Building Health System Resilience To Public Health Challenges

Building health system
resilience to public
health challenges
Guidance for implementation in countries
Building health system
resilience to public
health challenges
Guidance for implementation in countries
Building health system resilience to public health challenges: guidance for implementation in countries
ISBN 978-92-4-009432-1 (electronic version)
ISBN 978-92-4-009433-8 (print version)
© World Health Organization 2024

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iii
Contents
Acknowledgements vi
Abbreviations vii
How to use this technical product viii
Executive summary ix
1. Introduction 1
1.1 Context 2
1.2 Rationale, purpose, and target audience 3
2. Fundamentals of health system resilience 4

2.1 Building health system resilience: key areas of focus 6
2.1.1 Resilience-focused health system strengthening 7
2.1.2 Comprehensive and integrated delivery of public health functions
and services 7
2.1.3 Systematic capture and translation of lessons 8
2.2 Many entry points, one health system 8
3. Building health system resilience: a roadmap for action 10

3.1 Introduction 11
3.2 Overview of roadmap 12
Step 1: Prioritize resilience 13
Step 2: Identify the baseline and needs 15
Step 3: Adopt integrated planning and resourcing 18
Step 4: Institutionalize resilience building 22
Step 5: Monitor and evaluate progress 25
3.3 Consolidated matrix of actions and decision-making flowchart to support
application of the roadmap 27
3.4 Key stakeholders and their roles 32
3.5 Signs of progress in building health system resilience 32
4. Conclusion 34
References 36
Annex. Template to guide application of the resilience roadmap 39

iv
Figures
Figure ES.1 Roadmap for building health system resilience x
Figure 1. Roadmap for building health system resilience 11
Figure 2. Flowchart to support stakeholders in making decisions

on application of the roadmap for building health system resilience 30
Figure 3. Dividends of investing in health system resilience in terms

of enhanced recovery, performance and resilience following
each shock event 33
Tables
Table ES.1 Example scenario of country application of the roadmap

to build health system resilience xi
Table 1. Range of events that can challenge the resilience of health systems 9
Table 2. Illustrative examples of actions and tools to support prioritizing

resilience including developing a shared understanding and
commitment14
Table 3. Illustrative examples of actions and tools to support clarifying

baseline capacities and setting common objectives 17
Table 4. Illustrative example of actions and tools to support integrated

planning and resource mobilization and utilization 19
Table 5. Illustrative examples of actions and tools to support institutionalize

resilience building 22
Table 6. Illustrative example of actions and tools to support monitoring and

evaluating progress towards objectives 26
Table 7. Summary of examples of actions to build resilience across the five

steps of the roadmap and health system building blocks 27
Table 8. Key stakeholders in building health system resilience 32

v
Boxes
Box 1. Health system resilience attributes 5
Box 2. Operational definition of health system resilience 7
Box 3. Essential public health functions 8
Box 4. Key guiding principles 12
Box 5. Principles of a public health approach to health 13
Box 6. Promoting a common understanding of resilience in Liberia 15
Box 7. Using recovery to bridge current health sector policies and

planning in South Sudan 18
Box 8. An integrated approach to pandemic policy development in

Iran (Islamic Republic of) 19
Box 9. Maximizing resource use for resilience: opportunities to leverage

available resources 21
Box 10. Applying a systems approach to strengthening collaboration

between health systems and health security in Liberia and Ethiopia 24
Box 11. WHO Health Systems Resilience Toolkit 25
Box 12. Example scenario of country application of the roadmap

to build health system resilience 31
vi
Acknowledgements
This guidance document was developed by Redda Sincere thanks to the Assistant Director-
Seifeldin and Geraldine McDarby, Health System General’s Office, Universal Health Coverage and
Resilience and Essential Public Health Functions Life Course Division, and the Director’s Office,
(EPHFs) Team, Special Programme on Primary Special Programme on Primary Health Care, WHO
Health Care, Universal Health Coverage and Life headquarters, for their administrative support.
Course Division, World Health Organization (WHO),
This publication was produced with support from
with inputs from Yu Zhang and Desmond Hickey,
the Universal Health Coverage Partnership (UHC
Health System Resilience and EPHFs Team, WHO.
Partnership), one of WHO’s largest platforms for
The supervision and strategic coordination for this
international cooperation on universal health
work was provided by Sohel Saikat, Health System
coverage and primary health care. It is funded and
Resilience and EPHFs Team, WHO.
supported by: Belgium, Canada, European Union,
Sincere thanks to the following colleagues from Germany, Luxembourg – Aid & Development,
WHO headquarters and regional offices for their Ireland – Irish Aid, France
contributions: Ali Ardalan, James Campbell, Giorgio – Ministère de l’Europe et
Cometto, Ibadat Dhillon, Siobhan Fitzpatrick, Andre des Affaires étrangères,
Griekspoor, Manoj Jhalani, Humphrey Karamagi, Japan – Ministry of Health,
Nellie Kartoglu, Masaya Kato, Rania Kawar, Awad Labour and Welfare, United
Mataria, Tapas Nair, Denis Porignon, Edwin Ceniza Kingdom of Great Britain
Salvador, Archana Shah, Thaksaphon Thamarangsi, and Northern Ireland –
Jun Xing, Patrick Zuber, and the WHO Joint Working Foreign, Commonwealth &
Team for Primary Health Care and Universal Health Development Office.
Coverage.
Special thanks to Gerard Schmets (Deputy Director,
Special Programme on Primary Health Care, WHO)
for reviews and valued guidance in the delivery of
this activity. Sincere appreciation goes to Suraya
Dalil (Director, Special Programme on Primary Health
Care, WHO) for her support.
vii
Abbreviations
EPHF essential public health function

HeRAMS Health Resources and Services Availability Monitoring System
IHR International Health Regulations
NHSSP National Health Sector Strategic Plan
PHC primary health care
SARA Service Availability and Readiness Assessment
SDG Sustainable Development Goal
SMART specific, measurable, achievable, relevant, and time bound
SPAR State Party Self-assessment Annual Reporting
STAR Strategic Tool for Assessing Risks
WHO World Health Organization
viii
How to use this technical product
Below is a summary of how to use the contents of this technical product.
Explore the roadmap for building Utilize the decision-making

First familiarize yourself with the health system resilience, flowchart and template to guide
context and conceptual aspects including examples of required actions in applying the roadmap
of health system resilience actions, technical and strategic for building health system
tools and stakeholders’ roles resilience
Section 1 and 2 Section 3 Section 3 and Annex

ix
Executive summary
Context Fundamentals of health system resilience

Health systems are responsible for the provision Health systems consist of the people and actions
of essential health services alongside protecting whose primary purpose is to improve health. Like
populations from public health challenges, including any other system, all parts of the health system are
changing patterns of epidemiology and demography interdependent and must work and be strengthened
and large-scale shocks caused by emerging together to be effective in delivering its core
infectious threats or conflict, and the effects of functions and collaborating with other sectors to
climate and environmental changes. Experience has meet the health needs of people.
demonstrated that resilience is not an inevitable
Health system resilience means that systems
by product of any investment in health but must be
(including the institutions, infrastructure and
intentionally operationalized with necessary input,
populations) are able to anticipate, prevent,
investment and contextualization. Based on a global
prepare for, absorb and adapt in response to, and
review, the World Health Organization (WHO) Health
recover from a wide variety of shocks and stressors
Systems Resilience Toolkit highlighted the scarcity
while delivering quality individual and population
of guidance on implementing the concept in national
health services as needed, utilizing lessons from
health systems.
experiences within and outside their settings to
continuously improve on their baseline capacities
Purpose and performance in all contexts. This is achieved
This technical product aims to guide national, through the process of strengthening health systems
subnational and global health actors to to deliver and maintain quality individual and
operationalize the concept of health system population health services based on population
resilience for advancement of universal health needs in all contexts, by embedding considerations
coverage, health security and ultimately better for resilience within all relevant health system
health for all. It supports the translation of components, including capacities for comprehensive
relevant conceptual guidance and high-level and integrated delivery of public health functions
recommendations into practical actions. The specific and services, and ensuring the systematic capture
objectives are to: and the systematic translation of lessons into action
at all levels in health and allied sectors.1
• present a concise overview of the concept
of health system resilience;
• provide a roadmap outlining practical and
foundational steps for building health system
resilience to be adapted to different contexts;
• share examples of actions and tools, including
stakeholder roles, to support country application
of the roadmap.
1 A wide range of sectors are typically outside the health sector but significantly contribute to public health or are responsible for health determinants,
for example agriculture and food, environment, transport, education, finance, urban planning, sports, and social care.
Building health system resilience to public health challenges: guidance for implementation in countries x
Building resilience is a continual process dependent

on interconnected, proactive actions by stakeholders
at all levels within and beyond the health sector.
All health programmes, irrespective of their
specific objectives, can contribute to resilience
by using an integrated approach that strengthens
the baseline health system capacities in a unified,
rather than fragmented, manner. Harnessing these
complementarities supports the development of
resilience as a necessity for common objectives of
advancing universal health coverage, health security
and other interconnected Sustainable Development
Goal targets.
Figure ES.1 Roadmap for building health system resilience
Coordinated system wide and multisectoral joint working
Prioritize
resilience
Monitor and Identify the baseline

evaluate progress and needs
Health system
strengthening with
resilience focus
Institutionalize Adopt integrated

resilience building planning and resourcing
Building health system resilience: a This roadmap consists of five interconnected,

roadmap for action interdependent and continuous steps (Figure
ES.1). While some steps may overlap, the stepwise
A roadmap is defined in this technical product to approach is important, as each subsequent step
guide country-level actions. It will help in elucidating depends on the preceding steps for success. The
the status of health system capacity and capability, starting point in applying the roadmap should be
systematically embedding resilience-focused input determined by the achievement of the preceding
and orientation, and increasing resilience in health steps, followed by progressively working through the
systems (Figure ES.1). next steps and building on previous achievements
for continuous improvements in resilience. Table
ES.1 presents an example scenario of a country
application of the roadmap starting from step 1.
Executive summary xi
Table ES.1 Example scenario of country application of the roadmap to build health
system resilience
Roadmap steps Examples of actions

