studies and seven qualitative studies. The types and disciplinary origins of the frameworks differed widely. Of the concepts developed in the health systems resilience discourse, the ‘resilience index’ framework ( Kruk et al. 2017 ), ‘resilience capacities’ framework ( Blanchet et al. 2017 ) and ‘everyday resilience’ framework ( Barasa et al. 2017 ) were used. From the resilience engineering discourse, the Concepts for Applying Resilience Engineering (CARE) model ( Anderson et al. 2016 ) and the Four Cornerstones of Resilience framework ( Hollnagel 2009 ) were applied. Notably, three frameworks from the area of community resilience were used: CCRAM model ( Leykin et al. 2013 ), framework to assess seismic resilience of communities ( Bruneau et al. 2003 ) and the resilient communities framework ( Norris et al. 2008 ). Other frameworks used included the UK government’s humanitarian policy ( DfID 2011 ) and the WHO Operational Framework for Building Climate Resilient Health Systems ( World Health Organization 2015 ). Only two frameworks ( Hollnagel 2009 ; Kruk et al. 2017 ) were used twice, all other studies used distinctive frameworks for their analysis.

Dimensions of resilience addressed

We used the framework formulated by Blanchet et al. (2017) as an analytical lens allows for a more in-depth analysis of the content and dimensions of resilience addressed across the empirical papers using the definitions of management capacities and levels of resilience provided in Box 1. Across the empirical papers, 12 studies focused exclusively on resilience domains in the ex ante ‘management capacities’ side of Blanchet et al. ’s resilience definition, while 14 studies focused exclusively on absorptive, adaptive or transformative levels of the resilience process. Fourteen studies considered both management capacities and resilience levels. Qualitative studies more often considered both management capacities and resilience levels, while quantitative studies more often exclusively focused on one of the two ( Figure 4a ). Among the management capacities, the dimension of ‘uncertainty’ was most frequently assessed by all types of research, followed by dimensions of ‘interdependence’, ‘knowledge’ and ‘legitimacy’, in that order ( Figure 4b ).

(a–c) Domains of resilience addressed by key papers ( n  = 40), by research methodology.

Among the ex post resilience levels, ‘absorptive capacities’ was most frequently addressed across research types, although qualitative research explored ‘absorptive capacities’ and ‘adaptive capacities’ to an equal extent ( Figure 4c ). Only a limited number of quantitative and mixed methods studies considered the ‘adaptive capacities’ and ‘transformative capacities’ dimensions of health system resilience.

Looking across management capacities and resilience levels, qualitative research was able to address a much broader range of dimensions than quantitative research, with individual studies often exploring multiple dimensions of the resilience concept ( Figure 4b and 4c ).

Quantitative indicators used

A total of 24 studies used quantitative indicators to measure different aspects of the resilience concept, with several studies using multiple indicators across multiple domains of responsiveness ( Table 4 ). The reported indicators were collected using different data collection strategies, including the use of routine data, observational data and primary survey data. The indicators further differed in the level at which data were collected, spanning national, organizational, staff and patient/population levels. Across the ‘management capacities’ domains, several indicators at different levels of data collection addressed the domains of knowledge, uncertainties and interdependence. However, only two indicators, both collected at population level, captured the legitimacy dimension. Across the ‘levels of resilience’ domains, several studies used indicators across different levels of data collection for the ‘absorption’ domain. However, only three indicators were used for the ‘adaptation’ domain, collected at national and organizational level, while no indicators were identified for the ‘transformation’ domain.

Resilience indicators used in quantitative and mixed methods studies ( n  = 24), by resilience domain and level of data collection

The concept of health system resilience has soared in popularity in the health system field over the last years, not just in the theoretical or political discourse but also as an object of empirical inquiry. Its application has been incredibly diverse, with research from different disciplines applying the concepts in different healthcare sectors and in various settings. This diversity is not itself problematic. However, this review has demonstrated that empirical studies fundamentally differ in the way that resilience is understood in a health system context.

In terms of the content of the studies, much empirical research focuses on service delivery, health workforce or governance issues, whereas resilience of other health system building blocks is either barely studied, such as health financing, or only studied in high-income countries, as is the case of health information systems. This shows a distinct gap between the concepts and the operationalization of resilience in the context of health system research. If research on health system resilience is to live up to recent comprehensive definitions, the focus has to widen: all building blocks are interlinked and essential for well-functioning health systems, and should therefore not be analysed in singularity, but be considered jointly when assessing health system resilience.

Furthermore, despite much theoretical work on the dimensions which constitute health system resilience, we found that most of the empirical literature only addressed particular aspects. Applying the dimensions outlined by Blanchet et al. (2017) , we found that the importance of developing legitimate institutions appears to be neglected in empirical research. This is particularly concerning given that a lack of in healthcare institutions has recently emerged as one of the key barriers to the continued functioning of the health system, e.g. in the context of the Ebola outbreak ( Kittelsen and Keating 2019 ). The ability of health systems to demonstrate transformative capacities has been similarly under-evaluated, especially in quantitative research. Very few empirical studies took an approach to resilience that takes into account the various nuances in the conceptualization of the term which have recently emerged. This trend appeared to be particularly pronounced in those studies with a quantitative or mixed methods approach.

Thus, there is a mismatch between the conceptual models of health system resilience and the way resilience is understood and applied in empirical research both in terms of the breadth of health system factors considered and in terms of the resilience dimensions which are taken into account. Part of the issue may be that the empirical literature assessed in this review comes from a broad range of disciplines, with differing traditions of how ‘resilience’ is understood. While different traditions can offer unique and potentially complementary perspectives on the topic of resilience, this underlines the importance of more clarity in the empirical literature about which concepts and definitions are applied, and how these are then operationalized.

However, only very few empirical studies make use of an explicit conceptual framework for collection or analysis of data, thus not linking research objectives to the rich theoretical body of work on how resilience can be understood in a health system context. Arguably, those studies assessing resilience at a national level were most cognizant of using conceptual frameworks for their analysis. Our review showed that these studies were best able to capture the multiple dimensions of health system resilience. While several other studies aimed to measure health system resilience, they subsequently operationalized this concept in a very narrow way, e.g. by measuring only health service utilization, infrastructure resilience or emergency preparedness. Encouraging the use of an explicit framework for health system resilience could help to strengthen the links between the conceptualization and the operationalization of resilience, thus improving our understanding of health system resilience in different contexts and settings.

Our review further demonstrates that qualitative articles tend to employ a more comprehensive approach to the resilience concept than quantitative studies, which are often limited by availability of data and indicators to few aspects of resilience. The mismatch between concepts and research, therefore, appears to lie not in a lack of appreciation for the complexities of the resilience concept, but rather in a lack of measurable indices which reflect this complexity. While the proposed resilience index ( Kruk et al. 2017 ) specifies a list of potentially measurable indicators, so far these have only been operationalized in qualitative research. Similarly, the ‘resilience capacities’ framework specified by Blanchet et al. (2017) , and the ‘everyday resilience’ framework by Barasa et al. (2017) have been operationalized exclusively in qualitative research. All identified quantitative studies have utilized frameworks originating in discourses tangential to the health system resilience discourse.

Yet so far there has been no discussion about which aspects of the health system resilience frameworks are actually measurable. Within the ‘resilience capacities’ framework, the identified studies demonstrate that it is possible to measure ‘absorptive’ aspects by comparing levels of service provision and utilization in different circumstances. However, this is more challenging for ‘adaptive’ and ‘transformative’ aspects. Understanding whether a health system has truly transformed itself in response to a challenge needs to take into account multiple contextual factors and thus lends itself more naturally to be answered by qualitative methods and policy analysis, but also to complexity science. Equally, studies were able to quantitatively assess the presence or absence of preparedness plans to deal with uncertainties and data collection mechanisms for an improved knowledge of potential challenges, but quantifying the ability to handle cross-scale dynamics and develop legitimate institutions proved to be more difficult to capture. Incidentally, the identified studies developing resilience checklists and measurement tools all took a very narrow perspective of resilience by focusing on single healthcare facilities and organizations.

The key question in the development of a comprehensive resilience index, or a measure that allows for effective combination of quantitative and qualitative aspects, becomes whether the requirements to create a comparable measurement tool can be reconciled with the very broad and comprehensive definition of resilience which has emerged from an understanding of health systems as complex adaptive systems. According to Haldane et al. (2017) the resilience concept ‘should […] not be prescriptive, but have breadth and flexibility, recognize complexity, consider shocks and cumulative stresses, attempt to deal with disruptions and anticipate future failures’. It appears that, so far, the qualitative literature has been more successful in translating such a comprehensive framework into research practice, while quantitative studies have been limited both by theoretical models and a lack of appropriate data with which to measure resilience. Thus a key task for future researchers in the resilience field will be not only how the resilience concept can be operationalized, but—acknowledging that quantitative assessment of resilience in its entirety is illusionary—determine how measureable aspects can be combined with qualitative aspects in a way that allows for an assessment of health system resilience as a dynamic, complex phenomenon. Thus further research is required for the development of an operational framework on health system resilience which seamlessly integrates both qualitative and quantitative evidence; knowledge from existing guidelines on integrating quantitative and qualitative knowledge, e.g. in the realm of assessing the effectiveness of complex interventions, could be utilized for this purpose ( Noyes et al. 2019 ).

Our review adds to the existing conceptual review by Turenne et al. (2019) , who argue that the concept of health system resilience is still in infancy. We demonstrate the implications of this conceptual immaturity on existing empirical research: while the qualitative literature has explored the notion of health system resilience in its broad definition, the quantitative literature has been limited by the lack of clearly defined characteristics, preconditions and limits of the concept.

Our review makes a substantial contribution to the health systems research literature by analysing the operationalization of the health system resilience concept in empirical studies. Due to our inclusive search and broad inclusion criteria, we were able to consider a broad range of relevant articles from multiple disciplines and thus demonstrate the influence of other disciplines in the health systems research field. However, as search terms were geared to finding articles which specifically referred to the resilience concept, we may have missed empirical studies which operationalized aspects of resilience, but used different terminology. Further research could specifically identify such studies by using elements of the resilience definition instead of merely using the term itself. This could also help to better gain an understanding of how the concept of resilience overlaps with other health systems concepts such as health system strengthening or health system responsiveness and map potential synergies in assessment. We also did not include secondary research or grey literature in our review, which may provide further useful information on the operationalization of the resilience concept. Further research is needed to combine and integrate knowledge from these diverse sources in a comprehensive assessment framework.

A further limitation of our study is the initial exclusion of items based on titles, which was necessary due to the sheer number of results. This may have excluded several studies in associated disciplines, such as those relating to community resilience, which are of importance to the health systems resilience discourse. Findings of our review should be complemented by reviews of the resilience concept in other disciplines to check for congruence.

The health systems research community has made substantial advances in the conceptualization of health system resilience and its potential for the analysis of health systems in changing environments. However, the empirical literature has not yet caught up with the complexities of the concept: there is a mismatch between the nuances and the breadth of the concept at a theoretical level and the way it has been operationalized in empirical studies. In order to do justice to the complexities of the resilience concept, knowledge from both quantitative and qualitative research traditions should be integrated in a way that resilience as a complex, adaptive phenomenon. Only once a comprehensive assessment framework has been defined and applied across different research contexts will the theoretical ‘resilience idea’ be able to more convincingly prove its usefulness for the research community.

Supplementary Material

Czaa032_supplementary_file, acknowledgements.

The authors are supported by a grant from the German Federal Ministry for Education and Research (BMBF) in the scope of the project RESPOND (Grant number: 01GY1611). Further grants are received by the German Science Foundation (DFG) in the scope of the Research Unit PH-LENS and its subproject NEXUS (Grant no: FOR 2928 / BO 5233/1-1). The funders had no influence on study design, analysis or decision to publish.

Conflict of interest statement . None declared.

Ethical approval. No ethical approval was required for this study.

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ORIGINAL RESEARCH article

Urban amenity and urban economic resilience: evidence from china.

• 1 School of Economics, Huazhong University of Science and Technology, Wuhan, Hubei, China
• 2 International Business School, Shaanxi Normal University, Xi'an, Shaanxi, China

Under the influence of multiple uncertain factors at home and abroad, urban amenities, as the underlying support for urban renewal activities, are of great significance in enhancing urban economic resilience. The panel data of Chinese cities from 2011 to 2019 is used in this study. Urban amenity is measured from artificial amenities and climate amenities, respectively. By using a two-way fixed effects model, we empirically test the impact of urban amenities on urban economic resilience. The key findings of this study are as follows. (1) Urban amenities can significantly enhance urban economic resilience. (2) Heterogeneity analysis shows that there are regional differences in the role of urban amenities in promoting urban economic resilience, with cities in the eastern region, strong environmental regulations, and high urbanization rates benefiting more. (3) We further find that urban amenities mainly enhance economic resilience by promoting population agglomeration, attracting labor migration, improving the quality of human capital, and stimulating urban innovation. Our conclusions recommend to rationally allocate and optimize urban amenity resources, strengthen urban planning and construction management, and create a more livable urban environment, thereby enhancing urban economic resilience.

