Toward a theory-led meta-framework for implementing health system resilience analysis studies: a systematic review and critical interpretive synthesis

Anticipation is the first phase of any activity to achieve health system resilience [7, 30, 39, 53, 55, 57‐59]. Health systems need to acknowledge their vulnerabilities before providing any response [48, 60]. In this phase, risk analysis and risk assessment methods will be applied [41]. This concept is referred to as forecasting, foresight, predicting, or detection of adverse events [30], potential system vulnerabilities [30, 61], uncertainties [10], deteriorations [53], or possible scenarios using various tools such as simulation methods [61]. This phase requires a powerful information system as well as good collaboration and coordination [41].

In the preparation phase, based on the type of risk and system vulnerabilities identified, the essential capacities of the health system will be promoted [5, 6, 53]. During this phase, planning [32], different response plans [5], scenario exercises, leadership and command structure in emergencies, legal preparations, and control and monitoring structures are defined [54].

Responding is defined as the appropriate reaction to changing circumstances and is essential to guarantee good performance [2, 7, 10, 30, 32, 46, 61, 62]. It requires the proper anticipation and preparations [45]. This phase should include all health system building blocks (Leadership & governance, service delivery, human resources, financing, drug & medical equipment, and information system) [10]. Moreover, the quality and the rapidity of decisions depend on suitable collaboration and coordination [10, 25].

The majority of studies referred to recovery as the last phase to achieve system resilience [30, 33, 39, 49, 54, 58]. Indeed, resilient systems have plans to return to stable states [30]. Self-regulation, another expression of this phase, refers system’s ability to reduce performance deteriorations and absorb environmental changes [28, 47, 52, 59]. Recovery level and recovery time are two evaluation indicators of this phase [61]. The activities of this phase have a long-term view and require policymaking, analysis, and evaluation skills to detect optimal applied response plans. The recovery phase improves system preparedness through reactive and proactive activities to adapt old structures or create new ones [57, 63].

Some studies considered growth as the last phase of the creation of resilient systems [59]. In other words, system capabilities will improve during the challenging condition through learning tools and growth that occurs in the long term [57, 59, 64].

A resilient system with a good understanding of its existing situation, including the operational environment, needs, and resources, can well predict future internal and external changes as well as timely informing decision-makers and the public about crisis and its potential implications on the system [10, 20, 23, 31, 48, 65]. Kruk et al. named this attribute “cognitive capacity” and defined it as the ability of the system to detect and interpret shocks and chronic challenges (sense-making) [32]. Also, Blanchet et al. considered system “knowledge” and defined it as the capacity of collecting, analysing, and interpreting the information in addition to awareness [10]. Situation awareness requires appropriate collaboration and coordination between different stakeholders in the system [41]. Besides, a powerful information system with the ability to early detection, analyzing, and share information, including weak change signals from various internal and external parts of the health system, is a necessity for an aware health system, as a complex adaptive system [41, 52, 61]. In brief, awareness is composed of three main components of predicting, monitoring, and communicating, leading to sensemaking (ability to detect and interpret system changes) [28, 37, 47, 58, 59].

The ability to increase the capacity of various system components (Health system six building blocks) in response to shocks or everyday challenges defines surge capacity [20, 25, 27, 54]. Barasa et al. specified this attribute as “behavioural capacity” which is the system’s ability to respond to unforeseen circumstances based on learnings and preparations [44]. Also, some studies mentioned the term “agility” and the ability to change in an uncertain environment [61, 64, 65]. Hence, a resilient system will adapt the capacities of the health system building blocks upon understanding weak signals through its learning tools and awareness attribute [20, 27]. Learning tools assist the system in predicting appropriate and adequate capacity in different situations [44].