The country:
Step 1: Prioritize starts with reviewing the existing national health strategy, policy or plan from a
resilience resilience perspective through intersectoral coordination and sound understanding
of the concept.
Step 2: Identify the identifies critical capacities and gaps in health and allied sectors applying
baseline and needs relevant health system resilience-focused indicators, informed by (for example)
multisectoral health sector review during or after the COVID-19 pandemic, health
facility assessment, post-disaster needs assessment, IHR (2005) Monitoring and
Evaluation Framework.
Step 3: Adopt integrated uses the data from steps 1 and 2 to update existing or develop new health sector
planning and resourcing strategy, policy or plan that synergizes investments in universal health coverage,
health security and other priorities, with health system resilience as a cross-cutting
priority.
Step 4: Institutionalize establishes functional intersectoral accountability with funding to implement

resilience building adopted plan at all levels. This could involve an empowered role for the ministry of
health, the national public health institute, One Health coordination platform and
other coordinating entities.
Step 5: Monitor and conducts a periodic functional review of intersectoral coordination and
evaluate progress implementation of the plan and impact of resilience measures on health outcomes,
and uses the results to inform decisions regarding the next roadmap steps to
implement.
Building health system resilience requires the joint of existing investment in health while building
efforts of all stakeholders led by the ministry of operational collaboration with other sectors with
health with support from the national public health direct and indirect responsibility for population
institute (or equivalent) at all levels, each with health. The guidance contained within this document
their own unique roles and actions that cut across will help countries to develop a roadmap for building
the process of building resilience, represented health system resilience. Given the evolving and
by the above roadmap. This roadmap should be expanding landscape of public health challenges
applied within existing institutions, processes and – climate change, ageing populations, rising rates
programmes, ensuring progressive improvements of antimicrobial resistance, political instability
that reflect key guiding principles: integration, and mass displacements – building health system
sustainability and equity. It promotes primary health resilience represents a worthwhile investment for
care and essential public health functions (EPHFs) as healthier and safer populations as the foundation
key requirements for making health systems more for stable and sustainable social development and
resilient. economic prosperity.
Conclusion
As countries are reflecting on their experiences of
the COVID-19 pandemic and other emergencies
and conflicts, there is a window of opportunity
to change the way health systems are developed,
strengthened, and coordinated with other sectors.
Measures of resilience should guide smart use
xii
1
Introduction
Building health system resilience to public health challenges: guidance for implementation in countries 2
1.1 Context Many efforts to improve health systems and services

have, however, been siloed and fragmented in
Health systems are responsible for the provision
their approach, resourcing, and implementation,
of routine health services, alongside protecting
without clear prospects for contributing to resilience.
populations from public health challenges, including
For example, despite the acknowledgement
natural and anthropogenic hazards, changing
that investing in primary health care (PHC) can
patterns of epidemiology and demography,
enable health systems to deliver essential health
shortages of medical products and health workers
services and public health functions equitably
(1), and supply chain deficiencies. In recent years,
and comprehensively during and beyond
the need for health system resilience has become
emergency contexts, primary care remains widely
more prominent because of the increasing frequency
underdeveloped and underutilized. This failure to
and scale of public health emergencies, including
adequately consider and apply the requirements for
the 2014–2016 outbreak of Ebola virus disease
resilience explains the persistence of foundational
in West Africa and the COVID-19 pandemic, and
gaps in many health systems and their ongoing
their devastating impacts on health, society and
susceptibility to shocks and stressors, despite
economies. While these acute shocks highlight
continuous investment.
the need for resilience, health systems also need
to develop resilience to the more prevalent and Public spending on the health sector tends to be
chronic stressors, including climate change-related limited, with the bulk of available funding focused on
events, economic contractions, war and conflict, curative health care rather than preventive services
antimicrobial resistance, and the growing burden and promoting health and well-being (4). This
of noncommunicable diseases. These stressors inadequate and often siloed investment in public
have arguably had more devastating impacts on health has significantly hindered the development
populations and health system functionality, over of capacities for resilience, which is key to the
time, than the above-mentioned shocks (2, 3). attainment of universal health coverage, health
security and healthier populations as interdependent
An important reflection from experiences with public
objectives. In October 2021, the World Health
health events is that resilience is not merely a by-
Organization (WHO) published its position on
product or an inevitable outcome of any investment
Building health systems resilience for universal health
in the health sector. As demonstrated over the
coverage and health security during the COVID-19
course of the COVID-19 pandemic, across countries
pandemic and beyond (5) to guide Member States
from various income groups, resilience is also not
in recovery and building back better, fairer, and
achieved by simply developing epidemiological
more resilient health systems. WHO regional offices,
capacities and building more health care facilities.
national authorities, and various agencies have
Resilience must be proactively and intentionally
also released resolutions and strategies identifying
programmed into health system strengthening and
and recommending health system resilience as a
other complementary public health efforts, including
priority agenda moving forward (6–8). A 2023 report
those targeting health security, specific diseases,
of the Organisation for Economic Co-operation and
and life course-related and environmental issues.
Development identified s underinvestment among
In addition, resilience-focused efforts must be
the major health system vulnerabilities. The report
contextualized, for example to the specific needs of
recommended an annual targeted investment of
fragile, conflict-affected, and vulnerable settings or
1.4% of gross domestic product to build health
of Small Island Developing States.
system resilience (8).
The renewed attention and commitment provide
opportunities to use the lessons from various shocks
and day-to-day stressors to guide investment in
health systems and enhance their ability to manage
ongoing and future threats without compromising
the delivery of essential services.
1. Introduction 3
1.2 Purpose, approach and target audience This work complements and builds on existing
knowledge, technical resources, and experience
There is broad consensus on the principal features in supporting countries with varying contexts to
and attributes of health system resilience (9), make their health systems more resilient. It should
however, there is a gap in the availability of technical be used with reference to WHO’s previous work
resources to support implementation at country level on health system resilience, including the WHO
(10, 11). This technical product has been produced to position paper on Building health system resilience
address current gaps in global guidance for national for universal health coverage and health security
and global health actors to operationalize health during the COVID-19 pandemic and beyond (5), health
system resilience, building towards the advancement systems resilience toolkit (10), the training package
of universal health coverage, health security and An integrated approach to building health systems
ultimately better health for all. resilience (12), health system resilience indicators (13).
The specific objectives are to: The document was informed by literature reviews
• provide a concise overview of the concept of health conducted to underpin a recent synthesis of
system resilience; concepts of resilience to inform operationalization
• provide a roadmap outlining practical and of health systems resilience (9) and the WHO Health
foundational steps for building health system System Resilience Toolkit (10). It was developed by
resilience to be adapted to different contexts; consolidating, building on, and complementing
previous technical guidance provided by WHO on
• share examples of actions and tools, including
health system resilience. It represents the collective
stakeholder roles, to support country application
knowledge and experience of the experts involved
of the roadmap.
in and consulted in its development, including their
experience in supporting countries with varying
contexts to make their health systems more resilient.
This included experts across the three levels of WHO.
The target audience for this work is the various
stakeholders involved in strengthening health
systems and public health including emergency
management (from prevention and preparedness
to response and recovery) in countries. This ranges
from the donors, policy-makers and decision-
makers at global, national and subnational levels
to the implementing institutions and line managers
of health system functions and services across the
health system building blocks.
2
Fundamentals of health
system resilience
Health systems consist of the people and actions Health system resilience means that systems
whose primary purpose is to improve health (14). (including institutions, infrastructure, and
These elements within health systems have been populations) are capable of anticipating, preventing,
organized into six interconnected building blocks: preparing for, absorbing, adapting in response to,
leadership and governance; health financing; health and recovering from a wide variety of shocks and
workforce; health information; medicines, other stressors while delivering quality individual and
medical products, technologies and infrastructure; population health services as needed, and utilizing
and service delivery, with people and communities lessons from experiences within and outside their
recognized as central to decision-making and action. settings to continuously improve on their baseline
All parts of the health system are interdependent capacities and performance in all contexts (9, 10).
and must work together to be effective, ensuring While resilience is demonstrated during public health
necessary interlinkages with other systems that events, it must be built over time, ideally before the
contribute to or impact health. The functionality of shock or stressor, and further developed with each
the health system is demonstrated in the delivery of experience and learning across all the health system
comprehensive individual and population services to building blocks. Building resilience is therefore
meet individual and population health needs, from not limited to the response phase of shock events
prevention to palliation. but cuts across the entire cycle from prevention to
preparedness, response and recovery.
Box 1 describes the main attributes of health
system resilience.
Box 1. Health system resilience attributes