1 Introduction

Amid the complex backdrop of markedly increased internal and external environmental risks and the continued instability of the global economic situation, the Chinese economy is facing unprecedented challenges ( 1 , 2 ). Enhancing economic resilience and ensuring stable economic operations have become critical issues that urgently need to be addressed in the process of achieving sustainable economic development ( 3 ). Urban economic resilience refers to the adaptability and resilience of the economic system of a city in the face of external shocks and changes ( 4 ), and is a concentrated expression of whether a country or region could effectively cope with the uncertainty shocks or resist and resolve economic risks. Improving the economic resilience of cities is conducive to the stability of the urban economic system and the high-quality development of the urban economy and society, which is an important focus of urban construction and development, and an inevitable choice for building a new urban development pattern. However, previous studies on the factors affecting urban economic resilience mainly focus on land, labor and capital ( 5 – 7 ). This model of improving urban economic resilience from the perspective of industrial production ignores the “human” factor and the essential needs of human beings, leading to problems such as urban environmental pollution, traffic congestion, too little public space, and shortage of leisure and entertainment facilities. These consequences could constrain the improvement of urban economic resilience. Particularly, China has experienced a rapid urbanization process, with hundreds of thousands of people moving from the countryside to the cities, which has led to a rapid expansion in the size of cities, and cities are facing great challenges in resource allocation and environmental pollution control ( 8 ). Researching urban amenities and economic resilience helps understand how Chinese cities perform in this dynamic change and contributes to the formulation of sustainable urban development strategies.

The Chinese government pointed out that the level of urban planning, construction and governance should be improved, and urban renewal actions should be carried out to build livable cities. In the context of China's new-type urbanization with “people” as the core and people's increasing expectations for a high-quality living environment, urban amenities and livability have become key elements to attract talents, promote innovation and cultivate emerging industries ( 9 ), and are directly related to the quality of life of urban residents and the efficiency of resource utilization in cities ( 10 ). Therefore, the construction of urban amenities not only concerns the quality of life and welfare of individuals but has also become a new driving force for enhancing the overall competitiveness of cities. It could have a positive impact on the long-term economic resilience of cities. Within the overall framework of urban growth theory, research on urban amenity can effectively address the deficiencies of traditional growth theories in explaining urban economic resilience, aiding city policymakers in the rational planning of urban comfort facilities. This approach could enhance local attractiveness and, consequently, improve long-term economic resilience. However, to date, there is scarce literature that delves into the impact of urban amenity on urban economic resilience from both theoretical and empirical perspectives. Therefore, in the context of increasing economic uncertainty, could enhance urban amenity lead to improved economic resilience in cities? What pathways and mechanisms facilitate this impact? Exploring these questions can expedite urban renewal activities, promote the construction of comfortable and livable urban environments, and provide policy direction and practical guidance for exploring ways to strengthen urban economic resilience.

The remaining part of this paper is organized as follows: Section 2 presents the literature review; Section 3 provides theoretical analysis and research hypotheses; Section 4 outlines the setting of the econometric model and variable explanations; Section 5 presents empirical analysis results; Section 6 concludes the paper and provides research insights.

2 Literature review and theoretical analysis

2.1 literature review.

With the development of information technology in the post-industrial era, cities have become not only carriers for economic benefits but also organic entities that meet the growing needs of residents. In this context, the theory of urban amenity has emerged. Foreign research on urban amenities mainly focuses on the connotation of urban amenities, the evaluation of urban amenities and its realistic value. Amenities are categorized into natural amenities, artificial amenities, and social atmosphere amenities based on the connotation of amenities. The study that urban amenities as pleasant living conditions that could promote population growth and economic growth ( 11 ). Some scholars believe that urban amenity also include various amenities that make residents feel physically and mentally pleased and attract them to live and settle in the city ( 12 ). Rogerson ( 13 ) argued that urban amenities not only enhance the happiness and satisfaction of city residents but also attract investors and innovative talents, serving as a novel external marketing strategy ( 13 ). In the evaluation of amenities, foreign studies mainly measure urban amenities through the following three methods. First, economists generally use housing prices and wage levels to reflect urban amenity, and use hedonic price models to quantify it ( 14 ). Second, a questionnaire is used to investigate the perception of comfort at the individual level ( 15 ). Third, conduct a comprehensive evaluation based on the connotation construction index of amenity items ( 16 , 17 ). In addition, previous research has found that urban amenities can not only provide social value such as culture and art, but also promote urban economic development, thereby generating economic value ( 18 ). Currently, the research on urban amenities in China is mainly based on China's rapid urbanization process and the orientation of urban sustainable development policies, which provides an important research background. Research on urban amenities in China focuses mainly on two aspects: first of all, combined with the reality of China's development, the criteria for the construction of China's amenity system and the dynamic evolution process are proposed ( 19 ); secondly, empirically testing the economic effects of urban amenities on urban development, such as influencing land prices, increasing the degree of industrial agglomeration, and attracting labor inflow ( 20 – 22 ).

As the risks of uncertainty increasingly mount, the study of economic resilience has attracted widespread interest from scholars around the world. Davies explains economic resilience from three dimensions: first, the ability of an economy to withstand external risks and challenges, second, the ability of an economy to recover from negative shocks through self-regulation after the impact, third, the ability to innovate new growth pathways, enhancing the capacity for long-term growth ( 23 , 24 ). Currently, there are various methods for measuring economic resilience, ranging from the sensitivity index method to comprehensive indicator evaluation methods ( 25 – 27 ). Urban economic resilience is thought to be determined by the dynamics of four interacting subsystems: the structural and business subsystem, the labor market subsystem, the financial subsystem, and the governance subsystem ( 4 ). Firstly, in terms of industrial structure and business system, existing scholars mainly study the impact of diversified or specialized industrial structure and technological innovation on economic resilience ( 5 , 28 , 29 ). Secondly, in labor market and financial subsystem, some scholars study the impact of human capital ( 30 ) and digital finance ( 23 , 31 ) on economic resilience. Finally, there are also scholars discussing the influence factors of economic resilience from the perspective of governance such as policy support and political systems ( 32 , 33 ).

Existing theoretical and empirical research on urban amenities and urban economic resilience provides a solid foundation for this paper. However, there are still two shortcomings. Firstly, while current studies have examined the impact of various factors on urban economic resilience, there has been less focus on the influence of urban amenities on urban economic resilience. Therefore, the relationship and impact mechanisms between urban amenities and urban economic resilience require further in-depth research. Secondly, the current methods for measuring different urban amenities levels need improvement. Existing studies often measure urban amenities from the perspective of guaranteeing indicators such as transportation, medical care, and the environment, with less consideration for social factors such as education and culture within the city. In the meanwhile, there is also less focus on the impact of climate amenities on urban economic resilience. Therefore, this paper takes 255 prefecture-level cities nationwide as the research objects, constructs artificial amenities and climate amenities, and studies the impact and internal mechanisms of urban amenities on urban economic resilience.

The marginal contributions of this paper may be reflected in three aspects. Firstly, existing research primarily focuses on the impact of industrial structure ( 6 ), technological innovation ( 5 , 28 ), regional integration ( 7 ), infrastructures ( 34 ), digital finance ( 23 , 31 ), and on economic resilience. Unlike previous studies that mainly focused on economic perspectives in studying economic resilience, this paper starts from the basic needs of “people,” using urban amenities as an entry point to explain how to enhance economic resilience. It supplements relevant studies on factors influencing urban economic resilience.

Secondly, previous studies have often selected indicators focusing on the natural environment and infrastructure to measure urban amenities ( 35 , 36 ), with less emphasis on indicators related to healthcare and transportation. We chose a broader range of suitable indicators to assess the state of urban medical services and transportation infrastructure, thereby more comprehensively measuring urban amenities. Additionally, previous studies mainly used temperature and humidity indexes to study climate amenities ( 36 , 37 ). In our study, based on the national standard for Climatic Suitability Evaluating on Human Settlement formulated by the Chinese government, we measure urban climate amenities more comprehensively, considering factors such as city temperature, humidity, wind speed, and sunlight duration. Thus, our construction of indicators more fully reflects both the artificial and climate amenities of cities, enhancing the accuracy of the indicators.

Thirdly, in terms of research content, we will identify external factors that differentiate the impact of urban amenities construction on urban economic resilience. This paper conducts a heterogeneity analysis from the perspectives of local environmental governance and regional development situations, expanding the directions in which urban amenities exert positive effects and the application scenarios of amenity theory, providing a new development approach for urban development models, offering more targeted support to comprehensively enhance urban economic resilience. Furthermore, from the perspective of urban population aggregation effects and innovation effects, we explore the potential impact mechanisms of amenities construction on urban economic resilience. Through comprehensive analysis of various channels, it helps identify the underlying logical impact.

2.2 Theoretical analysis and research hypotheses

Cities with more amenities can attract highly mobile resources such as capital, technology, and manpower, as well as foreign consumers and investors. This improves the city's competitiveness in acquiring these resources, thereby improving the urban quality and overall competitiveness as a comprehensive consumer product ( 38 ). This is beneficial for strengthening urban economic resilience. In addition, cities that are rich in amenities such as cultural institutions, educational facilities, and leisure spaces generally exhibit higher levels of economic diversification and complexity ( 39 ). The diversity of the economic system can help cities reduce their dependence on a single industry, enhance the city's ability to withstand stress, and enable cities to better cope with the risks of economic uncertainty. In an era of rapid urbanization, urban amenity has received attention for its key role in shaping urban development patterns and enhancing economic resilience.

2.2.1 Urban amenity and population agglomeration effects

Firstly, according to the amenity migration theory, amenities in terms of natural environment, service environment, social culture, etc. are the main reasons for attracting population agglomeration and labor mobility. People tend to choose to move to cities with superior natural environments such as warm winters, cool summers, abundant sunshine, abundant green space and vegetation, and less pollution ( 40 , 41 ). They also tend to move to cities with comfortable service environments such as diverse dining facilities, shopping malls, and efficient transportation infrastructure. At the same time, cities with more amenities develop faster and are more able to attract labor to move in, because cities with high amenity levels not only provide higher economic income but also provide a better quality of life ( 18 ). The process of population agglomeration in high-amenity cities will enhance urban economic resilience. On the one hand, the scale effect caused by population agglomeration can reduce transaction costs and create demand, support stable urban economic growth, and thereby enhance economic resilience. Population agglomeration can bring abundant labor resources to cities, provide enterprises with a variety of labor forces with professional skills, and reduce enterprises' labor search costs ( 29 ). It can also improve the allocation level of factor resources and improve economic efficiency, thereby enhancing urban economic resilience ( 30 ). Population agglomeration can also provide enterprises with a higher degree of talent adaptability, which can effectively avoid sharp changes in enterprise labor demand after economic shocks, quickly realize adaptive production structure adjustments, and thereby achieve sustainable economic resilience. In addition, as the population agglomerates in cities, it will expand the city's internal market demand, prompting industrial entities to produce more products. It will also prompt the government to increase infrastructure construction and improve the level of public services such as education and medical care, thereby reducing the impact of sudden changes in the external environment ( 17 , 30 ). On the other hand, population agglomeration can also produce external effects. Population agglomeration will lead to the expansion and sharing of the labor market, which is conducive to increasing the degree of industrial agglomeration, promoting the refinement of the city's industrial division of labor, and forming an industrial structure system with complementary functions ( 42 ). The diversified industrial agglomeration has the function of an automatic stabilizer, which can effectively enhance urban economic toughness ( 43 ). Thus, urban amenities can increase population aggregation, thereby enhancing urban economic resilience.

Secondly, cities that offer a high quality of life, rich cultural experiences, a good social environment and diverse opportunities tend to attract more highly skilled people ( 44 ). Florida refers to the human capital that generates new technologies, knowledge and art as the “creative class,” which plays a decisive role in the innovative development of cities ( 45 ). Compared with low-skilled labor, high-skill “creative classes” are more sensitive to the living environment and working environment. A more comfortable environment can improve the work satisfaction and comfort of high-skilled talents, improve the efficiency of labor work, and reduce the loss of human capital ( 46 ). Multi-level and multi-skill labor can provide high-quality human capital for the professional industrial chain of the enterprise, and human capital is the key element of regional economic resilience construction ( 47 ). High-quality human capital can accelerate the flow and diffusion of innovative elements, release consumer domestic demand, and stimulate income effects, etc., promote the sustainable development of cities and enterprises ( 48 ). It gives cities the ability to adapt and resist external impact and enhance the urban long-term economic resilience ( 49 ). Therefore, cities with higher comfort standards such as culture and public services can attract the inflow of high-tech talents, and increase the local human capital stock, thereby promoting the high-quality development of cities and enhancing urban economic resilience ( 50 ).