A resilient health system has flexible managerial and executive structures and coping strategies which can be adjusted in an emergency [23, 28, 47, 54, 66]. In another definition, flexibility refers to the extent and rapidity of system adaptations to shocks without failure in system processes [61]. In this regard, studies referred to “Redundancy” which is the existence of various executive solutions, choices, and adaptive options under pressure conditions [42, 58, 65]. Also, redundancy is about continuity of services due to the presence of various staff and equipment that can perform specific tasks [61]. In addition, some researchers mentioned the “Diversity” of health system building blocks in different situations [28, 47, 52, 58]. Flexibility relates to the anticipation of uncertainties and is dependent on the learning tool and transformative strategies [67, 68]. Provision of safety inventory, multiple sources of supplies, and multipurpose equipment and staff are some examples of flexibility [68].

This attribute is also known as “Robustness”, “stability”, or “coping” is about the system withstanding challenges and deteriorations [30, 42, 49, 61, 65, 66]. This attribute results from the recovery phase and means the ability to maintain the main system characteristics and continuity of its critical operations [59].

Resource availability or resourcefulness, including human and financial resources, materials, and technologies specified to face a crisis, is an empowering factor to achieve system resilience [42, 66]. The resilience system can mobilize, acquire and distribute essential resources and assets against the crisis. Also, it has appropriate resource allocation strategies that ensure timely access to resources [37, 48, 49, 61].

Several studies referred to collaboration and coordination as an important resilient system attribute [2, 10, 33, 41, 48]. Collaboration and coordination are among the properties of an integrated system against crisis and emergencies [41, 52, 65, 68]. Health system resiliency is not possible without a proper understanding of the role of its actors and stakeholders [28, 53]. Resiliency requires predetermined coordination mechanisms in which power dynamics are considered [2, 20, 49]. Collaboration and coordination influence preparation, response, and recovery phases and contribute to flexibility through the creation of a shared understanding of the situation [41, 67, 68]. It also will be influenced by information and communication system [20]. Blanchet et al. called this attribute “capacity to manage interdependency” which means managing stakeholders’ cross skills and feedbacks [10].

“Community engagement” constitutes a necessary aspect of collaboration and coordination in most resilience system theories and models [28, 33, 41, 54]. Community engagement and community involvement in decision makings can lead to cultural consideration in the implementation of policies and programs, creating a shared understanding with community and trust [28, 41, 54].

Detecting system vulnerabilities and planning for preparation and mitigation of adverse effects requires risk analysis tools and measuring the magnitude and severity of risks [63]. Therefore, risk analysis is the first step toward awareness and requires good collaboration and coordination and promoting information and communication systems to anticipate them [41, 49].

The resilient health system should have plans to solve the aftermath problems of the crisis [48, 54, 63]. Adaptable responses and resource allocation plans are necessary to cope with rapidly changing circumstances and become a resilient health system [54]. A resilient system requires preparedness, responses, and recovery plans, including contingency plans and emergency regulations [49]. Planning clarifies roles and responsibilities and facilitates understanding of system structure and functions. An appropriate plan will lead to creating collaborative networks [41].

Monitoring of the outcomes health system and intermediate activities is an essential tool to reach health system resilience [14, 45, 50]. Monitoring uncontrolled or unwanted consequences of small changes is a necessity for anticipation [58, 61]. Also, early detection of any change signals through leading and lagging indicators will improve awareness and lead to an effective response [25, 62].

Information and communication systems are also vital tools for a resilient health system [20, 27, 28, 41, 49, 54]. The resilient health system provides communication links between network members and supports information and communication system infrastructures [54, 59] Also, risk communication protocols and feedback loops are two main functions of information and communication systems [10]. This tool will facilitate awareness, improve learning, collaboration and coordination, response, and preparedness against chronic challenges and shocks [7].

The effectiveness of information and communication systems depends on the availability of required data, quality of data, and essential infrastructures to transfer on-time information [7, 52]. Also, owning multiple information sources (Source resilience) will improve the reliability of information and communication systems [36, 37].

Learning from positive and negative experiences, success or failures, in extreme events or day-to-day activities, has a pivotal role in resiliency [14, 25, 27, 45, 50, 58, 59, 62, 65, 66]. Indeed, a resilient health system focuses on how to learn from events [52]. Effective learning provides appropriate analytical indicators to assist anticipation and monitoring [25]. In addition, learning will improve system responses and requires evaluation and feedback mechanisms [41]. Developing individuals and the entire system knowledge and skills to deal with the adverse condition through learning mechanisms, including training programs, practice, and experience, will lead to system resilience improvement [20, 33, 49, 66].