The resilience of health systems can be portrayed through several attributes (see figure). These enable
health systems to recognize their risks and capacities (awareness), mobilize and coordinate the required
resources and support (mobilization), make the decisions required to manage risks and respond to
threats, thereby limiting their negative impacts (self-mitigation), integrate health system strengthening
and public health, including health security actions (integration), provide the range of services needed
to meet population needs in all contexts (diversity), and apply lessons identified from experience with
health system challenges and shocks (transformation). These allow health systems to anticipate risks in
order to forecast, prevent and prepare as needed, and to absorb, adapt, and transform, as necessary,
to maintain services while responding effectively, and – incorporating lessons learned and experience –
recover quickly to a higher level of functioning.
Awareness
Transformation Mobilization
Health system
resilience
Diversity Self-mitigation
Integration
2.1 Building health system resilience: for resilience across health system building blocks
key areas of focus including public health functions and ensuring
continuous learning and utilization of lessons (Box 2).
Building resilience is a continual process dependent
on interconnected actions to enable, develop 2.1.2 Comprehensive and integrated delivery of
and sustain it (Box 2). Operationally, health public health functions and services
system resilience is built through the process of
Investments in health systems often fail to recognize
strengthening health systems with a focus on public
public health capacities (Box 3) as an inherent aspect
health and learning from shocks and day-to-day
of health systems and disproportionately prioritize
stressors in order to deliver and maintain quality
individual hospital-based care, disease-focused
individual and population health services based
interventions, and reaction to emergencies over
on population needs, in all contexts (for example,
public health as a whole (16). This has meant that
before, during and beyond shocks).
many health systems are not structured, equipped,
2.1.1 Resilience-focused health system or operated in a way that enables them to address
strengthening everyday public health challenges and are even less
likely to effectively manage unusual or disruptive
Health system strengthening includes an array of events while maintaining their regular functions and
initiatives and actions that enable and develop or services, irrespective of how well resourced they
strengthen core health system capacities in a holistic are. Efforts to strengthen, reform or rehabilitate,
and integrated way, ensuring proportionate focus on and stabilize health systems must therefore include
all components of the health system2 and relevant comprehensive and coordinated application of public
risks. Integrating considerations for resilience health within the health system and across allied
enables continuous improvement of the functionality sectors (food and environment, planning, and social
and ability of the health system, to sustainably services) for sustainable resilience (17).
meet the evolving health needs of populations
served, in routine times as well as in the contexts
of shocks. Health system strengthening to improve
performance in routine contexts without due
attention to building resilience leaves health systems
highly vulnerable to potentially disruptive events,
and small-scale events can easily become large-scale
shocks.
Efforts to make health systems more resilient
without systematically and proactively addressing
the foundational gaps in health systems will at best
produce short-term results at a higher cost in the
long term. This kind of unbalanced and fragmented
approach to resilience, which has been referred to as
‘bad resilience’ (15), will at best produce short term
results with a higher long-term cost as demonstrated
through lessons from public health emergencies,
including the Ebola virus disease outbreak (2014–
2016) and the COVID-19 pandemic. Building resilience
should therefore be considered as an integral part
of health system foundational design or redesign,
development, and operation and strengthening,
rather than an external attribute to be added or
developed in parallel, when health systems are faced
with crises. This entails embedding consideration
2 Strong governance and stewardship backed up with information, evidence-based legislation, policies and plans; functional mechanisms of collecting,
pooling and allocating funds; competent and motivated health workforce; well maintained service delivery platforms and infrastructure; and a reliable
and adequate supply of medicines, other medical products and technologies.
Box 2. Key starting points for building health system resilience

Building resilience is a process dependent on interconnected actions that cut across all contexts
(routine and emergency). It is described operationally as the process of strengthening health systems
to deliver and maintain quality individual and population health services in all contexts by embedding
considerations for resilience within all health system components. This includes embedding capacities
for comprehensive and integrated delivery of public health functions and services, and ensuring the
systematic capture and translation of lessons into actions at all levels in health and allied sectors (9).
When countries embark upon building health system resilience, it is important they begin by embedding
consideration for resilience within each health system building block. This can include (but is not limited
to):
Health system Actions that support embedding consideration for resilience

building blocks
Leadership and • Identifying a responsible entity or focal point for resilience

governance • Ensuring a multisectoral approach to public health issues
• Ensuring integration between health security and health system actors
• Promoting meaningful community participation
• Ensuring systematic learning from public health events
• Integrating public health functions and services into the everyday functioning of
health and allied sectors
Health financing • Ensuring that resilience-building activities in routine and emergency contexts,
are represented in relevant budgets, and funded
Health workforce • Ensuring the health workforce is of sufficient number, distribution, and
orientation to ensure the delivery of essential individual and population-
focused health services in all contexts
Health information • Ensuring comprehensive and integrated surveillance, assessment, and

monitoring with regards to population health needs, risks, health system
performance and resilience in all contexts
Service delivery • Ensuring comprehensive delivery and continuity of quality individual and
population-focused (public health) services based on population need in all
contexts
Medicines, other • Ensuring appropriate medicines, medical supplies and products and
medical products, infrastructure are available where and when needed and support quality and
technologies, and continuity of services in all contexts
infrastructure
Box 3. Essential public health functions

The weaknesses in public health capacities demonstrated by experience with COVID-19 and other public
health emergencies has led to global recognition of the role of essential public health functions (EPHFs)
for advancing the interconnected agendas of universal health coverage, global health security and
other Sustainable Development Goal (SDG) targets (18). The EPHFs are the fundamental set of activities
that must be ensured by the state (through national or subnational government entities) to support
effective public health action in all contexts (19). By applying the EPHFs, health systems can have public
health capacities systematically integrated into their foundations, including at primary care levels, while
drawing on and coordinating the required inputs of other sectors, as a necessity for building resilience.
Consideration of the EPHFs in health system strengthening allows proportionate consideration for
population-based health services and due focus on the social determinants of health and equity in
service delivery, with a particular focus on including marginalized and hard-to-reach populations.
2.1.3 Systematic capture and translation 2.2 Many entry points, one health system
of lessons
The multifaceted nature of health system challenges
Learning is consistently highlighted as central (Table 1) creates various entry points, including
to building resilience and to supporting the health system strengthening for universal health
transformation of health systems for better resilience coverage; preparedness for health security, climate
to ongoing and future stressors or shocks. Despite change, or antimicrobial resistance; disease-specific
this, limited attention and resources are devoted or life course-specific programmes; humanitarian
to ensuring learning. While most if not all countries response and recovery; and the humanitarian–
participate in the systematic capture of lessons development–peace nexus. While these efforts are
during and after acute events (for example, intra- important for meeting different population health
action and after-action reviews, independent and programme needs, their siloed pursuit creates
reviews), as well as having some level of quality gaps, misses opportunities to build core capacities,
improvement programmes, the translation of and thus sustains fragmentation, frustrating the
these lessons into practice is often not systematic. prospect of sustainable impacts.
In the context of COVID-19, it quickly became
apparent that many of the key lessons identified
from previous experience with public health
emergencies at both global and national levels had
not been implemented. The systematic capture and
translation of lessons identified from all contexts
support continuous improvement in routine times
while developing agility and adaptability that
supports resilience during shocks and stressors. To
support resilience, translation of lessons into actions
must be seen in the planning, budgeting, resourcing,
and measurement processes that enable results.
Table 1. Range of events that can challenge the resilience of health systems
Type Health system stressors and shock events
Disease Environmental Economic Sociopolitical
Acute: New or re-emerging Sudden disasters, Sudden fiscal Political events

sudden disease event of such as floods, event that changes forcing a sudden
onset, sudden onset and mudslides, or impact available funding for change in health
shorter expected shorter of acute climate event health, for example, direction, for
duration duration, for affecting health unexpected donor example, coup,
example, Ebola virus withdrawal, oil price political insurgence,
disease shocks sudden conflict,
attack on health
facilities or workers
Chronic: New or re-emerging Effects of climate Progressive fiscal Political events

gradual disease event of a change events events changing leading to slow,
onset, longer longer-term onset affecting health, for available funding for sustained change
duration and expected example, drought health, for example, in health direction,
longer-term duration, progressively for example, due
for example, reduced donor to imposed health
protracted cholera confidence, less stewardship
outbreaks, burden of government health or inadequate
noncommunicable prioritization leadership capacity
diseases Protracted conflict
or humanitarian
event, for example,
population
displacement
Economic recession
with donor
dependency
Source: Adapted from Karamagi et al. (20).
All health programmes, irrespective of their Integrating planning, resourcing and implementation
specific objectives, can contribute to resilience by of these priorities with systems thinking strengthens
including consideration of the wider health system the entire system (including the workforce, supply
functions in their design and implementation. This chain and service delivery platforms) in a unified
includes health system strengthening-focused rather than fragmented manner, increasing and
approaches, such as PHC and the EPHFs. as well as sustaining the impact of the various investments
other global frameworks and approaches, such as and supporting the common objectives of advancing
the International Health Regulations (IHR) (2005), health security, universal health coverage, and other
emergency and disaster risk management, the interconnected SDG targets.
humanitarian–development–peace nexus, and
disease- and life course-specific programmes.
3
Building health system resilience:
a roadmap for action
3.1 Introduction These are explained using a roadmap (Figure 1) that

provides stakeholders with steps to identify where
This chapter describes what building health system
they are and the relevant actions to take to make
resilience means in practice – what needs to be done
their health system more resilient.
and who should be involved.
Figure 1. Roadmap for building health system resilience
Coordinated system wide and multisectoral joint working
Prioritize
resilience
Monitor and Identify the baseline

evaluate progress and needs
Health system
strengthening with
resilience focus
Institutionalize Adopt integrated

resilience building planning and resourcing
It is important to note that this is a continuous This roadmap does not represent a siloed or parallel
process, as resilience can and should be approach but should be applied within existing
progressively enhanced to meet the ever-evolving health sector planning processes, institutions and
challenges of health systems. The starting point in operations. For example, it can be applied within
applying the roadmap should be determined by the efforts to promote PHC or emergency preparedness
achievement of the preceding step or steps, followed and response, creating a win–win situation by
by progressively working through the next steps and intentionally plugging consideration of resilience
building on previous achievements for continuous into existing priorities and programmes reflecting
improvements in resilience. For example, if step 1 principles of integration, equity and sustainability
is already established, stakeholders can start with (Box 4). The examples of actions indicated under
step 2, and so on. Where to start can therefore vary each step of the roadmap are inexhaustive and
depending on the progress made in intentional focused on foundational aspects of building
efforts to build health system resilience. It is also resilience across all building blocks of the health
important to note that given the interconnection system. They are generic examples serving as
between steps, some aspects may overlap or be pointers for stakeholders to apply or adapt to their
pursued in tandem. contexts as needed. The more specific details of how
to operationalize these examples and the indicated
supportive tools will therefore depend on specific
contextual considerations, including population
need, existing services and delivery platforms, and
risks such as those related to climate change or
resulting from war or conflict.
Box 4. Key guiding principles