2.2.2 Urban amenity and innovation effects

As mentioned above, urban amenity is a key influencing factor of talent migration. Cities with higher levels of amenities are more able to attract innovative talents, and the comfort migration of talents can enhance urban economic resilience by stimulating innovation ( 51 ). Firstly, high-amenity cities can provide more space and facilities for relieving stress for innovative talents facing high work pressure, helping to create an inclusive and diverse social atmosphere, and providing greater social support for high-risk innovation ( 52 ). Secondly, a pleasant and comfortable environment, along with an innovative atmosphere, contributes to lowering the “talent entry barrier” ( 38 ). It encourages employees to showcase their abilities, enhances the enthusiasm for technological innovation among talents, attracts innovative companies and venture capital institutions, prompts cities to increase policy support for innovation resources, reduces innovation costs for relevant enterprises, and improves overall innovation efficiency. Finally, the concentration of innovative talents with diverse knowledge backgrounds in highly comfortable cities may lead to higher levels of technological spillover. Not only does this enhance the diversity and depth of technology, but it also encourages open and diverse innovative thinking, thereby expanding the boundaries of urban innovation ( 53 ). In addition, well-established infrastructures such as communication facilities can also facilitate technical exchange and information sharing among different cities, creating a diversified pool of technologies and a spillover effect of knowledge. The basis of promoting the efficient integration of traditional factors, drives the emergence of innovative schemes and products, providing businesses with more technological choices and higher-quality technological innovation ( 54 ). Furthermore, the technological innovation of cities also contributes to enhancing the city's economic resilience. On the one hand, innovation can improve the efficiency of resource allocation and the output efficiency of production factors. It can eliminate old production models and expand the scope of use of production factors, thereby deepening specialization, exerting the core driving force of market entities, and thus enhancing economic resilience ( 5 , 55 , 56 ). On the other hand, innovation can drive industrial structural transformation and upgrading, promote the transformation of industries toward rationalization, diversification, and sophistication, improve the overall division of labor and cooperation level of the urban economy, and enable cities to have a strong economic foundation to cope with adverse shocks ( 57 ). Therefore, urban amenities affect the spatial mobility of innovative talents, enhancing the level of urban innovation, and thus forming a city development model of “city amenity attracts talents, talents stimulate innovation, and innovation enhances resilience.”

Based on this, this paper proposes the following hypotheses:

Hypothesis 1: The improvement of urban amenities can enhance the city's economic resilience.

Hypothesis 2: Urban amenities can enhance economic resilience by promoting population agglomeration, attracting labor migration, and increasing the quality of human capital.

Hypothesis 3: Urban amenities can enhance the city's economic resilience by enhancing urban innovation.

In conclusion, the research framework is shown in Figure 1 . It includes impact effects and impact mechanisms.

Figure 1 . Influence diagram of the mechanisms by which urban amenity affects urban economic resilience.

3 Methods and data

3.1 empirical model.

We control individual fixed effects and time-fixed effects. Individual fixed effects are used to control unobservable individual characteristic factors that do not change over time at the individual level but affect urban economic resilience. Time-fixed effects are time-characteristic factors that do not change with individuals but affect urban economic resilience. Fixed effects models can reduce endogeneity problems caused by omitted variables ( 58 ). We use Equation 1 to verify the impact of urban amenities on urban economic resilience.

Where i and t represent the city and time, respectively, j represents the j -th control variable; Resilience represents the economic resilience of the city, Amenity represents the level of artificial amenities of the city, X represents control variables, μ i represents city fixed effects, δ t represents time fixed effects, and ε it is the error term.

3.2 Variables

3.2.1 dependent variable.

There are two main methods for measuring urban economic resilience. One is the indicator system method, which uses a series of indicators to measure economic resilience ( 59 , 60 ). However, the indicator method has certain flaws. There is still no recognized reasonable indicator, and it is easy to confuse the causal relationship. The indicators used by researchers may be the reason why cities have economic resilience. Another method is to measure economic sensitivity indicators such as employment and GDP. Considering that the single indicator method has the characteristics of representativeness and continuity, we use this method to measure economic resilience ( 61 ). At the same time, considering that GDP is the core indicator of urban economic development, the sustained growth of urban GDP is the basis for solving a series of problems such as employment and welfare, and can directly reflect the ability of the urban economy to withstand shocks. Therefore, this article draws on Martin's economic sensitivity index and calculates urban economic resilience based on the ratio of the growth rate of urban regional GDP to the growth rate of China's national regional GDP ( 62 ). The city's economic resilience is evaluated by comparing the sensitivity index value with 1. If the sensitivity index is >1, then the city is more resilient and resistant to shocks than the national average, so the city is more resilient.

3.2.2 Independent variable

At present, urban amenity is mainly measured by constructing an index system. Referring to the research of Diamond ( 46 ) and Zhang and Fang ( 20 ), our selects five major categories of indicators: culture, education, medical care, transportation, and environment, and uses the analytic hierarchy process to construct a comprehensive index that reflects urban artificial amenity (Amenity). We first constructed a hierarchical evaluation index system based on the principles of systematicness and availability of indicators. To avoid randomness in indicator selection, we fully draw on previous research and suggestions from experts in related fields. Secondly, use the upper-level indicators as the benchmark, compare each indicator at the same level, construct a judgment matrix, conduct consistency testing, and determine the weight of each indicator. Finally, according to the weighting method, the weight value of all indicators at this level to the previous level is calculated, and the comprehensive weight is obtained layer by layer. Previous literature also used the entropy weight method to calculate index weights, but the entropy weight method will lead to the loss of data information ( 63 ). Therefore, we use the analytic hierarchy process to determine specific weights. The five major categories of indicator data are all from the “China Urban Statistical Yearbook.” Table 1 reports the types and specific descriptions of the five major categories of indicators. We constructed the urban amenity variable based on these indicator systems.

Table 1 . Selection of indicators for principal component analysis of urban artificial amenities.

In the robustness test, we constructed a climate amenity index (Climate) based on the climate amenity evaluation standard for human settlements proposed by the China Meteorological Administration (GB/T 27963-2011) and replaced artificial amenity with climatic amenity as a proxy variable for urban amenity. The steps to construct climate amenities are as follows. The temperature and humidity index I and wind efficiency index K are calculated according to the following formulas (2) and (3), respectively. Based on the availability of data, the wind efficiency index is used in areas where the average wind speed during the evaluation period is >3m/s, otherwise, the temperature and humidity index is used. Finally, to ensure a consistent trend, according to the classification table of human settlement environment amenity levels in Table 2 . Reassign “levels 1 and 5, levels 2 and 4, and level 3” to 1, 2, and 3, that is, the higher the value, the more comfortable the urban climate will be.

Table 2 . Habitat amenities classification table.

We use Equation 2 to calculate the temperature and humidity index. Among them, I represents the temperature and humidity index, T represents the average temperature during the evaluation period, and RH represents the average relative air humidity during the evaluation period.

We use Equation 3 to calculate the wind efficiency index. Among them, K represents the wind efficiency index, T represents the average temperature during the evaluation period, V represents the average wind speed during the evaluation period, and S represents average sunshine hours during the evaluation period. We construct an urban climate amenity index from this standard design.

3.2.3 Control variables

When conducting empirical analysis, we refer to the research of Xu and Deng ( 56 ), Feng et al. ( 7 ), and Zhang et al. ( 64 ), and select economic scale, financial development level, fixed asset scale, industrial structure, fiscal expenditure and urban freight carrying capacity as control variables. 1. Economic scale (GDP). Cities with larger economies have stronger economic bases and resources in multiple dimensions, making them better able to adapt and respond to adverse economic conditions. This article uses the logarithm of GDP to measure the economic size of a city. 2. Financial development level (Finance). Cities with high financing potential are often able to attract more resources and investments, which can help cities build more resilient economies. We measure it by the ratio of deposit balances of financial institutions to GDP at the end of the year. 3. Scale of fixed assets (Investment). The scale of fixed assets is measured by the ratio of the city's total fixed assets to GDP. 4. Industrial structure (Structure). A diversified industrial structure can not only disperse the risks of economic shocks in a short period but also promote regional innovation and new technology innovation, allowing cities to adapt to resource reorganization and structural transformation and adjustment after the crisis. 5. Financial expenditure (Expenditure). Fiscal spending can improve economic resilience by stimulating demand, building infrastructure, and providing social protection. The city's financial expenditure is measured as the logarithm of the city's general fiscal budget expenditure. 6. Urban freight carrying capacity (Freight). The city's transportation infrastructure helps the city resist the impact of economic risks. The city's freight carrying capacity is measured by the logarithm of highway freight volume.

3.2.4 Mechanism variables

We select the following variables as mechanism variables. 1. Population aggregation (Population). We measure the degree of population agglomeration using the logarithm of urban population density. 2. Labor supply and human capital. Labor supply (Labor) is measured by the ratio of the number of urban employees to the total population at the end of the year. Human capital stock (Humancap) is measured by the number of students in school. 3. Urban innovation. This article uses the following two indicators to evaluate urban innovation: the number of urban patent applications (Patent) and the level of R&D investment (R&D). The level of urban R&D investment is measured by the ratio of urban science education expenditure to GDP.

Considering the completeness of the data and the impact of public events, our study selects 255 cities in China from 2011 to 2019 as research samples. All macro-level data of cities are sourced from the “China Urban Statistical Yearbook.” The climate amenities indicators selected in this study include variables such as average temperature, average relative humidity, average wind speed, and average hours of sunshine for each city. The original meteorological data are obtained from the China Surface Climate Data Daily Value dataset (V3.0). We refer to the design method of Deschênes and Greenstone ( 65 ). We use the inverse distance weighted interpolation method (IDW) to interpolate daily meteorological data into grid data, and then obtain annual meteorological data for each district and county. To eliminate the influence of extreme values, all continuous variable data are trimmed by 1% above and below.

3.4 Probability density plot and descriptive statistics

Figures 2 , 3 respectively present the three-dimensional probability distribution diagrams of urban resilience and amenity of Chinese cities over the years. From Figure 2 , it can be observed that the dispersion and right-skewness of the amenity probability distribution in Chinese cities are increasing year by year, the right tail is lengthening year by year, and the range is gradually expanding. The reason is that although the resilience values in the high quantile increase year by year, the values in the middle and low quantiles do not increase significantly, resulting in the gradual widening of the spatial gap in amenity among Chinese cities. From Figure 3 , we can understand that the overall distribution of urban resilience in China fluctuates violently over the years, and the concentration ratio shows an “S”-shaped trend of first declining, then rising, and then falling again. Overall, there has been no significant improvement. Compared with other years, China's urban resilience was generally low in 2011, while in 2017 China's urban resilience was generally high. This may be due to the impact of the global financial crisis in 2008. China's resilience had not yet fully recovered in 2011. After 2015, China's implementation of supply-side structural reforms revitalized urban resilience. Secondly, we can also find that the spatial differences in urban resilience in 2019 are large, which may be due to the severe differences in urban resilience in China due to the Sino-US trade dispute in 2018. The above characteristics show that China's urban resilience still has room for optimization and improvement.

Figure 2 . Probability density plot of amenity.

Figure 3 . Probability density plot of resilience.

Descriptive statistics of variables are presented in Table 3 . The mean value of resilience is 1.198, that is, the majority of urban economies demonstrate resilience. In addition, the average value of urban amenity is 2.295, the minimum value is 0.769, and the maximum value is 7.152, indicating that there is a significant difference in amenity levels in various cities.

Table 3 . Descriptive statistics.

4 Empirical results analysis

4.1 baseline regression results.

The baseline regression results are shown in Table 4 . Column (1) only includes core explanatory variables, and the results show that the improvement of urban amenities can significantly increase the economic resilience of a region. When control variables, city fixed effects, and year fixed effects are added in sequence from column (2) to column (5), the goodness of fit of the model is significantly improved. At the same time, the test results all show that the impact of urban amenities on urban economic resilience is significantly positive. As can be seen from column (5) in Table 4 , after controlling for other factors, every 1-unit increase in urban amenities will increase urban economic resilience by 0.091 units. This result shows that the improvement of urban amenities can significantly enhance urban economic resilience. Economic resilience. Hypothesis 1 was verified.

Table 4 . Baseline regression results.

4.2 Robustness test

4.2.1 replacing the dependent variable.

