Resilient Health Systems Appraisal Model. Whole-of-system approach to health system resilience in fragile contexts: a best-fit framework synthesis

Introduction Fragile contexts are characterized by multiple shocks combined with limited resources and inadequate institutional capacity to manage and respond effectively. These contexts account for 25% of the world population and are home to 72% of those living in extreme poverty, making resilient health systems essential to respond to the health needs of more than 2 billion people. This study aims to develop a framework for assessment and implementation of health system resilience in fragile contexts. Method The best-fit framework synthesis approach was employed to adapt the WHO’s health system building blocks framework for the assessment of health system resilience in fragile contexts. A two-stage synthesis approach was used; first, a scoping review was conducted to identify how the performance and resilience of health systems were assessed and measured in fragile, low-income contexts. Key concepts were extracted and thematically analyzed to construct an a priori framework. A desk review of operational tools from global health agencies was undertaken. Indicators from the scoping and desk reviews were mapped against the framework. New themes emerged and the framework was refined. An iterative process employing both deductive and inductive synthesis was employed. Results 918 indicators were extracted from scoping and desk reviews. The adapted framework, Resilient Health Systems Appraisal Model (ReHSAM), presents 17 domains, 45 subdomains, and 69 standards for health system resilience in fragile contexts. ReHSAM Standards are focused on the operational components of a health system. The related actions to implement the standards are context specific and dynamic across the multiple levels of the health system Conclusions This study presents a new framework and a standardized method for assessing the resilience of health systems in fragile contexts employing a whole-of-system approach. It provides a tool for assessment of resilience, comparisons across contexts, and development of actions to integrate resilience into the operations of health system.