The following general principles should guide stakeholders in adapting the roadmap and related actions
at country level.
• Integration. Integrated approaches to health system strengthening require intentional actions
and a conscious shift from the status quo. Integration in building resilient health systems can be
demonstrated by governance arrangements that promote synergies across health system components
and priorities; collaborative working across disciplines and stakeholders within health and allied
sectors; alignment of policies, plans, financing, operations, and monitoring and evaluation across the
various entry points into the health system; institutionalized capacities at all service delivery levels
for preventing, preparing for, responding to, and recovering from emergencies; and the delivery of all
aspects of public health, from promotive and preventive to rehabilitative and palliative services, as
needed by populations served.
• Equity. Health equity is a fundamental human right that is achieved when everyone can reach their
full potential for health and well-being and there is an absence of unfair, avoidable, and remediable
differences in health status between groups of people (21). By meeting the health needs of the entire
population, including vulnerable and marginalized groups, building resilience helps to reduce or even
prevent the effects of disruptive public health events. This in turn supports the attainment of universal
health coverage, as that cannot be achieved while health systems are frequently overwhelmed in
responding to shocks and stressors. Resilience and equity are therefore mutually beneficial and
reinforcing.
• Sustainability. Resilience is a process built over time through continuous learning and sustained
investments that produce sustained benefits. Actions to build resilience have a long-term focus
on systematically addressing the foundational gaps in the health system. This requires ongoing
consideration within plans and mechanisms of the promotion of efficiency and effectiveness in the
use of available resources, and sustainability in resourcing in order to produce broader benefits for
population health and well-being, as well as socioeconomic growth and development (8).
3.2 Overview of roadmap progress towards the set objectives is of utmost

importance for continuous learning, improvement
The process begins with the recognition of the
and accountability. While monitoring and evaluation
need to make the health system more resilient and
actions are implemented later in the roadmap,
establishing a common understanding of health
appropriate evaluative measures and approaches
system resilience across all key stakeholders. With
should be considered throughout the process.
this shared understanding based on lesson learned,
Insight into how each component of this process
stakeholders can better identify what is available (the
can be operationalized using an integrated systems
baseline), what is missing (gaps), and what is needed
approach is presented below. The approach is
(additional resources and actions required) to make
underpinned by public health principles (Box 5) and
their health system more resilient. This supports the
can be used to strengthen the role of PHC through its
identification of clear, focused objectives towards
operational framework.
the common goal, which inform actions in terms
of strategizing, planning, and drawing internal and The process can be categorized into five steps, as
external resources that leverage existing strengths outlined in the subsections below.
and mobilize what is needed to fill the identified
gaps in line with identified objectives. This is further
supported by deliberately institutionalizing the key
inputs and processes needed to progress and sustain
resilience at all levels. Monitoring and evaluating
Box 5. Principles of a public health approach to health

A public health approach to health is based on the promotion of population health and well-being
through the prevention of disease, the protection and promotion of health, and health service design
that is based on population health needs. It is a value-based approach with a focus on equity and
community engagement towards the attainment of universal health coverage. A public health approach
is multisectoral, with a strong focus on actions on the determinants of health.
Step 1: Prioritize resilience In addition, policy-makers, leaders, managers, and

other decision-makers within health and allied
The identification of resilience as a strategic priority
sectors need to create a shared understanding
provides the foundation for action and engagement of what resilience means and why it is important
with the relevant stakeholders required to build for their context, applying lessons learned from
resilience in health systems. There are several disruptive emergencies and routine challenges.
ways in which resilience can be identified as a Bringing these key decision-makers together with
strategic priority. In order to be meaningful, this a shared understanding of what is required to
should include high-level commitment to resilience
build health system resilience can influence their
as a national priority articulated within national-
priority-setting actions and generate a ripple effect
level documents, such as national strategies or
throughout the entire health system, supporting
health sector strategic plans, policies, or political
reorientation and competency development
statements. This should be supported by the
that enables the vital roles of all stakeholders at
identification of an entity with responsibility for
an operational level. Examples of ways in which
resilience, visible at all levels, with a clear mandate,
conceptual clarity and understanding can be
authority and support that ensures that the entity
developed include advocacy workshops, training
can coordinate, guide, and draw on the necessary
courses, and developing and disseminating relevant
resources and stakeholders to support resilience-
technical resources on health system resilience (12).
building efforts. A clearly defined and accountable
coordinating role enables better participation and Further examples of actions to support prioritizing
accountability across the various stakeholders resilience and developing a shared understanding
involved in building resilience. are outlined in Table 2, according to the health
system building blocks. Box 6 provides an example of
promoting a common understanding of resilience in
Liberia.
Table 2. Illustrative examples of actions and tools to support prioritizing resilience, including
developing a shared understanding and commitment
Health system Prioritize resilience: examples of actions

building blocks Attributes: awareness, integration
Leadership and • Identify health system resilience as a priority in national health policies, strategies
governance and plans
• Establish and support institutional focal point or entity for health system resilience
• Conduct advocacy and training to orient relevant stakeholders to health system
resilience; multisectoral convening during major emergency can guide mapping of
stakeholders
• Establish and strengthen collaborations with global, regional and national entities
with a demonstrated focus on health system resilience
Health financing • Allocate and guide funding for development of initiatives and actions that prioritize
and promote health system resilience, leveraging existing and new funding
• Orient stakeholders responsible for health financing on health system resilience,
define their roles, and identify longer-term dividends
Health workforce • Review health workforce education to ensure that the workforce has the relevant
skills and competencies for the public health practice that ensures health system
resilience
• Identify and include the public health roles of all occupational groups of health
workers (including community-based health workers) when defining their
responsibilities
Health information • Support review and adaptation of indicators for health system resilience for
integration in routine health information system
• Create awareness among stakeholders responsible for health information
management on their roles in building health system resilience
Medicines, other • Provide orientation to stakeholders responsible for medical products, technologies
medical products, and infrastructure on their roles in building resilience
technologies, and • Integrate resilience considerations in health facility development, for example,
infrastructure structural and environmental safety and resilience considering the risk profile of the
setting
Service delivery • Include considerations for resilience, including public health functions and services,
in defining national package of essential health services
• Ensure that national and subnational policies, strategies and plans on the role of
services in building health system resilience are communicated at all service delivery
levels and platforms, including national IHR (2005) focal point and other health
emergency teams
Examples of technical • Policy document, for example, policy briefs that promote prioritization of health
and strategic system resilience
resources and tools • Training package on health system resilience targeting service provision, for example
to support the above on routine health service continuity in emergency contexts
actions (10)
• WHO health system resilience indicators, PHC monitoring framework and indicators,
approach of WHO Regional Office for Africa to monitoring resilience, IHR (2005)
Monitoring and Evaluation Framework
• Case examples of service delivery models that comprehensively provide public health
services, including those for emergency management
Box 6. Promoting a common understanding of resilience in Liberia

At the beginning of a multiyear project aimed at strengthening resilience in Liberia, the WHO training
course An integrated approach to building health systems resilience (12) was used to orient leaders
from the Ministry of Health and Social Welfare, national public health institutes, county health teams,
health facilities, academia, professional bodies and others towards a common understanding of health
system resilience (22). The package aims to create greater understanding of health system resilience
and its application. An online version of this course is available from OpenWHO and the package can
be adapted for application within national contexts. In addition to the shared understanding that
informs awareness, the adaptation and roll-out of this training package in Liberia supported resilience
by building integration between health system, health security and other relevant stakeholders. The
course has been incorporated into the pre-service training curricula for health workers (nurses, midwives
and medical doctors) and has been used to define the scope of the national continuous professional
development programme for in-service training of health workers. This demonstrates the added value
of partnering with organizations and other entities that have supported conceptual and operational
work on health system resilience as countries embark on understanding and applying the concept as
appropriate to their context.
Step 2: Identify the baseline and needs The required information can be obtained from
a broad range of existing data sources, including
Building resilience requires a clear understanding routine health information systems and reports
of where the system is now – the current baseline. from periodic and ad hoc reviews, such as health
This includes the current resources and capacities service or facility assessments. These may include
of the health system, including gaps, based on an the Harmonized Health Facility Assessment,
understanding of what it takes to build health system service coverage, State Party Self-assessment
resilience. The current baseline reflects capacities Annual Reporting (SPAR), Joint External Evaluation,
(including human, financial, material, technical and multisectoral review during and after COVID-19,
political resources), performance, and gaps across and post-disaster needs assessment. Missing
the health system building blocks and other relevant information may need to be collected, depending
sectors. It will include, for example, the current on the data required to provide a comprehensive,
policies, plans, structures and initiatives that support
coherent picture of what is currently available and
an integrated approach to health system resilience,
what is needed to improve the resilience of the
and the quantity, skills mix, occupational grouping,
health system. Up-to-date data on ongoing (burden
distribution, and competencies of the health
of diseases, risks and vulnerability) and potential
workforce in relation to population health needs.
population health needs should also be included in
these analyses to ensure that the resulting objectives Further examples of actions to support clarifying
and targets are ultimately aligned with those needs baseline capacities and setting common objectives
while reducing the risks of ongoing and future shocks are outlined in Table 3, according to the health
to the health system. Lessons from health system system building blocks, while Box 7 presents an
shocks, including intra-action, after-action and example of using recovery to bridge current health
other multisectoral reviews, can also provide a good sector policies and planning in South Sudan.
indication of the real-life performance of the health
system in the face of crises.
A comprehensive assessment of the baseline should
present a clear picture of health system strengths
and weaknesses in relation to resilience. A clear
baseline also forms the basis for evidence-informed
objectives, grounded in the contextual realities of
a country. These should inform the collaborative
identification of priorities for building health system
resilience that should be refined into objectives,
including both short- and longer-term targets to
be achieved by stakeholders at all levels within
a specific period. Consideration of appropriate
measures and mechanisms to monitor and evaluate
progress is essential at this stage to ensure that
progress towards identified targets can be measured
in a meaningful way.
Table 3. Illustrative examples of actions and tools to support clarifying baseline capacities and
setting common objectives
Health system Identify the baseline and needs: examples of actions