In the robustness test, we use two alternative indicators to measure the economic resilience of cities. The first method follows the research of Tan et al. ( 66 ), using China's annual actual GDP growth rate as the counterfactual basis for urban development, then calculating the difference between each city's annual actual GDP growth rate and this counterfactual basis, and using this difference to reflect the city's economic resilience level. This difference is used to construct a sensitivity index reflecting the level of economic resilience of cities. We put the sensitivity index into the benchmark model for regression, and the regression results are shown in column (1) of Table 5 . The second method draws on the relevant research by Chen ( 67 ), using the regional employment sensitivity index to measure China's economic resilience and perform regression using the ratio between the change rate of urban employment and the change rate of national employment as the proxy explained variable. Regression is conducted with the ratio of the change rate of urban employment to the change rate of national employment as the proxy for the explained variable. The regression results are shown in column (2) of Table 5 . The results all show that urban amenities can improve the economic resilience of the city, validating the baseline regression results.

Table 5 . Robustness test.

4.2.2 Replacing the independent variable

This study replaces urban artificial amenity with the climate amenity index. The empirical results are shown in column (3) of Table 5 . The results show that climate amenities can significantly improve a city's economic resilience. The possible reason is that improved climate amenities are more conducive to attracting population agglomeration and business investment. Cities with a pleasant climate are usually rich in natural resources and ecosystem services, which not only provide urban residents with natural places for leisure and entertainment but also help improve their health and quality of life. High-quality ecosystem services can also attract more tourists and businesses, promoting the vigorous development of tourism and cultural industries. In addition, the improvement of investment attractiveness will help promote the city's infrastructure construction and industrial diversity development, thereby improving the city's overall economic level and enhancing the city's economic resilience.

4.2.3 Excluding capital cities samples

As the administrative center of a province, provincial cities usually receive more government support and often have stronger resource attraction. These cities have large populations, high levels of economic development, complete infrastructure, and resource advantages in the construction of urban amenities. The interaction of these factors helps to improve the ability of provincial capital cities to cope with challenges and uncertainties, so the economic resilience of provincial capital cities may be stronger. Therefore, compared with non-provincial capital cities, provincial capital cities have a certain “siphon effect” in terms of resource acquisition and policy support, which may have an impact on the empirical results. To improve the credibility of the research conclusions, the empirical analysis was re-conducted after deleting provincial capital city data from all samples. Column (4) of Table 5 reports the results of regression on all non-provincial capital city samples after excluding provincial capital cities. A one-unit increase in urban amenities is associated with a 0.119-unit increase in economic resilience for non-capital cities. After provincial capital cities are eliminated, non-provincial capital cities without excess resources can also improve urban economic resilience through the construction of amenities. The results show that the impact of urban amenities in non-provincial capital cities on the city's economic resilience is still significantly positive, and the baseline regression is robust.

4.2.4 Different samples and variable selection

We further select different samples and variables for robustness testing. Firstly, to further reduce the impact of extreme values on model estimation, the samples are winsorized at the 5% level, and the results are shown in column (5) of Table 5 . Robustness results show that the core conclusions of this article still hold. Secondly, industrial agglomeration usually leads to the concentration of resources such as technology, talents, and raw materials, thereby forming a diversified industrial chain and economies of scale, which in turn helps the city respond to market changes and shocks and improve the city's economic resilience. In addition, FDI can introduce new technology and management experience and attract large amounts of capital investment, which is also important for the stable growth of the urban economy. Therefore, we add the proxy variables of industrial agglomeration and FDI to the control variables. This article selects the industry Herfindahl index to measure the degree of industrial agglomeration and uses the proportion of the total output value of foreign-invested enterprises in GDP to measure FDI. The results in column (6) of Table 5 show that after controlling for industrial agglomeration and FDI, the results are still significant.

4.2.5 Endogeneity discussion

To reduce the problem of biased estimation results caused by reverse causality and omitted variables between urban amenities and economic resilience, this paper uses the instrumental variable method for empirical analysis. Drawing on the research of Xu and Deng ( 56 ), urban terrain slope was selected as the instrumental variable. First of all, terrain slope will have a significant impact on the construction form and investment costs of urban infrastructure such as roads, bridges, and parks. It also affects China's population distribution and labor concentration. The layout of infrastructure and population distribution are closely related to urban amenities. Therefore, there is a correlation between urban amenity and urban terrain slope, which meets the assumption of correlation between endogenous variables and instrumental variables. Secondly, the terrain slope is a naturally formed geographical information variable in the city. It has relatively natural exogenous characteristics and does not directly affect the current economic development level and resilience level of the city. It satisfies the homogeneity assumption of instrumental variables.

However, terrain slope is cross-sectional data in the data dimension and does not change with time, which will result in the inability to control the individual effects of cities in empirical regression. Secondly, the impact of the urban slope index on urban amenities may also change over time, and appropriate instrumental variables need to take into account this difference in time dimension. In addition, consider that urban wind speed may affect urban amenities and urban wind speed is determined by large-scale weather systems. Therefore, it is an exogenous factor in local economic activity. To this end, we multiplied the urban terrain slope (Slope) and the urban wind speed (Wind) and took the logarithm to construct an instrumental variable with a time effect.

Columns (1) and (2) of Table 6 are the instrumental variable regression results after adding only core explanatory variables, and columns (3) and (4) are the instrumental variable regression results after adding control variables. As can be seen from Table 6 , the F values in the first stage are all >10, indicating that the instrumental variables and endogenous variables are related, eliminating the problem of weak instrumental variables. It can be seen from the regression results of the second stage that the coefficient of urban amenity is still significantly positive. This result is consistent with the baseline regression results and verifies the improvement effect of urban amenities on urban economic resilience.

Table 6 . Instrumental variable analysis.

4.3 Heterogeneity tests

4.3.1 regional heterogeneity.

Due to geographical differences, preferential policies, and other reasons, China's urban amenity construction and economic development levels have obvious regional differences. Therefore, there may also be differences in the role of urban amenities in promoting urban economic resilience. We divide the sample into eastern central and western cities for group regression. As shown in columns (1) and (2) of Table 7 , for eastern cities, the improvement of urban amenities can significantly enhance urban economic resilience. The possible reason is that eastern cities usually have high population density, large market size, better infrastructure, and richer development resources. Secondly, eastern cities also have advantages in terms of openness and policy support, which results in the level of technology accumulation and the number of high-quality talents in eastern cities being far superior to that in central and western regions. Therefore, the more eastern cities can create a comfortable living environment through a series of policy measures, thereby enhancing urban economic resilience. The central and western regions are faced with problems such as weak economic foundations, lagging infrastructure construction, and serious population loss, which make them face relatively greater difficulties in improving economic resilience through urban amenity construction.

Table 7 . Heterogeneity test.

4.3.2 Environmental regulation

Environmental regulation, as a means of government environmental governance, can effectively reduce environmental pollution problems, improve environmental quality, and enhance urban amenities. In addition, environmental regulatory policies can promote the growth of economic resilience by improving the level of urban technological innovation and promoting urban green transformation. Therefore, areas with strong environmental regulations may enhance the role of urban amenities in promoting urban economic resilience. Referring to the research design method of Chen and Chen ( 68 ), we selected the frequency of words related to environmental regulation in the “Government Work Report” of the prefecture-level city that year to measure the intensity of the city's environmental regulation. We grouped each city according to the median frequency of annual environmental regulation words and obtained the group with high environmental regulation intensity and the group with low environmental regulation intensity. Finally, the group regression analysis results are shown in columns (3) to (4) of Table 7 .

4.3.3 Degree of urbanization

There are significant differences in urbanization rates among different cities, which leads to diversity in the development patterns and speeds of various cities. We divide cities into cities with high urbanization rates and cities with low urbanization rates according to the median urbanization rate of each city. The results are shown in columns (5) and (6) of Table 7 . The results show that when a city's urbanization rate is high, improvements in urban amenities will significantly enhance urban economic resilience. The possible reason is that the urbanization process is usually accompanied by the construction of infrastructure and the optimization of public services, including public transportation, public facilities, education, medical, and community services. High-quality infrastructure and public services can significantly improve the quality of life and satisfaction of urban residents, thereby enhancing the amenities of the city, promoting the development of the urban economy, and improving economic resilience. When the urbanization rate of a city is low, the concentration of production factors is usually relatively low, which may affect the improvement of economic benefits. At the same time, these cities have deficiencies in infrastructure construction and public service provision. Its ability to withstand various risks may also be weaker, affecting the city's economic resilience. Therefore, the urbanization process plays an important supporting role in improving urban amenity and economic resilience.

4.4 Mechanism analysis

According to the aforementioned theoretical analysis, urban amenities may have a significant impact on regional factor supply and resource allocation efficiency. High urban amenity means that the city has good living conditions, employment opportunities, educational resources, medical services, etc. These will increase people's expectations for the quality of life and happiness after migration, thereby increasing their utility expectations of migration. At the same time, areas with high urban amenities can attract high-quality talents in different fields or at different levels, further improving the quality of labor supply and improving the city's human capital level. Therefore, cities with high urban amenities can attract more population inflows and increase the quantity and quality of labor supply. In addition, cities with high urban amenities can also promote technological innovation and increase the supply of intellectual capital. Innovation is an important driving force for economic growth and a key factor in improving production efficiency and competitiveness. Therefore, high urban amenity means that the city has a good innovation atmosphere, scientific research institutions, talent training systems, knowledge exchange channels, etc. These will enhance the effects of population agglomeration and innovation, thereby enhancing urban economic resilience.

To test the channel through which urban amenity affects urban economic resilience, we take urban amenity as the core explanatory variable and replace the explained variables of the model (1) with the degree of population agglomeration, the number of labor forces, human capital, and urban innovation. This model is used to examine the impact of urban amenity on mechanism variables. Columns (1) to (5) of Table 8 respectively verify that the degree of population agglomeration, the number of labor force, human capital, innovation patents, and innovation investment are the paths through which urban amenity affects urban economic resilience. In conclusion, cities with high levels of amenities have a higher quality of life, more labor and high-quality talent inflows, and a stronger innovation atmosphere, which have a positive effect on urban economic resilience. The above analysis has verified to a certain extent the impact mechanism of urban amenities on urban economic resilience.

Table 8 . Mechanism analysis.

5 Discussion

We analyze the relationship between urban amenities and urban economic resilience. Our empirical evidence suggests that urban amenities significantly contribute to enhancing urban economic resilience. This aligns with prior research emphasizing the various benefits of amenities in urban sustainable development ( 16 , 21 , 69 ). Urban amenities, encompassing factors such as green spaces, cultural attractions, and public infrastructure, not only enhance the quality of life for residents but also attract investments, stimulate economic activity, and promote sustainable development. The presence of green spaces, for instance, not only enhances environmental sustainability but also fosters community wellbeing and social cohesion, thereby contributing to enhancing urban economic resilience ( 70 ). Similarly, investments in cultural institutions and recreational facilities not only enrich the urban experience but also promote economic development through tourism, cultural events, and creative industries ( 71 ). In particular, we found that the population agglomeration effect and innovation effect are the influencing mechanisms through which urban amenity improves urban economic resilience. Population agglomeration and innovation effects play a very important role in enhancing the economic resilience of urban areas ( 64 , 67 ). Concentration and innovation of population facilitate economies of scale, resource sharing, and enhanced labor market efficiency, all of which contribute to the resilience of local economies. In conclusion, investing in the development and maintenance of urban amenities emerges as a strategic approach to improving economic resilience.

The regional disparities in the impact of urban amenities on economic resilience are noteworthy. Previous studies find that unreasonable investments in amenities in poor regions could exacerbate socioeconomic inequalities, thereby leading to the exclusion of underprivileged residents from benefiting from urban amenities and displacing long-standing communities ( 72 ). This highlights the importance of tailoring urban development strategies to regional contexts. Similar to previous studies, we find that in more economically developed areas such as the East, the construction of infrastructure and other amenities is more conducive to promoting urban economic development ( 73 , 74 ). Economically developed regions tend to have more diversified economies, meaning they are not solely reliant on one industry. Building amenities can contribute to this diversification by attracting different types of businesses and residents. For instance, a city with a vibrant arts scene may appeal to creative professionals, while excellent recreational opportunities may attract outdoor enthusiasts or retirees. This diversity can help protect the city against economic shocks. In addition, we also found that the stronger the urban environmental regulation, the more conducive it is to enhancing economic resilience through the construction of amenities. Environmental regulations targeting climate change mitigation and adaptation measures can enhance urban resilience to cope with extreme weather events and other economic-related challenges. Investments in green infrastructure, such as flood protection systems and sustainable urban planning, can minimize economic disruptions caused by environmental disasters ( 75 ). Therefore, policymakers should consider local conditions, socio-economic dynamics, and environmental factors when planning and allocating resources for urban amenities.