Several researchers specified the importance of capacity building and providing necessary institutional software and hardware to respond, cope with and adapt to crisis conditions [48]. For example, Blanch et al. argued that a resilient system could create organizations that are socially accepted and contextually compatible and called it “legitimacy” which can be achieved through community engagement [10]. Also, Albanese et al. introduced institutional capacity building as one of the necessary infrastructures for building a resilient hospital and achieving minimum standards [33, 69].

Absorptive strategies, also known as persistence or situated resilience strategies, protect the system against shocks and the impact of hazards, which are usually small-scale shocks or events [32, 62, 70]. These strategies return the system to its original state or reduce the severity and implications of the crisis on the system without making any particular change in structure, using available resources and capacities (skills, knowledge, tools, and data) [10, 30, 32, 44, 62, 70]. Such strategies are generally used in the response phase [62].

Adaptive strategies, named structural resilience, can lead to a limited number of gradual adjustments in the structure or process of the system [32, 44, 62, 70]. These strategies promote service delivery at the same level before the crisis and maintain core system activities using less or different resources [10]. Adaptive strategies will apply for more intensive challenges which absorptive strategies can’t deal with [32].

Transformative strategies or systemic resilience create long-term and significant changes in the system structure and functions in response to massive environmental changes or challenges [10, 32, 44, 52, 62, 70].

Leadership can cause influence and be affected by resilient system attributes, strategies, and tools simultaneously. A resilient health system creates a transparent and flexible crisis leadership and governance structure [54, 71]. It chooses the leadership style according to the context [71]. The leadership and governance affect coordination and collaboration by identifying and employing various actors (for example between the private and public sectors in the health system). Also, it makes capacity for anticipation, planning, and institutionalization possible [41, 48]. The leadership and governance should focus on transparency, responsiveness, equity, and control and monitoring of other system components (service delivery, financing, human resources, etc) [41, 71].

To achieve health system resiliency, we need a resilient workforce as well [41, 45]. The resilient health system workforce has flexibility, including redundancy, adequate health workforce, additional workforce, and health workforce with multiple skills [7, 41, 54]. In addition, they receive the necessary training to deal with various crises (learning tools), for example, communication and collaboration, as the basic skills to deal with the crisis [20, 49, 54].

Crisis financial management [49], sufficient financial capacity to deal with the crisis [20, 48], using diverse and sustainable financial resources (flexibility) [54], timely access to financial resources [54], effective allocation, and using current resources [7], and planning to distribute resources during the crisis [20], are essential tips for creating a resilient health system.

The possibility of timely knowledge and information exchange and the existence of quality monitoring systems will lead to improved policymaking and resiliency of the health system through improving preparedness, response, and accelerating adaptation to various shocks and chronic challenges [7, 33, 52]. A resilient health system has “source resiliency” which is the existence of multiple information sources that can improve policymakers’ understanding of the system status in the time of crisis [36, 37]. The information system is a prerequisite for monitoring and learning through all levels (including the workforce, patients, families, and healthcare providers) [62].

Also, preservation, maintenance, and safety assurance of information and communication systems are necessary for resiliency in the health system [49]. A robust information system will improve collaboration and coordination, such as creating client-based information systems that can improve the relationships between the health system and its client [10]. In summary, the resiliency of the health system depends on the resiliency of its networking capacity to receive accurate and timely information [27].

Reducing services or patient discharges are usually the first reactions of health systems against the crisis [27]. However, the resilient health system sustains a basic level of routine health services and provides additional services for the community [7, 49, 54]. Focus on preventive services before the crisis prepares the health system against shocks, changes, and challenges [7]. In this regard, establishing governance structures, such as safety committees or infection control committees were recommended [49].

Shortages of high-quality drugs and medical equipment are a common problem during the crisis [49]. Using network capacity or collaboration and coordination attributes will improve the efficiency and effectiveness of procurements [27].