building blocks Attributes: awareness, integration
Leadership and • Coordinate with all responsible stakeholders to collect and consolidate baseline data.
governance This includes mapping required resources and capacities across all health system
components and allied sectors, reflecting population health needs and context-
specific risk profiles
• Utilize baseline data to inform development of national and subnational priorities
and SMART (specific, measurable, achievable, relevant, and time bound) targets to
guide planning, actions and collaboration for building resilience reflecting areas for
improvement and strengths to maintain
• Maintain up-to-date, comprehensive documentation of public health risks (for
example, risk register) and population health needs at national, subnational and
service delivery levels based on regular risk and population health needs assessments
Health financing • Define current funding available within health sectors as well as those identified for
wider public health within allied sectors
• Map and streamline available funding to align with building resilience
Health workforce • Map and measure the occupational groups that contribute to the delivery of essential
public health services
• Identify gaps in national workforce capacity to deliver the EPHFs and services
Health information • Develop and apply an integrated framework and mechanisms for collecting and
monitoring baseline data on capacities and resources in the health system to identify
resource gaps and requirements
• Review existing monitoring tools and platforms for their adequacy to measure health
system resilience, identifying indicators to be integrated in the health information
system
Medicines, other • Review and identify the current state of intersectoral coordination and capacity, and
medical products, gaps in medical products and supplies, technologies, and infrastructure, and set
technologies, and priorities to build resilience
infrastructure • Report the status of medicines, other medical products, technologies and
infrastructure to relevant authorities
Service delivery • Identify and communicate with stakeholders, including those at community levels,
on public health risks, and state of and priorities for ensuring service continuity in
routine and emergency contexts
• Document and report to relevant authorities the data needed to understand
the current state of service delivery in terms of availability, quality, accessibility,
affordability and utilization in routine and emergency contexts
Examples of technical • Tools for assessing population health needs

and strategic • Health system resource mapping tools, for example, Health Resources and Services
resources and tools Availability Monitoring System (HeRAMS) (23)
to support the above
• Tools for conducting risk assessments and profiling, for example, Strategic Tool for
actions (10)
Assessing Risks (STAR) (24)
• Tools for assessing health system and sector performance, for example, adaptation
of health system resilience indicators (13), Health Systems in Transition reviews (25),
Service Availability and Readiness Assessment (SARA), Harmonised Health Facility
Assessment (26)
• Guidance to map and measure national workforce capacity for delivering essential
public health functions (1)
Box 7. Using recovery to bridge current health sector policies and planning in
South Sudan
Following independence, South Sudan embarked upon an ambitious plan to achieve universal health
coverage and the SDGs through the implementation of the National Health Sector Strategic Plan (NHSSP)
(2017–2022). This plan was disrupted by a resurgence of conflict in 2016, which affected health policy
processes and delayed development investments. In 2019, a Health Systems Stabilization and Recovery
Plan was drafted to revitalize health development and efforts to achieve universal health coverage. The
process was informed by a review of all major national health strategy documents and engagement
and discussions with major stakeholders on the scope, content, focus and underpinning principles of
a recovery plan. The WHO health system building blocks were used as the framework to assess health
system challenges and identify strategic interventions to support the attainment of national goals. For
each building block, the following questions were applied:
• What are the current capacities and critical gaps (i.e., baseline)?
• What are the key results the country wants to attain?
• What are the current bottlenecks hindering their attainment?
• What would an effective stabilization and recovery intervention entail?
• What are three to five critical interventions that will facilitate attainment of results for each
intervention area?
The identified intervention areas were linked with the NHSSP 2017–2022 and humanitarian assistance
in health. Note was also taken of ongoing efforts in such areas as immunization and health security;
HIV, tuberculosis, malaria and other communicable diseases; and reproductive, maternal, neonatal,
child and adolescent health in order to gain the maximal benefit from health system investments and
health service outcomes. This kind of integrated planning, if supported by the required resources for
implementation, builds resilience through strengthening integration of the needed capacities within the
health system and between other relevant sectors.
Source: South Sudan Health Systems Stabilization and Recovery Plan (27).
Step 3: Adopt integrated planning and consistent with the shared understanding of health
resourcing system resilience achieved in step 1; should identify
and build on the clear understanding of the baseline
Well-integrated and effective planning is essential identified in step 2; and should identify opportunities
for achieving meaningful progress in building to align with existing priorities and resources that
resilience. It entails enhancing synergy between could be leveraged towards the identified objectives.
health priorities and relevant stakeholders to Box 8 provides an example of an integrated approach
avoid fragmentation and promote efficient use of to policy development from Iran (Islamic Republic
limited resources. When common objectives and of).
targets are identified, these should be used to
inform strategy, planning and resource mobilization
to promote a focus on resilience. Such planning
facilitates the mainstreaming of considerations and
requirements for resilience in the health system
throughout implementation and associated resource
utilization and mobilization. This can be achieved
either by developing a distinct plan or strategy for
health system resilience or by incorporating health
system resilience as a priority within overall health
sector plans, investment plans, recovery plans
and humanitarian response plans. Regardless of
the method, the approach and context should be
Box 8. An integrated approach to pandemic policy development in Iran (Islamic

Republic of)
In June 2022, multisectoral stakeholders were invited to participate in developing an integrated
pandemic influenza and COVID-19 preparedness, response, and recovery plan for Iran (Islamic Republic
of). The plan incorporated lessons from experience with the COVID-19 pandemic, as well as integrating
acute respiratory infections with epidemic potential. Three multidisciplinary workshops were attended
by 175 stakeholders from all relevant departments within the Ministry of Health and Medical Education
and other relevant government ministries and organizations. Strategic actions were categorized
according to four phases (interpandemic, alert, pandemic, and recovery). Following extensive
multidisciplinary and multisectoral engagement, respective activities for each action were included,
with timelines, responsible agencies, partners and budgets. In addition to promoting an integrated
approach in planning for long-term resilience, the process strengthened health and emergency and
disaster risk management by creating a platform to tackle multihazards.
Source: Gouya, Seif-Farahi and Hemmati (28).
While good planning is essential, it must be contribute to the broader goal of strengthening the
translated into tangible actions to contribute health system, achieving more lasting results within
towards health system resilience. This requires the same investment.
effective resource mobilization with an emphasis on
Further examples of actions to ensure integrated
maximizing the available resources and leveraging
planning and resource mobilization and
existing opportunities, while seeking increased
utilization are outlined in Table 4, according to the
investment to address gaps. Integrated planning
health system building blocks. Box 9 considers
supports efficient use of resources by identifying
opportunities to leverage resources to maximize
opportunities to align investments across all areas to
their use for resilience.
Table 4. Illustrative example of actions and tools to support integrated planning and resource
mobilization and utilization
Health system Adopt integrated planning and resourcing: examples of actions

building blocks Attributes: integration, mobilization, self-mitigation, diversity
Leadership and • Apply an integrated approach to health sector planning and budgeting by considering
governance diverse and interrelated population health needs, including health security, specific
diseases, life course, antimicrobial resistance, climate change
• Promote integrated planning through joint working between stakeholders within
and beyond the health sector, promoting alignment, efficiency and integration of
resources
• Identify and utilize multisectoral, whole-of-government and community platforms
to coordinate and mobilize support to comprehensively strengthen public health
capacities (beyond emergency response)
• Define and plan an essential package of services that reflect population health needs
and risk profile resources, including innovations at all levels
Health financing • Identify and fund budget lines for specific input and actions that catalyse health
system resilience, leveraging existing funding streams to address health system gaps
• Promote investments in resilience by highlighting the long-term economic benefits
• Ensure integrated approach to financing, leveraging available resources, for
example from response to emergencies or crises towards broader health system
strengthening, avoiding duplication of efforts and closing gaps
Table 4 (continued). lllustrative example of actions and tools to support integrated planning and
resource mobilization and utilization
Health system Adopt integrated planning and resourcing: examples of actions