Previous research shows urban growth and economic development have not coincided with urban resilience policies, plans, and practices ( 76 ). Urbanization, especially in developing nations, is often characterized by rapid expansion and resource-intensive development aimed at bolstering economic growth. However, this growth frequently occurs without adequate consideration for the resilience of urban systems to withstand various shocks, ranging from environmental disasters to economic downturns. Consequently, cities may become more susceptible to disruptions, thereby impeding sustained economic progress. Our research underscores the significance of integrating resilience-focused approaches into urban development strategies, particularly through the adoption of suitable amenities. By investing in infrastructural solutions that prioritize both economic growth and economic resilience, cities can better withstand and recover from adverse events while fostering long-term prosperity. In conclusion, our study underscores the importance of aligning urban development efforts with economic resilience principles to promote sustainable economic growth in developing countries. By the construction of rational and moderate amenities, cities can enhance their capacity to withstand and recover from challenges, ultimately fostering more resilient and prosperous urban environments.

6 Conclusion

At this stage, economic uncertainty is becoming normalized. Increased economic uncertainty may increase market risks and trigger economic turmoil, which will have a profound impact on urban economic development. Therefore, how to deal with economic uncertainty and improve the economic resilience of cities has become an important current research topic. This is related to the efficiency of economic operation and the strategic goal of high-quality development of the Chinese economy. At the same time, urban amenity is an important indicator to measure people's happiness. The construction of urban amenities is an important task that conforms to the laws of urban development and the requirements of the times and reflects the comprehensive strength of the city. This is not only an effective way to deal with economic uncertainty, but also an important measure to achieve high-quality urban development. After measuring the city's artificial amenities and climate amenities, we conducted an empirical analysis based on China's urban panel data from 2011 to 2019, tested the impact of urban amenities on urban economic resilience, and came to the following empirical conclusions. Firstly, whether urban amenity is measured in terms of artificial amenities or climate comfort, cities with more amenity show stronger economic resilience when facing external shocks. Secondly, the impact of urban amenity on urban economic resilience shows regional differences. Compared with central and western cities, eastern cities can significantly enhance the city's economic resilience by improving their amenity. At the same time, the greater the intensity of environmental regulation and the higher the degree of urbanization in a city, the stronger the role of urban amenities in promoting economic resilience. Finally, we find that urban amenity affects economic resilience mainly through mechanisms such as population agglomeration, labor migration, improving the quality of human capital, and stimulating innovation vitality.

In light of the above conclusions, we propose the following policy recommendations: First, we suggest strengthening the incentives for local governments to build livable cities and, based on urban development goals and residents' needs, conduct reasonable allocation and optimization of amenity resources. The government should enhance residents' awareness of participation in urban governance, establish surveys on urban residents' satisfaction with livability, and incorporate urban livability satisfaction into the assessment and evaluation of government performance. Additionally, the government should delve deeply into and make good use of urban cultural resources, creating distinctive cultural blocks and cultural industry parks, among others. In the meanwhile, it should improve the allocation of urban land resources, dedicating more land to the construction of parks, green spaces, sports, and fitness facilities, and other public spaces. Lastly, according to the climate characteristics of different cities, the government should actively create green development space, optimize the urban heat island effect, strengthen environmental governance and ecological restoration, in particular, strictly implement the discharge standards of air pollutants and urban sewage and environmental protection policies, improves the quality of air and water resources, and improves the urban climate environment.

Second, considering the differences in natural conditions and the level of economic and social development between different regions, the government should promote the construction of urban amenities in a manner tailored to local conditions. In the eastern regions and cities with higher urbanization rates, it's crucial to fully leverage the advantages of factor agglomeration and location. The focus should be on improving urban environmental quality and public service levels. By intensifying environmental governance, advancing green and low-carbon development, optimizing urban spatial structure, and enhancing urban management efficiency, the goal should be to create ecologically livable, modern, resilient cities. In addition, the government should pay attention to the regional balance of the allocation of amenity resources, improve the financial transfer payment system, and increase the tilt of amenity resources in the central and western regions and cities with low urbanization rates. Governments at all levels should improve the resource scheduling mechanism for amenity construction and increase special support for these areas such as funds. In the meanwhile, the government should promote the central and western regions and cities with low urbanization rates to invest appropriately in infrastructure construction according to the needs of the population, strengthen the development of the value of natural resources, and foster tourism, leisure, and health care industries. The government should narrow the differences in education, medical, and other resources between regions, and strengthen exchanges between cities in school management, curriculum education, and student training. In particular, it should solve the problem of remote medical care and difficult access to medical care, guide the rational flow of the population, and thus enhance the economic resilience of regional cities.

Third, the government should improve the overall environmental quality of the city, attract population and capital inflows, and stimulate the quality of urban innovation. First and foremost, the government should prioritize human-centric improvements in urban public services and infrastructure, enhance urban green spaces, air quality, and other environmental aspects, foster a shared local culture, and judiciously promote unique cultural products in crafts and cuisine to fully accommodate the diverse needs of various demographics and activities. Concurrently, it should establish a tiered housing system to enhance living comfort, expedite the development of affordable housing, and bolster community governance capabilities, all aimed at forging a conducive environment for work, living, leisure, and travel, thereby attracting populations and labor migration. Moreover, the government should ease household registration constraints, diminish labor mobility barriers, and fortify the urban social welfare system, crafting an open, inclusive, and diverse social milieu. Lastly, the government ought to underscore the significance and timing of constructing various amenities, forge an inclusive environment for innovative talents, and high-caliber research platforms, actively recruit and nurture top-tier talent, bolster the growth of diverse innovative bodies, and facilitate the translation and deployment of scientific and technological advancements to fortify urban economic resilience.

The shortcomings and future development ideas of this paper are as follows: First of all, we mainly use objective index data at the city level. Future studies could further consider the use of subjective evaluation index data of urban residents on the amenity level or individual characteristics data at the micro level, and use Hedonic or other models to estimate the implied price of urban comfort attributes and improve the comfort index construction system. Secondly, the measure of economic resilience in this paper has limitations in the selection of variables and the evaluation of effects and lacks the dynamic evaluation of the time dimension. In the future, multiple macroeconomic indicators and time-varying impulse response functions could be selected and used to measure urban economic resilience, to provide ideas for measuring macroeconomic resilience from a dynamic perspective.

Data availability statement

The original contributions presented in the study are included in the article/ supplementary material, further inquiries can be directed to the corresponding author.

Author contributions

RD: Conceptualization, Formal analysis, Funding acquisition, Software, Writing – original draft, Writing – review & editing. KL: Writing – original draft, Writing – review & editing. DZ: Formal analysis, Software, Writing – review & editing. QF: Conceptualization, Writing – review & editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This work was supported by “the Fundamental Research Funds for the Central Universities” (Grant No. YCJJ20230686).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: urban amenity, economic resilience, livable city, population agglomeration, sustainable development

Citation: Du R, Liu K, Zhao D and Fang Q (2024) Urban amenity and urban economic resilience: evidence from China. Front. Public Health 12:1392908. doi: 10.3389/fpubh.2024.1392908

Received: 28 February 2024; Accepted: 15 April 2024; Published: 09 May 2024.

Reviewed by:

Copyright © 2024 Du, Liu, Zhao and Fang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Ke Liu, liuke7936@snnu.edu.cn

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Health system resilience – a conceptual and empirical review of health system literature

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K Wahedi, L Biddle, K Bozorgmehr, Health system resilience – a conceptual and empirical review of health system literature, European Journal of Public Health , Volume 29, Issue Supplement_4, November 2019, ckz186.070, https://doi.org/10.1093/eurpub/ckz186.070

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The concept of health system resilience has gained popularity in the global health discourse, featuring in UN policies, academic articles and conferences. The term is commonly used to refer to the ability of health systems to respond to challenges. However, there has been no comprehensive overview of how the concept is understood and assessed in health systems research (HSR).

We conducted a conceptual and empirical review in 3 databases using systematic methods. Quantitative and narrative synthesis was used to trace the introduction of the concept to HSR, identify relevant definitions and examine its use in research.

From 4063 references, we identified 96 articles concerned with health system resilience from 2007 - 2017, with a recent increase in literature (45% of studies published since 2016). Many articles take a general perspective; others focus on specific HSR building blocks (e.g. 28% on service delivery) or a particular type of crisis, such as climate change (12.5%) or natural disasters (10.4%). While the concept was developed from the ecological sciences, its meaning has been adapted in HSR, with a shift towards people-centred and process-oriented definitions. We identify three frameworks operationalising resilience: the “attributes” framework by Kruk et al. (2017), the “everyday resilience” framework by Barasa et al. (2017) and the “complex adaptive systems” framework by Blanchet et al. (2017). However, we find a mismatch between these frameworks and how the concept is assessed in 13 quantitative and 8 qualitative empirical studies.

The HSR literature has converged around a definition of resilience focusing on the system’s ability to mitigate ongoing challenges. Differences in emphasis remain, resulting in a variety of operational frameworks. The frameworks require further adaptation and testing in empirical studies to demonstrate the usefulness of “resilience” as an analytical category in HSR.

There is a mismatch between conceptualisation and operationalisation of resilience in the HSR literature.

Existing operational frameworks of resilience require further adaptation and testing in empirical studies to demonstrate the usefulness of “resilience” as an analytical category in HSR.

• delivery of health care
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• world health
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Health system resilience: a literature review of empirical research.

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• Bozorgmehr K 1

ORCIDs linked to this article

• Bozorgmehr K | 0000-0002-1411-1209
• Biddle L | 0000-0003-4521-4574

Health Policy and Planning , 01 Oct 2020 , 35(8): 1084-1109 https://doi.org/10.1093/heapol/czaa032   PMID: 32529253  PMCID: PMC7553761

Abstract 

Free full text .

Health system resilience: a literature review of empirical research

Louise biddle.

c1 Social Determinants, Equity and Migration Working Group, Department of General Practice & Health Services Research, University Hospital Heidelberg, Marsilius Arkaden, Turm West, Heidelberg 69120, Germany

Katharina Wahedi

Kayvan bozorgmehr.

c2 Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, 33501 Bielefeld, Germany

• Associated Data

The concept of health system resilience has gained popularity in the global health discourse, featuring in UN policies, academic articles and conferences. While substantial effort has gone into the conceptualization of health system resilience, there has been no review of how the concept has been operationalized in empirical studies. We conducted an empirical review in three databases using systematic methods. Findings were synthesized using descriptive quantitative analysis and by mapping aims, findings, underlying concepts and measurement approaches according to the resilience definition by Blanchet et al . We identified 71 empirical studies on health system resilience from 2008 to 2019, with an increase in literature in recent years (62% of studies published since 2017). Most studies addressed a specific crisis or challenge (82%), most notably infectious disease outbreaks (20%), natural disasters (15%) and climate change (11%). A large proportion of studies focused on service delivery (48%), while other health system building blocks were side-lined. The studies differed in terms of their disciplinary tradition and conceptual background, which was reflected in the variety of concepts and measurement approaches used. Despite extensive theoretical work on the domains which constitute health system resilience, we found that most of the empirical literature only addressed particular aspects related to absorptive and adaptive capacities, with legitimacy of institutions and transformative resilience seldom addressed. Qualitative and mixed methods research captured a broader range of resilience domains than quantitative research. The review shows that the way in which resilience is currently applied in the empirical literature does not match its theoretical foundations. In order to do justice to the complexities of the resilience concept, knowledge from both quantitative and qualitative research traditions should be integrated in a comprehensive assessment framework. Only then will the theoretical ‘resilience idea’ be able to prove its usefulness for the research community.

Key Messages

The way in which resilience is currently applied in the empirical literature does not match its theoretical foundations.

In order to do justice to the complexities of the resilience concept, knowledge from both quantitative and qualitative research traditions should be integrated in a comprehensive assessment framework.

• Introduction

The word ‘resilience’ origins from the Latin prefix ‘re-’ (back) and the verb ‘salire’ (to jump, leap). In science, it has long been used by engineering and material science to describe the ability of a material to absorb energy without losing its original form or characteristics ( Hollnagel 2009 ). Over time, different disciplines adopted and adapted the term, adding different interpretations and facets to it: In ecology, resilience describes the persistence of ecological systems and measures a system’s ability to absorb changes of variables and maintain relationships between different populations ( Holling 1973 ). In psychology, resilience is understood as the individual human capability to cope with crises, losses or hardships without negative consequences ( Tugade and Fredrickson 2004 ).