building blocks Attributes: integration, mobilization, self-mitigation, diversity
Health workforce • Plan for the needed workforce requirements and development with clear budget lines
to address existing and anticipated gaps
• Maintain regular roster of multidisciplinary workforce shared between different
catchment areas for surge capacity
• Allocate resources to support and enable the workforce to provide the full range of
public health services
Health information • Identify necessary resources (within health and allied sectors) to develop capacity for
measuring resilience as part of the routine health information system
• Analyse available relevant routinely monitored indicators to monitor and evaluate
resilience, for example, outpatient and other health service utilization in emergency
contexts
• Adapt and institutionalize additional indicators from existing resources, as needed
Medicines, other • Develop list of essential medicines and medical products reflective of the risk profile
medical products, and health needs of the population served
technologies, and • Leverage and fast-track innovation for long-term health system strengthening
infrastructure
• Ensure flexibility to pull resources from various sectors, including the private sector,
to address emergency health needs
Service delivery • Participate in developing plans for routine health service continuity in emergency
contexts, integrated with emergency management planning
• Work with collaborative interdisciplinary teams to provide comprehensive and holistic
services, as needed by the individuals and population served
• Establish and utilize two-way referral systems that ensure that primary care facilities
(as the first point of contact for most people) can refer seamlessly to other service
delivery platforms
Examples of technical • Tools on integrated planning, including budgeting and monitoring and evaluation
and strategic aspects
resources and tools • Guidance on identifying and sustainably engaging relevant multisectoral stakeholders
• Integrated health sector plans, investment case
actions (10)
Box 9. Maximizing resource use for resilience: opportunities to leverage

available resources
It is important to note that while increased investments are likely to be necessary for building resilience,
success is more dependent on making smarter use of the available resources, whether they are from
domestic or external sources. Resources are inherently limited; therefore, their allocation should aim to
produce the greatest benefit by addressing foundational gaps, sharing of infrastructure (for example,
laboratory systems, supply chain, interoperable data sharing), and strengthening the system to serve the
multiple health needs of the population, with a focus on efficiency, cost–effectiveness and sustainability
in addition to health outcomes. Opportunities for mobilizing support for resilience by leveraging existing
resources include the following.
• Adapting existing investments in health security, disease-specific and population-specific
programmes. In most settings, health sector investments are focused on only a few of the range of
public health challenges facing the health system, such as specific diseases or acute emergencies.
More could be achieved in terms of lasting impacts with the same resources if investments were
harnessed to coherently contribute to broader health system strengthening and resilience alongside
their specific objectives. This requires integrated planning based on clear resource mapping to identify
and fill the gaps in health system resources for short-term objectives as well as the longer-term goals
of strengthening the system. In countries dependent on external support, this integrated approach can
contribute to greater self-reliance, developing the ability to tackle future public health challenges.
• Leveraging ongoing humanitarian response efforts. Around 25% of the world’s population are
living in settings that are fragile, conflict affected and vulnerable, and the protracted nature of many
of these crises requires prolonged support from multiple donors, sectors and partners at global and
country levels. The humanitarian–development–peace nexus provides an approach to transition
these response-focused efforts towards recovery, stabilization and health system strengthening.
Coordinating and integrating humanitarian, development and peacebuilding efforts to address
foundational health system gaps make the affected health systems incrementally more resilient over
time. For example, application of the humanitarian–development–peace nexus is currently being
promoted as a means of leveraging scarce resources to drive the rebuilding of health systems and
tackle the underlying drivers of crises in the context of fragility, conflict and vulnerability in Africa (29).
• Harnessing existing health sector and multisectoral platforms. The various multisectoral
platforms in countries, including One Health platforms, disaster risk management forums, health
clusters, and health sector working groups, represent key resources that can be leveraged to mobilize
the support and resources needed to ensure better resilience in health systems. The presence of
a wide range of stakeholders from health and other sectors provides an excellent opportunity to
promote and coordinate resilience efforts, positioning health as central to national agendas for
socioeconomic development, with the participation of all sectors (30). Local resilience forums in
the United Kingdom provide a multiagency platform tasked with providing a systematic, planned
and coordinated approach to emergency preparedness and response, from the development of risk
profiles to emergency and contingency planning (31). These platforms help to institutionalize resilience
at local levels while driving integrated policy and planning.
• Leveraging existing political momentum for recovery and resilience building. Large-scale shocks
and other health sector challenges can set the stage for effective recovery and building back more
resilient health systems by leveraging the substantial investments in health, heightened political
impetus at national and global levels, and stronger collaborations between actors within and beyond
the health sector seen during public health events. Socioeconomic recovery agendas following health
crises can also provide an important platform to improve health system and public health capacities
beyond the pre crisis baseline, using a multisectoral approach. For example, lessons from the COVID
19 pandemic are informing health sector reviews using the EPHFs with the aim of better positioning
of public health in health sector policy, infrastructure and services to enable more effective action
against ongoing and future public health challenges.
Step 4: Institutionalize resilience building As articulated within the WHO Operational

Framework for Primary Health Care (32), a strong
The aim of investing in health system resilience PHC orientation of health systems can promote
includes but goes beyond meeting short-term resilience by enabling the delivery of essential public
targets. Ensuring sustained focus on the longer health functions and services at primary and other
term is achieved by institutionalizing the actions levels of care with whole-of-society engagement
and capacities that support resilience into all and greater involvement of communities in health
components of the health system and allied public policy- and decision-making. Health promotion, risk
health sectors. This can be achieved by intentionally communication, disease prevention and surveillance,
orienting health systems and other relevant contact tracing, screening and testing, vaccination,
organizational structures using resilience as a key community engagement, and other population-
consideration to inform their structure, roles and focused services are most effective when anchored
responsibilities, and introducing ways of working at primary care level, including within community-
that encourage prioritization and integration of based platforms (33, 34).
efforts contributing to resilience as part of routine
ways of working. This is further supported by Further examples of actions to support
defining the roles, responsibilities and required institutionalizing priority actions that build resilience
resourcing of all stakeholders within and outside are outlined in Table 5, according to the health
the health system, ensuring that all health system system building blocks. Box 10 presents examples
components are adequately resourced to support of applying a systems approach to strengthening
resilience in coordination with other components collaboration between health systems and health
and relevant sectors. security in Liberia and Ethiopia, while Box 11
provides information on the WHO Health Systems
Resilience Toolkit.
Table 5. Illustrative examples of actions and tools to support institutionalizing resilience building
Health system Institutionalize resilience building: examples of actions

building blocks Attributes: integration, self-mitigation, diversity, transformation
Leadership and • Use and sustain resilience considerations in deciding the organization, roles and
governance responsibilities of institutions such as ministries of health, public health institutes and
health facilities
• Establish and sustain mechanisms and structures for coordinating multidisciplinary
and multisectoral inputs in building health system resilience
• Institutionalize joint planning, monitoring and evaluation, coordination, and
information-sharing mechanisms between health and other relevant sectors at all
administrative and service delivery levels
• Establish mutual aid arrangements to share resources between health facilities and
subnational and national authorities for emergency management and routine service
continuity when needed
• Establish mechanisms to recognize and prioritize the contribution of communities
and civil society organizations not only during crises but also in addressing routine
health system challenges
• Ensure that packages of essential health services and health sector, health security
and disease-specific strategies, plans and initiatives reflect the vital roles of public,
private and community-based service providers in identifying and managing public
health risks, at all levels of care
Health financing • Proportionately allocate available funds to public health capacities of health systems,
including contingency funding for service continuity during emergency contexts, and
sustain levels of funding
• Maintain locally accessible contingency funding
• Routinely test and improve the financing systems to withstand shocks to the health
system
Table 5 (continued). Illustrative example of actions and tools to support institutionalizing

resilience building
Health system Institutionalize resilience: examples of actions

building blocks Attributes: integration, self-mitigation, diversity, transformation
Health workforce • Ensure that national health workforce planning, recruitment and retention includes
the necessary skills mix and availability for health system resilience
• Integrate competencies for practice activities to deliver the essential public health
functions in pre- and in-service training of all occupational groups of health workers
• Institutionalize mechanisms to ensure occupational health and safety and the well-
being of health workers in all contexts
Health information • Conduct routine monitoring and evaluation of resilience for evidence-driven decision-
making and actions
• Establish and institutionalize mechanisms for monitoring the impact of health system
resilience efforts on population health and socioeconomic outcomes
• Establish interoperability of data sources and data-sharing arrangements between
and across health and allied sectors, authorities, and service delivery levels
• Routinely test and improve the information system to withstand shocks to the health
system
Medicines, other • Preposition medical products with capacity for a responsive supply chain based on
medical products, population risk profile and health needs
technologies and • Establish mechanisms for routinely identifying and troubleshooting issues related
infrastructure to procurement and supply chain management, including standard operating
procedures and regular testing through simulation exercises
• Establish regulatory mechanisms to ensure the implementation of policies, guidelines
and standards on medicines and health infrastructure
Service delivery • Integrate the EPHFs in the delivery of health services at all levels according to an
essential package of health services, applying innovative and appropriate health
technologies that can facilitate a holistic approach to quality service delivery
• Ensure functional referral connections, including with the national IHR focal point,
between community-based health services, primary care facilities and hospital care,
with capacity for managing public health threats
• Institute mechanisms to enable individuals, families and communities to provide
feedback on quality health services (for example, patient complaint forms), and utilize
the feedback in improvement efforts
Examples of technical • Case examples on institutionalization of health system resilience-focused actions

and strategic • Up-to-date repository of lessons identified from experience with public health
resources and tools challenges
• Guidelines and tools for integrating health system resilience considerations in
actions (10)
planning and financing
Box 10. Applying a systems approach to strengthening collaboration between health

systems and health security in Liberia and Ethiopia
The figure below illustrates a model that is being taken forward in countries through a health system
resilience project to improve horizontal and vertical synergies between health service delivery,
public health entities and the animal sector. A systems approach was applied to the national referral
system, examining the entire referral system from remote primary care centres and their affiliated
community health workers to tertiary centres. In addition, the delivery architecture for public health
and the veterinary sector at all levels was mapped. This supported the development of alignment and
collaboration within and across these structures. This approach can be adapted and further expanded
to include other relevant sectors based on contextual considerations, with clear and supporting policies
and guidance for its operationalization.
Public health Health care delivery Animal health