In the last decade, the concept of resilience has also gained popularity in global public health. This development is reflected by major UN frameworks adopted in the last decade: The 2005–15 Hyogo Framework for Action ( UNISDR, 2005 ) was subtitled ‘Building the Resilience of Nations and Communities to Disasters’. Its successor, the 2015–30 Sendai Framework for Disaster Risk Reduction ( UNISDR, 2015 ), increases the focus on health in the disaster preparedness discourse and correspondingly calls for health resilience. Various sustainable development goals point to resilience as a target (1.5: ‘resilience of the poor’, 2.4 ‘resilient agricultural practices’, 11b ‘resilience to disasters’; Bahadur et al. 2015 ; UNISDR 2015 ) In a 2016 editorial of Bulletin of the World Health Organisation (WHO), health system resilience is named as a critical concept for global health, in the same vein as health system strengthening, universal health coverage and health security ( Kutzin and Sparkes 2016 ).

The shifting conceptualization of health system resilience

While definitions and concepts of health systems resilience differ substantially throughout the literature, all have a common core: they regard resilience as the degree of change a system can undergo while maintaining its functionality. The concept of resilience was introduced to the health systems literature from the ecological sciences through an increased understanding of health systems as complex adaptive systems ( Blanchet and James 2013 ). In this context, the idea of resilience, defined as ‘a measure of the amount of change a system can experience while maintaining the same controls on structure and function’ ( Blanchet and James 2013 ), can act as a useful tool to help us understand health system dynamics. The ecological idea that strategies to enhance resilience can be absorptive, adaptive or transformative depending on the impact and intensity of the crisis has been particularly impactful in the health system resilience discourse.

Popularized further during the Ebola crisis, health system resilience underwent a conceptual shift; from a mere ‘system’ capacity to recognizing the contribution of individuals and their agency within that system and acknowledging the wider social, economic and political context in which responses occur. Critics argued that the application of the resilience concept—as a ‘top-down’ approach—obscured important factors which prevented an adequate response to the Ebola crisis. They emphasized instead the importance of ‘understanding and reducing local power disparities, building the trustworthiness of health actors […] both between and during crisis’ which improves the ‘everyday functioning of the health system’ ( Martineau 2016 ). In response to these criticisms, Barasa et al. (2017) proposed the idea of ‘everyday resilience’, emphasizing in particular the importance of the capacities and resources available to individuals faced with delivering health services every day. Everyday resilience may especially be of relevance, they argued, in low- and middle-income countries where managers may ‘routinely face structural and policy instability, such as changes in governance structures, payment delays, abrupt and imposed policy directives […], unstable authority delegations, unpredictable staff and […] changing patient and community expectations’ ( Barasa et al. 2017 ).

Similarly, Blanchet et al. (2017) proposed a new model of understanding health systems resilience which focuses not just on the outcome of the resilience process (i.e. absorptive, adaptive and transformative capacities), but also on the underlying management capacities of the system and its actors to response to change: knowledge, uncertainties, interdependence and legitimacy ( Box 1 ). These operational dimensions are interlinked with each other and together characterize the management of resilience in health systems ( Figure 1 ). While these two more recent conceptualizations of resilience can be understood as different in terms of taking a ‘top-down’ ( Blanchet et al. 2017 ) and ‘bottom-up’ ( Barasa et al. 2017 ) approach, they both acknowledge the importance of the context in which the resilience process takes place and the agency of actors involved, and thus represent two sides of the same coin.

Box 1 Resilience domains used in conceptual analysis of studies, as defined by Blanchet et al. (2017)

Management capacities:

Knowledge—‘Capacity to collect, integrate and analyse different forms of knowledge and information’

Uncertainties—‘Ability to anticipate and cope with uncertainties and surprises’

Interdependence—‘Capacity to manage interdependence: to engage effectively with and handle multiple- and cross-scale dynamics’

Legitimacy—‘Capacity to build or develop legitimate institutions that are socially accepted and contextually adapted’

Three levels of resilience:

Absorptive capacity—‘capacity of a health system to continue to deliver the same level (quantity, quality and equity) of basic healthcare services and protection to populations despite the shock using the same level of resources and capacities’

Adaptive capacity—‘capacity of the health system actors to deliver the same level of healthcare services with fewer and/ or different resources, which requires making organisational adaptations’

Transformative capacity—‘the ability of health system actors to transform the functions and structure of the health system to respond to a changing environment’

Conceptual overview of health system resilience, adapted from Blanchet et al. (2017) .

Conceptual influences from other fields

In addition to the conceptualization of resilience outlined above, other disciplinary fields have influenced the discourse on health system resilience, most notably the disaster management and healthcare quality literature.

In the disaster management sciences, resilience discussions were initially focused on the maintenance of infrastructure, functionality of health care facilities and continued service delivery ( Crowe et al. 2014 ; Balbus et al. 2016 ; Cimellaro et al. 2017 ) operationalizing resilience as ‘capability of a health system to mitigate the impact of major external disruptions on its ability to meet the needs of the population during the disaster’ ( Crowe et al. 2014 ). However, experiences of Hurricane Catrina in the USA shifted the dominant discourse in the disaster management literature to the concept of community resilience ( Wulff et al. 2015 ; Olu 2017 ). Community resilience proposes that the key to a good disaster response lies in communities, and their ability to ‘prepare, respond, and recover’ from major events through a range of measures including increased social connectedness, adaptive health and social systems and emergency preparedness planning ( Wulff et al. 2015 ).

A further prominent influence on the health system resilience discussions has been the concept of ‘resilience engineering’ or ‘health care resilience’, emerging from the healthcare quality literature. This approach, developed as a critique to traditional views of healthcare safety as an ‘absence of failures’, defines safety as the ‘ability to succeed under varying conditions’ ( Hollnagel et al. 2006 ). It thus focuses on nurturing the everyday functioning of healthcare teams and facilities to strengthen resilience and reduce clinical mistakes. A recent review on the topic has found that this approach has garnered significant attention in both the primary and secondary literature since its emergence around 2012 ( Ellis et al. 2019 ).

The need for a review of the empirical literature

Existing literature reviews have been conducted on the theoretical conceptualization of health system resilience ( Turenne et al. 2019 ) and the factors contributing to resilient health systems ( Barasa et al. 2018 ). The concept of resilience has also been extensively discussed outside the health sector ( Tanner et al. 2017 ). While grasping the theoretical background of the concept is certainly crucial, understanding how theory is translated into evidence is equally important for assessing the usefulness of the ‘resilience idea’ for the research community. However, so far there has been no critical appraisal of how the concept of health system resilience has been operationalized and applied in the empirical literature.

We thus conducted an empirical review of health system literature in order to better understand how the resilience concept has been operationalized in empirical studies. Within this research aim, we address three specific sub-questions: (1) What are the key aspects (methodological approach, geographic focus, health system building block addressed and crisis/challenge discussed) of research on health system resilience and how have these changed over time? (2) What concepts and frameworks on health system resilience have been used to operationalize resilience in the health systems literature? (3) What is the scope of empirical research on health system resilience within current definitions of the concept? We thus provide an overview of the existing empirical literature on health systems research which can be used to further develop the concept and inform its operationalization in future studies.

• Methodology

We conducted a review of empirical literature, following systematic review methodology in line with the understanding brought forward by Moher et al . (2015) . This included a systematic literature search, and a rigorous and systematic data screening and extraction process ( Peters et al. 2015 ).

Searches were conducted in Medline, Social Science Citation Index and CINAHL (Cumulative Index to Nursing and Allied Health Literature) using Resilien* AND a health system related terms (see Box 2 ).

Box 2 Search terms

Search terms:

((((((((secondary health care [mh]) OR primary health care [mh]) OR health services [mh]) OR delivery of health care [mh]) OR health services research [mh])) OR ((((((((((((““health system””) OR ““health systems””) OR ““health care system””) OR ““health care systems””) OR ““health care””) OR ““health care sector””) OR ““health care sectors””) OR ““health service””) OR ““health services””) OR ““service delivery””) OR ““health care service””) OR ““health care services””))) AND Resilien*

The searches were conducted on 18 October 2019 and were limited to articles published since 2008 in English or German language to keep the extent of the review feasible. The search produced 6136 publications for screening after the removal of 794 duplicates [see Figure 2 for the PRISMA flow diagram in line with Moher et al. (2009) ].

Prisma flow diagram.

Due to the high number of items, we used a three-stage screening process, eliminating non-relevant articles at the stage of title-, abstract- and full text-screening. Items were excluded if they did not report primary data, or were concerned with individual/psychological resilience including resilience of healthcare providers (e.g. nurses, physicians), resilience in the non-health space (e.g. social resilience, resilience of urban environments and resilience of biological systems), community resilience without link to health systems or articles that were concerned neither with health systems nor resilience. We also excluded articles which were concerned with health system resilience, but only used the term as a ‘buzzword’, without further definition, discussion or operationalization of the concept. As the research objective was to understand the application and use of resilience in health system research, items with any research design, geographic scope and health system focus were included.

After the abstract-screening stage, 517 references remained, with another 444 references excluded after screening full texts (see Figure 2 ). Both abstract- and full text-screening were carried out by the first and second author with joint synthesis until consensus was reached. Two further articles were from the reference lists of the literature reviews by Barasa et al. (2018) and Turenne et al. (2019) met the inclusion criteria for the present study and were included in the review. The remaining articles were divided into two categories: (1) those papers which specifically assessed health system resilience by including this as a specific research objective or applying a framework allowing for the operationalization of health system resilience (‘key papers’) and (2) articles reporting research which led to a discussion of health system resilience or how to achieve health system resilience.

Data extraction was carried out by the first and second author using Microsoft Excel. To answer the first research question on key aspects of the empirical health systems literature, data on type of research (primary/secondary research), discipline of the first author, the health system building block studied [according to World Health Organization (2010) ], the type of crisis or conflict studied, study location (country, continent, low-/middle-/high-income country), the organizational level being studied (e.g. global, national or regional) and type of data used were extracted from all identified studies.

To answer the second and third research objectives, only those studies directly measuring or assessing health system resilience (‘key papers’) were analysed. In order to evaluate the use of existing empirical frameworks in the empirical literature (second objective), information on frameworks used was extracted if these guided either the data collection or analysis process, or both. To further extract the scope of empirical research in terms of aspects or elements of the concept being addressed (third objective), we were guided by the conceptual framework of Blanchet et al. (2017) . We used this framework because it captures the various ways in which resilience is used in the empirical literature: it describes both the management capacities essential for a resilient system (management capacities: knowledge, uncertainties, interdependence, legitimacy) as well as those describing the outcome (three levels of resilience: absorptive, adaptive and transformative capacities). It thus is able to capture a broad range of research on post ex ante and ex post ( Béné et al. 2015 ) aspects of the resilience process. Research articles were classified within this framework using the definitions listed in Box 2.

We synthesized the findings by combining a narrative synthesis with descriptive quantitative analysis of key aspects addressed. We further tabulated and mapped aims, findings, underlying concepts and measurement approaches according to the resilience definition by Blanchet et al. (2017) . Indicators used to measure aspects of resilience in quantitative and mixed methods studies were also extracted and mapped according to their respective resilience domain and the level of data collection (national, organizational, staff or population/patient level).

A total of 71 articles met our inclusion criteria, comprising 40 research papers specifically measuring or addressing health system resilience and 31 discussing health system resilience using empirical research ( Figure 2 , see Supplementary file for full list of studies).

Quantitative synthesis and mapping of empirical literature in health system resilience

Overall, the empirical studies identified differed in terms of their disciplinary tradition or conceptual background. Studies from the public health sciences tended to converge in three groups: (1) quantitative studies focusing on service delivery, making use of service utilization indicators provide an easily accessible measure to assess resilience before, during and after a crisis ( Paterson et al. 2014 ; Gizelis et al. 2017 ; Sochas et al. 2017 ; Kozuki et al. 2018 ; Ray-Bennett et al. 2019 ), (2) qualitative studies focusing on the health workforce, influenced by ideas of ‘everyday resilience’ and addressing the contributions of social connectedness and leadership on health system resilience ( Mash et al. 2008 ; Witter et al. 2017 ; Raven et al. 2018 ; Brooke-Sumner et al. 2019 ; Thude et al. 2019 ), and (3) studies taking a broad perspective of health system resilience, looking at multiple health system building blocks or aspects of a health system to assess resiliency ( Ager et al. 2015 ; Ammar et al. 2016 ; Fukuma et al. 2017 ; Ling et al. 2017 ; Meyer et al. 2018 ; Watts et al. 2018 ).

However, influences from outside the public health sciences could also be identified in the empirical health system resilience literature. As a relatively distinct influence, the disciplines of engineering and architecture have contributed empirical research assessing the infrastructure and thermal resilience of healthcare facilities and structures ( Lomas et al. 2012 ; Iddon et al. 2015 ; Short et al. 2015 ; Dippenaar and Bezuidenhout 2019 ). A further relatively distinct influence has been the contribution of specific checklists to assess facility and organizational resilience from the fields of disaster management and emergency preparedness ( Paterson et al. 2014 ; Zhong et al. 2014a , 2015 ; Dobalian et al. 2016 ; Khan et al. 2018 ; Meyer et al. 2018 ). Also from the field of disaster management, but perhaps more intertwined with resilience in the way it has been conceptualized in the health systems literature, are studies assessing community resilience and its relationship with service delivery during a crisis ( O’Sullivan et al. 2013 ; Andrew et al. 2016 ; Toner et al. 2017 ; Alonge et al. 2019 ; Cohen et al. 2019 ). Finally, hailing from the tradition of medical sciences concerned with patient safety and quality of care, concepts of ‘health care resilience’ or ‘resilience engineering’ have also influenced the empirical literature on health system resilience ( Brattheim et al. , 2011 ; Franklin et al. , 2014 ; Falegnami et al. 2018 ; Merandi et al. , 2018 ; Patriarca et al. , 2018 ). While study object of these studies is also the health workforce, the focus is placed on the analysis of work processes and the avoidance of medical errors to maintain functionality of services.

Methodological analysis of key empirical papers

Assessing national-level health system resilience in context of a specific crisis.

Of the eight studies which assessed an entire, national health system in the context of a particular crisis, two studies took a purely quantitative approach: Fukuma et al. (2017) assessed Japan’s health system responsiveness and resilience after the Great East Japan Earthquake and Watts et al. (2018) assessed the resilience of 101 health systems in the context of climate change. Fukuma et al. (2017) operationalized resilience by using composite routine data indicators during the time of crisis, including: service utilization, cause-specific mortality rates incl. suicides, number of hospitals, health expenditures, human resources and immunization coverage. Watts et al. (2018) assessed resilience by surveying for the presence of specific policy efforts and strategies in the context of climate change at a national level.

Three further studies assessed the resilience of a health system at the country level using a mixed methods approach. Ammar et al. (2016) studied the Lebanese health system in the context of the Syrian refugee crisis using a case study approach. Orru et al. (2018) assessed the ways in which the Estonian health system was able to assess and manage the health risks of climate change using a combination of document review, expert interviews and population survey data as applied to the WHO Operational Framework for Building Climate Resilient Health Systems ( World Health Organization 2015 ). Thomas et al. (2013) assessed the performance of the Irish health system in the face of the economic crisis by applying quantitative indicators developed from their own resilience framework to government documents and supplementing these with semi-structured interviews.

Finally, three qualitative studies considered national health system resilience. Ager et al. (2015) assessed key barriers to the provision of responsive service in the context of Boko Haram in Nigeria, Alameddine et al. (2019) assessed the resilience of Lebanon and Jordan’s health systems in the context of the Syrian crisis and Ling et al. (2017) assessed the resilience of Liberia’s health system during the Ebola crisis. All three studies used semi-structured interviews with health professionals and other key health stakeholders for data collection, with Ling et al. (2017) complementing these with focus group discussions.

Out of these eight studies, all studies except one ( Fukuma et al. 2017 ) applied a specific conceptual framework to study resilience. However, the frameworks used in the other studies vary, including frameworks developed by international or development agencies, such as the World Health Organization or the United Kingdom’s Department for International Development ( Ager et al. 2015 ; Orru et al. 2018 ; Watts et al. 2018 ), general health system frameworks ( Ammar et al. 2016 ) and resilience frameworks developed in the academic literature ( Thomas et al. 2013 ; Ling et al. 2017 ; Alameddine et al. 2019 ).

Assessing resilience of health service delivery

Ten studies focused on the resilience of health service delivery. Six studies assessed the delivery of emergency services, three focused on the delivery of maternal health services, while one considered the continuity of a community health worker programme.

Two quantitative studies from the USA take a specific look at the delivery of emergency services: Radcliff et al. (2018) analyse ambulatory care measures during and after a storm, while Simonetti et al. (2018) model the potential of the US blood supply system during an emergency. Both make use of available administrative data, with Radcliff et al. (2018) relying in utilization data from Veterans Affairs clinics and Simonetti et al. (2018) using data on the national availability of blood stocks. The provision of emergency services during a crisis is also explored in four qualitative studies. Two of these assess service provision in the context of a particular crisis: Ridde et al. (2016) describe the emergency response to the Ouagadougou Terrorist attack in Burkina Faso, using a mixture of observations and expert interviews as their data source and structuring insights around Kruk et al. ’s (2017) ‘resilience indicators’ framework. Landeg et al. (2019) assess the emergency response to localized flooding in the UK using semi-structured interviews with decision-makers and document analysis. Finally, two qualitative studies explore the functionality of emergency service processes: while Back et al. (2017) use policy analysis and observation to examine escalation policies in UK hospitals, Errett et al. (2019) use semi-structured interviews with key informants to identify the impact of disruption of maritime transportation on the provision of emergency services during a disaster.

Being the only purely quantitative study to do so, Sochas et al. (2017) analysed the utilization of reproductive, maternal and neonatal health services in Sierra Leone in the context of the Ebola crisis using antenatal health service utilisation data. Gizelis et al. (2017) also assessed the impact of the Ebola epidemic on maternity delivery services, using a mixed methods approach by complementing maternity service utilization data from population surveys with semi-structured interviews and focus group discussions. Ray-Bennett et al. (2019) looked at the provision of reproductive health services in the context of flooding in Bangladesh, applying a structured facility assessment tool complemented by structured interviews with patients.

Kozuki et al. (2018) use a process evaluation methodology to document the ability of an integrated community case management programme to continue operation during the active conflict of 2013 and 2014 in South Sudan. The authors use routine programme data, including reporting, supervision, contact, treatment and referral rates, as well as interviews and focus groups with key stakeholders to evaluate the programme’s resiliency.

Only two of these studies ( Ridde et al. 2016 ; Back et al. 2017 ), both using qualitative methodologies, apply a specific framework of health system resilience. All quantitative studies and one mixed methods study focus on the absorptive capacities of service delivery, while the other studies address a more varied set of resilience dimensions.

Health workforce issues

A total of seven studies were identified which address aspects of health workforce resilience. These include studies both from the tradition of ‘resilience engineering’, as well as research influenced by the concept of ‘everyday resilience’.

One quantitative and one mixed methods study were conducted in the field of resilience engineering and safety research. Falegnami et al. (2018) surveyed the resilience of anaesthesia professionals in different work conditions in Italy using the four cornerstones of resilience framework ( Hollnagel 200 9). In the same setting, Patriarca et al. (2018) applied the functional resonance analysis method to explore the potential of the tool in enhancing the resilience of anaesthesia practices, drawing on documentary studies, interviews, observations and patient pathway modelling to do so.

Three studies considered health workforce issues on the context of a specific crisis. Applying a mixed methods approach, Witter et al. (2017) explored the impact of shocks on the health workforce across different contexts in Uganda, Sierra Leone, Zimbabwe and Cambodia, with a particular focus on vulnerabilities and coping strategies employed. The authors employed a mixture of methods for analysis, including surveys, human resource data, document review and qualitative interviews. Also taking a cross-national perspective, Raven et al. (2018) conducted observations and in-depth interviews with healthcare workers and management in Sierra Leone during the time of the Ebola crisis and in Nepal during a major earthquake to explore coping strategies of staff in both settings. In Portugal, Russo et al. (2016) explored physician’s perceptions of the changes in their work environment during the economic crisis in semi-structured interviews.

Finally, two qualitative studies take an ‘everyday resilience’ perspective to understand the ability of health workers in dealing with everyday challenges. Comparing experiences in Kenya and South Africa, Gilson et al. (2017) synthesize information from documents, interviews, group discussions and observations to understand factors influencing everyday resilience of staff. In Denmark, Thude et al. (2019) conducted semi-structured interviews with healthcare staff to explore the resilience of the workforce faced with challenges in their work environment, including changing leadership structures.

Only two of these studies ( Gilson et al. 2017 ; Falegnami et al. 2018 ) make use of an explicit resilience framework in their analysis. The dimensions assessed in individual studies varies: while Gilson et al. (2017) and Raven et al. (2018) explore a broad range of management capacities and resilience outcomes, the other five studies focus on only one of these two aspects, with three studies restricted in their analysis to a single outcome dimension ( Witter et al. 2017 ; Patriarca et al. 2018 ; Thude et al. 2019 ).

Taking a community resilience perspective

Three studies approached health system resilience from a community perspective. Cohen et al. (2019) quantitatively analyse the relationship between community resilience and the public’s confidence in the availability of healthcare services during emergency situations in Israel. Data for this study were conducted using the conjoint community resilience assessment measurement tool ( Leykin et al. 2013 ) in a household survey. Alonge et al. (2019) apply a qualitative approach to understand the relationship between community resilience and health system resilience. Combining information from key informant interviews and a national stakeholder meeting, they look at the contribution of responsible leadership and social capital into the resilience of the health system during the Ebola outbreak in Liberia. Finally, Andrew et al. (2016) take a slightly different approach to the issue of community resilience, by focusing on the resilience of community organizations involved with the relief efforts in the aftermath of the Thailand floods in 2011. Applying Bruneau et al. (2003) framework on the seismic resilience of communities, the authors quantitatively assess whether the bonding or the bridging effect made a larger contribution on the ability of organizations to deliver essential services after the crisis.

Both quantitative community resilience studies made use of an explicit framework for their analysis, while the qualitative study did not. While one study ( Cohen et al. 2019 ) focused entirely on dimensions of resilience management capacities, the other two studies explored a mix of management capacities and outcomes.

Infrastructure and thermal resilience

Three studies assessed the infrastructure and thermal resilience of hospitals, taking a purely quantitative approach. Resilience in this context is understood as the capability of buildings to withstand extreme conditions such as heat or earthquakes. Iddon et al. (2015) , Lomas et al. (2012) and Short et al. (2015) assessed the thermal resilience for specific building styles of wards in the UK in order to ensure climate change resiliency. None of these studies used specific conceptual frameworks for their analysis. In terms of the dimensions of resilience addressed, they focused entirely on dimensions of outcome, rather than management capacities. All three studies considered ways in which hospital infrastructure was able to absorb temperature changes, with two studies additionally assessing the potential for adaptation in response to these changes.

Development of preparedness checklists and assessment tools

A total of nine articles described the development of checklists to prepare for future catastrophic events or tools with which such preparedness can be measured. These have been developed at different levels: six studies focused on healthcare facilities and hospitals, two studies considered communities, while one study developed a conceptual framework at the national level.

Four articles described the quantitative development of checklists or measurement tools for assessing resilience of healthcare facilities. Dobalian et al. (2016) developed a general hospital preparedness tool, while Zhong et al. (2015) developed a framework for measuring hospital resilience and applied it to 41 tertiary care hospitals in a province in China ( Zhong et al. 2014a ). Goncalves et al. (2019) adapted and validated the short-form version of the Benchmark resilience tool for assessing the resilience of healthcare organizations. Using a mixed methods approach, Paterson et al. (2014) developed a toolkit for assessing the resiliency of healthcare facilities in the context of climate change. The methods for development differ: while Zhong et al. (2015) and Paterson et al. (2014) , respectively, used a Delphi consultation and workshops for an expert evaluation of proposed domains, Dobalian et al. (2016) , Goncalves et al. (2019) and Zhong et al. (2014a ) used psychometric assessments to assess validity and reliability. One of the instruments was operationalized as a survey of workers ( Goncalves et al. 2019 ), while the other three carried out assessments at the organizational level—either by external evaluation ( Dobalian et al. 2016 ), as a survey completed by managers of the facility ( Zhong et al. 2014a , 2015 ) or as a toolkit for facilities aiming to improve their climate resiliency ( Paterson et al. 2014 ). Finally, Meyer et al. (2018) conduct semi-structured interviews with key informants involved in the Ebola response in the USA to develop an actionable checklist to enable preparedness for future responses.

Two further papers used a qualitative approach to develop checklist for enhancing community resilience in a health system context. O’Sullivan et al. (2013 ) identify levers to promote community resilience for health during disasters using a community-based participatory research approach. Toner et al. (2017) used experiences from Hurricane Sandy collected through key informant interviews and focus groups to develop a checklist for assessing and strengthening communities’ health sector resilience.

Finally, Khan et al. (2018) conducted focus groups to develop a framework comprising of essential elements of a resilient public health system in during emergencies, using the lens of complex adaptive health systems. They discuss the importance of recognizing the interconnectedness of actors and processes during an emergency response, acknowledging that these dimensions, while crucial, are particularly difficult to measure and quantify.