Admin sector sector
levels
National National public Specialized hospital Ministry of

health institute (Tertiary care) agriculture
e.g., General hospital e.g.,

Region, state, regional, state, (Secondary care) regional, state,
county county county animal
health authority health authority
Primary District-level
District health hospital
District, zone authority for
authority
animal health
Health Health
center center
Primary care
Health
Local health Community animal
Village, town post
forum / authority health units
Urban Rural
Health extension
Community, workers, Community Animal owners,
household community health farmers
health volunteers volunteers
Composition and structure of the Toolkit

Box 11. WHObyHealth
Informed Systems
the various technical Resilience Toolkit
consultations, findings from the scoping review and technical
experience obtained through country support, four core modules were proposed to constitute the
The WHOarchitecture of the Toolkit.
Health Systems These are
Resilience mainlyiscentred
Toolkit around promoting
a consolidated (1) an
reference understanding
package of health
containing technical
systems resilience as a concept and its application; (2) integrated approach to policy-making and
tools to support countries in strengthening resilience at national and subnational levels, from policy and
planning; (3) health systems resilience at the implementation and operational level;1 and (4) health
planning, through operational and service delivery, to monitoring
systems resilience in monitoring and evaluation (see Fig. 1). and evaluation. When objectives and
actions to promote resilience are identified, specific technical tools that support the integrated approach
outlined
Fig.in1.this document
Architecture can
of the be found
Health within
Systems the toolkit
Resilience Toolkit
Health Systems Resilience Toolkit
Module 1 Module 2
Understanding health systems resilience Integrated policy and planning for health
systems resilience
● Overview – evidence synthesis, concepts
● Relevance of technical resources for ● Overview
health systems functions ● Compendium of tools and resources
● Global frameworks and regulations ● Considerations for adaptation to local
supporting health systems resilience context
Module 3 Module 4
Health systems resilience at operational Health systems resilience in monitoring and
level evaluation
● Overview ● Overview
● Compendium of tools and resources ● Compendium of tools and resources
● Considerations for adaptation to local ● Considerations for adaptation to local
context context
Relevance to health systems functions (leadership and governance; health financing; health workforce; health information;
medicines and technologies; service delivery; community) and administrative levels (national, subnational, community)
These four core modules not only address the current gaps identified, but ensure that audiences of
the Toolkit at all levels within health systems can identify their role and the relevant support within this
document, whether they are at the policy-making, implementation, operational or monitoring level.
This also helps to ensure accountability and responsibility towards all attributes of health systems
Step 5: Monitor andthe
resilience across evaluate progress
various functions. Lastly, these four SPAR capacity
modules 9 on
represent health
critical service
levers which,provision.
if
strengthened, can have a cascade effect to improve and strengthen all aspects of health systems
Resilienceresilience.
needs to be proactively monitored and As for other areas of work in building resilience,
evaluated. This can be done to some degree by these and other measurement efforts need to be
leveraging existing health system performance systematic and coherent, and appropriate for each
How to use the Toolkit
monitoring frameworks and national health context while avoiding creation of parallel systems.
information
Thissystems. However,
Toolkit is designed to many arepurpose
be fit for too siloed The choice
and fit for context. Users,of appropriate
regardless indicators
of their contextualtherefore
in their scope
setting,and
arefocus to adequately
encouraged measure
to start with needs to be informed by consideration
Module 1, which provides an overview of the concept of resilience, of some key
the contents of the Toolkit and the technical resources included. After reading through Module
features, including representation across all health 1
resilience. This may be due to limitations in health
information systems or availability and quality of system building blocks; proactive application before,
The operational level also includes service delivery at different administrative levels, as well as related administrative, infra-
1
data, or lack of clear

structural indicators
governance thathealth
(e.g. district identifiedteams, One during
are management Health) and and afterdevelopment
capacity shock events; measurement of
at the subnational
level.
and regularly tracked with the aim of monitoring and requirements for health system resilience attributes;
evaluating resilience in the system and proactively inclusion of input, process, output, outcome
4
addressing any gaps identified. Examples of resources and impact indicators; applicability at national,
developed with a focus on resilience include the subnational and health facility levels; and inclusion
health system resilience indicators package (13), the of public and private entities at all levels of care,
WHO PHC monitoring and evaluation framework including primary care.
(35), and the WHO Regional Office for Africa’s tool Further examples of actions to ensure monitoring and
for assessing inherent health system resilience3 (20). evaluating progress towards objectives are outlined
The recent IHR (2005) Joint External Evaluation and in Table 6, according to the health system building
SPAR reviews have further developed health system blocks.
resilience-related indicators, building on the previous
3 Inherent health system resilience is a new term used to describe the ability of the health system to respond to day-to-day stressors and challenges.
Table 6. Illustrative example of actions and tools to support monitoring and evaluating progress
towards objectives
Health system Monitor and evaluate progress: examples of actions

building blocks Attributes: integration, transformation
Leadership and • Mandate accountability for health system resilience, for example, monitoring of
governance health service continuity and utilization in routine and emergency contexts
• Establish mechanisms to collect feedback from service delivery levels and
communities as partners in health – routinely and during emergencies – including
integrated after-action reviews and routinely testing the resilience of the health
system through simulation exercises at all levels
• Document and systematically utilize data and lessons identified from shocks and
simulation exercises to inform policies and planning, resource mobilization and
allocation in recovery and building back a more resilient health system
Health financing • Finance integrated and interoperable information management systems that inform
actions for resilience
• Monitor the allocation and use of intersectoral funds towards shared objectives and
ensure accessibility of the information for decision-making and actions
Health workforce • Monitor indicators 4 identified for workforce planning and development and ensure
accessibility of the information for decision-making and actions
• Monitor the well-being of health workers and their families during and after
emergency deployment and ensure accessibility of the information for decision-
making and actions
Health information • Regularly monitor the functionality of the health information system to capture
requirements for health system resilience comprehensively, including EPHFs,
community trust, and service access, quality, and utilization
• Monitor indicators of resilience in the health system, including impact on health
system functionality and population health, for example, maintenance and utilization
of health services in emergency contexts
• Monitor the utilization of health information in policy, planning and actions
Medicines, other • Monitor medical products, technologies and infrastructure development, availability
medical products, and use, considering their impacts on resilience
technologies and • Monitor the availability and functionality of regulatory mechanisms for medical
infrastructure products, technologies and infrastructure for supporting resilience
Service delivery • Document and report on relevant indicators for health system resilience in a
complete, accurate and timely manner
• Conduct and participate in regular simulation exercises and after-action reviews
to test and review implementation of health service continuity plans in emergency
contexts and utilize the findings to improve as needed
Examples of technical • Integrated monitoring and evaluation tools and indicators for measuring health
and strategic system resilience
resources and tools • Simulation exercise package for testing health system resilience
• Guidance for conducting intra- and after-action reviews using an integrated approach
actions (10)
4 National Health Workforce Accounts has a set of indicators that can be adapted in countries using a systems approach.
3.3 Consolidated matrix of actions and decision-making flowchart to support application of the roadmap
3. Building health system resilience: a roadmap for action

The matrix presented in Table 7 presents high-level actions summarizing and combining the more detailed examples in Tables 2–6. It includes the examples of types of
strategic and technical resources that countries would need to support application of the roadmap (as presented in Tables 2–6). Many of the listed resources or related
materials can be found in the WHO Health Systems Resilience Toolkit.
Table 7. Summary of examples of actions to build resilience across the five steps of the roadmap and health system building blocks
Health system Prioritize resilience Identify the baseline and Adopt integrated planning Institutionalize resilience Monitor and evaluate
building blocks needs and resourcing building progress
Leadership and • Adapt health sector • Convene multisectoral • Coordinate between • Embed and sustain • Utilize available data
governance policies based on scoping of the baseline responsible focus on resilience and identified lessons
shared understanding for prevailing health stakeholders to in institutions and to inform decision-
of and commitment to system capacities, undertake integrated operations within and making
building health system gaps, and cross- planning with a focus beyond the health
resilience sectoral bottlenecks on long-term health sector
• Designate a focal system resilience
point for multisectoral building
coordination based on
adapted policy
Health financing • Leverage existing and • Identify intersectoral • Align and mobilize • Sustain optimum • Monitor the allocation
new funding to support funding available to intersectoral funding to funding for health and use of intersectoral
activities for system support the shared avoid duplication and sector (including funds towards shared
resilience objectives gaps contingency funding for objectives
service continuity) with
proportionate focus on
public health capacities
27
Table 7 (continued). Summary of examples of actions to build resilience across the five steps of the roadmap and health system building blocks
Building health system resilience to public health challenges: guidance for implementation in countries
Health workforce • Include appropriate • Identify the workforce • Plan for workforce • Ensure current • Monitor indicators5
skills mix and within health and allied requirements and and future needs identified for workforce
competencies sectors that deliver development with clear assessments, strategies planning and
for health system essential public health budget lines to address and institutions on development
resilience in workforce functions and services existing and anticipated health workforce
development gaps maintain a focus
on health system
resilience
Health information • Support integration of • Review existing • Identify necessary • Embed a focus on • Monitor indicators of
resilience measurement monitoring tools and resources (within health resilience in routine resilience in health
as part of routine health platforms for their and allied sectors) to monitoring of health system, including
information system adequacy to measure develop capacity for system functions and impact on health
health system resilience measuring resilience as services system functionality
• Select appropriate part of routine health • Establish data-sharing and population health
health system information system arrangements between in all contexts
resilience indicators for and across health and
integration in health allied sectors
information system
Medicines, other • Orient responsible • Review and define • Pull resources from • Define standard • Monitor medical
medical products, stakeholders and current state various sectors to operating procedures products, technologies
technologies, and processes on their of intersectoral address critical ongoing between responsible and infrastructure
infrastructure role in health system coordination and and emergency stakeholders to development and
resilience based on capacity, and gaps in needs, with shared ensure routine use, considering their
lessons learned from medical products and accountability for interdependence, impacts on resilience
disruptive events supplies, technologies mutual aid interoperability, mutual
and infrastructure, and aid provision and surge
set priorities to build capacity in supplies
resilience and logistics and
infrastructure
28
5 National Health Workforce Accounts has a set of indicators that can be adapted in countries using a systems approach.
Table 7 (continued). Summary of examples of actions to build resilience across the five steps of the roadmap and health system building blocks
3. Building health system resilience: a roadmap for action