Many of these studies understandably did not use a specific resilience framework, as part of the research aim was to develop key dimensions of resilience in a particular context. However, three studies did use frameworks to guide the selection of their proposed dimensions ( Zhong et al. 2014a , 2015 ; Goncalves et al. 2019 ) or the development of topics for discussion in focus groups ( O’Sullivan et al. 2013 ). Checklists tended to focus on measuring the management capacities of facilities, organizations and systems, with a noticeable trend towards a more diverse set of dimensions among the qualitative studies. Only two studies ( O’Sullivan et al. 2013 ; Khan et al. 2018 ) considered assessment of the system’s ability for absorption and adaptation.

Conceptual analysis of key empirical studies

Conceptual frameworks used.

Across the empirical studies, a specific framework for assessing resilience was used by four quantitative studies, two mixed methods studies and seven qualitative studies. The types and disciplinary origins of the frameworks differed widely. Of the concepts developed in the health systems resilience discourse, the ‘resilience index’ framework ( Kruk et al. 2017 ), ‘resilience capacities’ framework ( Blanchet et al. 2017 ) and ‘everyday resilience’ framework ( Barasa et al. 2017 ) were used. From the resilience engineering discourse, the Concepts for Applying Resilience Engineering (CARE) model ( Anderson et al. 2016 ) and the Four Cornerstones of Resilience framework ( Hollnagel 2009 ) were applied. Notably, three frameworks from the area of community resilience were used: CCRAM model ( Leykin et al. 2013 ), framework to assess seismic resilience of communities ( Bruneau et al. 2003 ) and the resilient communities framework ( Norris et al. 2008 ). Other frameworks used included the UK government’s humanitarian policy ( DfID 2011 ) and the WHO Operational Framework for Building Climate Resilient Health Systems ( World Health Organization 2015 ). Only two frameworks ( Hollnagel 2009 ; Kruk et al. 2017 ) were used twice, all other studies used distinctive frameworks for their analysis.

Dimensions of resilience addressed

We used the framework formulated by Blanchet et al. (2017) as an analytical lens allows for a more in-depth analysis of the content and dimensions of resilience addressed across the empirical papers using the definitions of management capacities and levels of resilience provided in Box 1. Across the empirical papers, 12 studies focused exclusively on resilience domains in the ex ante ‘management capacities’ side of Blanchet et al. ’s resilience definition, while 14 studies focused exclusively on absorptive, adaptive or transformative levels of the resilience process. Fourteen studies considered both management capacities and resilience levels. Qualitative studies more often considered both management capacities and resilience levels, while quantitative studies more often exclusively focused on one of the two ( Figure 4a ). Among the management capacities, the dimension of ‘uncertainty’ was most frequently assessed by all types of research, followed by dimensions of ‘interdependence’, ‘knowledge’ and ‘legitimacy’, in that order ( Figure 4b ).

Among the ex post resilience levels, ‘absorptive capacities’ was most frequently addressed across research types, although qualitative research explored ‘absorptive capacities’ and ‘adaptive capacities’ to an equal extent ( Figure 4c ). Only a limited number of quantitative and mixed methods studies considered the ‘adaptive capacities’ and ‘transformative capacities’ dimensions of health system resilience.

Looking across management capacities and resilience levels, qualitative research was able to address a much broader range of dimensions than quantitative research, with individual studies often exploring multiple dimensions of the resilience concept ( Figure 4b and 4c ).

Quantitative indicators used

A total of 24 studies used quantitative indicators to measure different aspects of the resilience concept, with several studies using multiple indicators across multiple domains of responsiveness ( Table 4 ). The reported indicators were collected using different data collection strategies, including the use of routine data, observational data and primary survey data. The indicators further differed in the level at which data were collected, spanning national, organizational, staff and patient/population levels. Across the ‘management capacities’ domains, several indicators at different levels of data collection addressed the domains of knowledge, uncertainties and interdependence. However, only two indicators, both collected at population level, captured the legitimacy dimension. Across the ‘levels of resilience’ domains, several studies used indicators across different levels of data collection for the ‘absorption’ domain. However, only three indicators were used for the ‘adaptation’ domain, collected at national and organizational level, while no indicators were identified for the ‘transformation’ domain.

The concept of health system resilience has soared in popularity in the health system field over the last years, not just in the theoretical or political discourse but also as an object of empirical inquiry. Its application has been incredibly diverse, with research from different disciplines applying the concepts in different healthcare sectors and in various settings. This diversity is not itself problematic. However, this review has demonstrated that empirical studies fundamentally differ in the way that resilience is understood in a health system context.

In terms of the content of the studies, much empirical research focuses on service delivery, health workforce or governance issues, whereas resilience of other health system building blocks is either barely studied, such as health financing, or only studied in high-income countries, as is the case of health information systems. This shows a distinct gap between the concepts and the operationalization of resilience in the context of health system research. If research on health system resilience is to live up to recent comprehensive definitions, the focus has to widen: all building blocks are interlinked and essential for well-functioning health systems, and should therefore not be analysed in singularity, but be considered jointly when assessing health system resilience.

Furthermore, despite much theoretical work on the dimensions which constitute health system resilience, we found that most of the empirical literature only addressed particular aspects. Applying the dimensions outlined by Blanchet et al. (2017) , we found that the importance of developing legitimate institutions appears to be neglected in empirical research. This is particularly concerning given that a lack of in healthcare institutions has recently emerged as one of the key barriers to the continued functioning of the health system, e.g. in the context of the Ebola outbreak ( Kittelsen and Keating 2019 ). The ability of health systems to demonstrate transformative capacities has been similarly under-evaluated, especially in quantitative research. Very few empirical studies took an approach to resilience that takes into account the various nuances in the conceptualization of the term which have recently emerged. This trend appeared to be particularly pronounced in those studies with a quantitative or mixed methods approach.

Thus, there is a mismatch between the conceptual models of health system resilience and the way resilience is understood and applied in empirical research both in terms of the breadth of health system factors considered and in terms of the resilience dimensions which are taken into account. Part of the issue may be that the empirical literature assessed in this review comes from a broad range of disciplines, with differing traditions of how ‘resilience’ is understood. While different traditions can offer unique and potentially complementary perspectives on the topic of resilience, this underlines the importance of more clarity in the empirical literature about which concepts and definitions are applied, and how these are then operationalized.

However, only very few empirical studies make use of an explicit conceptual framework for collection or analysis of data, thus not linking research objectives to the rich theoretical body of work on how resilience can be understood in a health system context. Arguably, those studies assessing resilience at a national level were most cognizant of using conceptual frameworks for their analysis. Our review showed that these studies were best able to capture the multiple dimensions of health system resilience. While several other studies aimed to measure health system resilience, they subsequently operationalized this concept in a very narrow way, e.g. by measuring only health service utilization, infrastructure resilience or emergency preparedness. Encouraging the use of an explicit framework for health system resilience could help to strengthen the links between the conceptualization and the operationalization of resilience, thus improving our understanding of health system resilience in different contexts and settings.

Our review further demonstrates that qualitative articles tend to employ a more comprehensive approach to the resilience concept than quantitative studies, which are often limited by availability of data and indicators to few aspects of resilience. The mismatch between concepts and research, therefore, appears to lie not in a lack of appreciation for the complexities of the resilience concept, but rather in a lack of measurable indices which reflect this complexity. While the proposed resilience index ( Kruk et al. 2017 ) specifies a list of potentially measurable indicators, so far these have only been operationalized in qualitative research. Similarly, the ‘resilience capacities’ framework specified by Blanchet et al. (2017) , and the ‘everyday resilience’ framework by Barasa et al. (2017) have been operationalized exclusively in qualitative research. All identified quantitative studies have utilized frameworks originating in discourses tangential to the health system resilience discourse.

Yet so far there has been no discussion about which aspects of the health system resilience frameworks are actually measurable. Within the ‘resilience capacities’ framework, the identified studies demonstrate that it is possible to measure ‘absorptive’ aspects by comparing levels of service provision and utilization in different circumstances. However, this is more challenging for ‘adaptive’ and ‘transformative’ aspects. Understanding whether a health system has truly transformed itself in response to a challenge needs to take into account multiple contextual factors and thus lends itself more naturally to be answered by qualitative methods and policy analysis, but also to complexity science. Equally, studies were able to quantitatively assess the presence or absence of preparedness plans to deal with uncertainties and data collection mechanisms for an improved knowledge of potential challenges, but quantifying the ability to handle cross-scale dynamics and develop legitimate institutions proved to be more difficult to capture. Incidentally, the identified studies developing resilience checklists and measurement tools all took a very narrow perspective of resilience by focusing on single healthcare facilities and organizations.

The key question in the development of a comprehensive resilience index, or a measure that allows for effective combination of quantitative and qualitative aspects, becomes whether the requirements to create a comparable measurement tool can be reconciled with the very broad and comprehensive definition of resilience which has emerged from an understanding of health systems as complex adaptive systems. According to Haldane et al. (2017) the resilience concept ‘should […] not be prescriptive, but have breadth and flexibility, recognize complexity, consider shocks and cumulative stresses, attempt to deal with disruptions and anticipate future failures’. It appears that, so far, the qualitative literature has been more successful in translating such a comprehensive framework into research practice, while quantitative studies have been limited both by theoretical models and a lack of appropriate data with which to measure resilience. Thus a key task for future researchers in the resilience field will be not only how the resilience concept can be operationalized, but—acknowledging that quantitative assessment of resilience in its entirety is illusionary—determine how measureable aspects can be combined with qualitative aspects in a way that allows for an assessment of health system resilience as a dynamic, complex phenomenon. Thus further research is required for the development of an operational framework on health system resilience which seamlessly integrates both qualitative and quantitative evidence; knowledge from existing guidelines on integrating quantitative and qualitative knowledge, e.g. in the realm of assessing the effectiveness of complex interventions, could be utilized for this purpose ( Noyes et al. 2019 ).

Our review adds to the existing conceptual review by Turenne et al. (2019) , who argue that the concept of health system resilience is still in infancy. We demonstrate the implications of this conceptual immaturity on existing empirical research: while the qualitative literature has explored the notion of health system resilience in its broad definition, the quantitative literature has been limited by the lack of clearly defined characteristics, preconditions and limits of the concept.

Our review makes a substantial contribution to the health systems research literature by analysing the operationalization of the health system resilience concept in empirical studies. Due to our inclusive search and broad inclusion criteria, we were able to consider a broad range of relevant articles from multiple disciplines and thus demonstrate the influence of other disciplines in the health systems research field. However, as search terms were geared to finding articles which specifically referred to the resilience concept, we may have missed empirical studies which operationalized aspects of resilience, but used different terminology. Further research could specifically identify such studies by using elements of the resilience definition instead of merely using the term itself. This could also help to better gain an understanding of how the concept of resilience overlaps with other health systems concepts such as health system strengthening or health system responsiveness and map potential synergies in assessment. We also did not include secondary research or grey literature in our review, which may provide further useful information on the operationalization of the resilience concept. Further research is needed to combine and integrate knowledge from these diverse sources in a comprehensive assessment framework.

A further limitation of our study is the initial exclusion of items based on titles, which was necessary due to the sheer number of results. This may have excluded several studies in associated disciplines, such as those relating to community resilience, which are of importance to the health systems resilience discourse. Findings of our review should be complemented by reviews of the resilience concept in other disciplines to check for congruence.

The health systems research community has made substantial advances in the conceptualization of health system resilience and its potential for the analysis of health systems in changing environments. However, the empirical literature has not yet caught up with the complexities of the concept: there is a mismatch between the nuances and the breadth of the concept at a theoretical level and the way it has been operationalized in empirical studies. In order to do justice to the complexities of the resilience concept, knowledge from both quantitative and qualitative research traditions should be integrated in a way that resilience as a complex, adaptive phenomenon. Only once a comprehensive assessment framework has been defined and applied across different research contexts will the theoretical ‘resilience idea’ be able to more convincingly prove its usefulness for the research community.

• Supplementary Material

czaa032_Supplementary_File

• Acknowledgements

The authors are supported by a grant from the German Federal Ministry for Education and Research (BMBF) in the scope of the project RESPOND (Grant number: 01GY1611). Further grants are received by the German Science Foundation (DFG) in the scope of the Research Unit PH-LENS and its subproject NEXUS (Grant no: FOR 2928 / BO 5233/1-1). The funders had no influence on study design, analysis or decision to publish.

Conflict of interest statement . None declared.

Ethical approval. No ethical approval was required for this study.

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Funding 

Funders who supported this work.

German Federal Ministry for Education and Research (1)

Grant ID: 01GY1611

3 publication s

German Science Foundation

Research unit ph-lens (1).

Grant ID: FOR 2928 / BO 5233/1-1

1 publication

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