Service delivery • Include considerations • Identify public health • Plan for routine health • Embed public health • Report on indicators
for resilience, including risks and state of and service continuity functions and services of health system
public health functions priorities for service in emergency in the day-to-day resilience relevant to
and services, in continuity in routine contexts, integrated delivery of health health service delivery
defining national and emergency with emergency services at all levels, levels
package of essential contexts management planning including primary care
health services • Identify collaborative • Mainstream health
mechanisms needed to service continuity
deliver comprehensive planning in health
and integrated health sector policy and
services as needed by planning, including
the individuals and in emergency
population served preparedness and
response
Examples of technical • Policy documents, for • Tools for assessing • Tools on integrated • Case examples on • Integrated monitoring
and strategic example policy briefs that population health needs planning, including institutionalization of and evaluation tools and
resources and tools promote prioritization of • Health system resource budgeting and monitoring health system resilience- indicators for measuring
to support the above health system resilience mapping tools, for and evaluation aspects focused actions health system resilience
actions • Training package on example, HeRAMS (23) • Tools for identifying • Up-to-date repository of • Simulation exercise
health system resilience • Tools for conducting risk and engaging lessons identified from package for testing health
targeting service assessments and profiling, relevant multisectoral experience with public system resilience
provision, for example for example, STAR (24) stakeholders in planning health challenges • Guidance for conducting
on routine health service and resource mobilization • Guidelines and tools for intra- and after-action
• Tools for assessing
continuity in emergency • Integrated health sector integrating health system reviews using an
health system and
contexts plans and investment case resilience considerations integrated approach
sector performance, for
• WHO health system example, adaptation of in planning and financing
resilience indicators, PHC health system resilience
monitoring framework indicators (13), Health
and indicators, approach Systems in Transition
of WHO Regional Office reviews (25), Service
for Africa to monitoring Availability and Readiness
resilience, IHR monitoring Assessment (SARA),
and evaluation Harmonised Health
Facility Assessment (26)
29
In identifying requirements for health system reference to define the technical resources needed
resilience, stakeholders should be mindful of to support health system resilience in a country
the interconnectivity and interdependence of and in identifying which and how stakeholders can
the building blocks. None of the activities can contribute to developing and implementing the
be successfully implemented by acting on just required tools.
one component of the health system; collective,
Figure 2 presents a simplified flowchart to further
coordinated support from all relevant building blocks
support stakeholders in making decisions on
is essential. People and their communities must
application of the roadmap for building resilience in
also remain at the centre of all actions across the
their health systems. Depending on the response to
health system and roadmap. The above examples
each stage, decision-makers can identify the next
of actions can be adapted and expanded to address
steps to focus on while referring to Table 7 above
the situation and needs in various contexts. For
for examples of required actions for that step. Box
example, they can be used to define the package of
12 provides an example scenario of country-level
support that internal and external stakeholders can
actions based on the steps in the roadmap.
work together to deliver. They can also serve as a
Figure 2. Flowchart to support stakeholders in making decisions on application of the roadmap for
building health system resilience
Is health system resilience identified

as a strategic priority?
No Yes
Identify and engage stakeholders Stakeholders have common and

within health and allied sectors sound understanding of and
recognize health system resilience
No as a strategic priority?
Develop relevant competencies and Yes
skills, starting with any decision-makers Baseline of required capacities and
resources is known?
Review existing baseline data No Yes
including national health policy and
strategies, and obtain missing data, Clear objectives/priorities and targets
using selected health system resilience are set to inform planning and actions
indicators at all levels?
No Yes
Identify objectives/priorities, and
Health sector plan includes a focus on
timebound and verifiable targets that
resilience with supporting budget and
build on existing capacities
monitoring and evaluation?
No
Develop or update health sector Yes
strategy/plan integrating health system Required resources are mobilized,
resilience with budget and indicators allocated and accessible at all levels?
for monitoring and evaluation
No Yes
Ensure proportionate resourcing of Planned actions are implemented and
planning actions for health system institutionalized?
resilience at all levels No Yes
Progress is monitored and lessons
Implement planned actions ensuring
are documented?
institutionalization at all levels
No Yes
Review and document progress Data are used to inform next steps
and lessons from any point in the roadmap,
depending on progress made
Box 12. Example scenario of country application of the roadmap to build health
system resilience
Below is an example scenario of country-level actions based on the steps in the roadmap. In this
scenario the country’s response to the first question (“Is health system resilience identified as a strategic
priority?”) in the decision-making flowchart in Figure 2 is “No”. The country therefore progressively
applies each step of the roadmap, with each step building on the previous step.
Roadmap steps Examples of actions

The country:
Step 1: Prioritize starts with reviewing the existing national health strategy, policy or plan from a
resilience resilience perspective through intersectoral coordination and sound understanding
of the concept.
Step 2: Identify the identifies critical capacities and gaps in health and allied sectors applying
baseline and needs relevant health system resilience-focused indicators, informed by (for example)
multisectoral health sector review during or after the COVID-19 pandemic, health
facility assessment, post-disaster needs assessment, IHR (2005) Monitoring and
Evaluation Framework.
Step 3: Adopt integrated uses the data from steps 1 and 2 to update existing or develop new health sector
planning and resourcing strategy, policy or plan that synergizes investments in universal health coverage,
health security and other priorities, with health system resilience as a cross-cutting
priority.
Step 4: Institutionalize establishes functional intersectoral accountability with funding to implement

resilience building adopted plan at all levels. This could involve an empowered role for the ministry of
health, the national public health institute, One Health coordination platform and
other coordinating entities.
Step 5: Monitor and conducts a periodic functional review of intersectoral coordination and
evaluate progress implementation of the plan and impact of resilience measures on health outcomes,
and uses the results to inform decisions regarding the next roadmap steps to
implement.
3.4 Key stakeholders and their roles Examples of stakeholder roles for each level, to
facilitate the intentional orientation of systems
Building health system resilience requires the joint towards resilience, are summarized in Table 8. These
efforts of all stakeholders at all levels, each with cut across the entire process of building resilience
their own indispensable, unique roles that must and the relevant actions presented in the above
be harmonized towards their shared objectives. subsections on the roadmap and indicative actions.
Table 8. Key stakeholders in building health system resilience
Stakeholders Examples of roles in health system resilience
Global stakeholders (for example, • Guiding global health agenda towards health system
international donors, United strengthening and emergency preparedness and response for
Nations agencies, professional resilience
bodies, international humanitarian • Defining norms and standards
organizations)
• Funding, technical support
• In low-resource or humanitarian settings, providing and
maintaining essential health services
National and subnational (regional, • Political commitment for prioritizing health system resilience in
county, state, zonal, district, local) policies, strategies, plans, interventions
stakeholders (public and private), for • Essential individual and population health service delivery in all
example, national and subnational contexts
health and public health authorities,
• Designating health system resilience functions within health
health facilities, academic institutions,
system strengthening and health security structures
allied non-health authorities (such as
agriculture, transport, security, water, • Engagement and coordination with all stakeholders and joint
environment, education), businesses, resource mapping and mobilization towards health system
religious organizations, nongovernmental resilience (whole of society, whole of government)
organizations • Allocation of required resources for emergency preparedness and
Local stakeholders (public and private), response and building resilience
community leaders, religious groups • Capacity-building for health system resilience, emergency
and leaders, primary care facilities, preparedness and response towards resilience
community-based health workers, civil • Data sharing to inform health system response to public health
societies, businesses, schools, local emergencies and resilience building
authorities in non-health sectors (such
• Documenting and sharing experience for joint learning and
as agriculture, transport, security,
improvement
water, environment, education),
nongovernmental organizations
3.5 Signs of progress in building health • Public health risks (including associated hazards
system resilience and vulnerabilities) and the available resources
and capability to tackle them are known by
Building health system resilience is a continuous stakeholders at all levels (awareness), with up-
process with incremental changes and benefits to-date information available and utilized for
(Figure 3) that lead to overall improvements in decision-making. This means more proactive
population health through advancement of universal anticipation and management of context-relevant
health coverage and health security in tandem. risks with involvement of all stakeholders at
Based on the definition and attributes of health national to subnational, community and service
system resilience, changes that can be expected delivery levels, including primary levels of care.
when operationalizing resilience in health system
include timely, effective and efficient demonstration
of the following.
• EPHFs are integral to the routine functions, • Routine health system operations and services
services and improvement efforts of the health are adapted and scaled up as necessary to provide
system at all levels, in coordination with relevant emergency-specific services for the public health
sectors (including those outside the ministry of response to shock events, and to meet evolving
health) and communities (integration). This means needs from broader population health threats
a shift from organizing, developing and investing (self-regulation and mobilization). This ensures
in health systems based on siloed programmes to more active and appropriate participation of
systemwide strengthening for comprehensively primary care levels in emergency management
addressing population health needs and with functional referral linkages to other levels of
determinants. care.
• Quality and accessible routine individual and • Lessons are systematically identified from
public health services (promotion to palliation) are experience within and outside specific settings and
delivered, trusted by the populations served, and used to inform decisions and actions, resulting in
utilized prior to, maintained during, and improved continuous improvements in resilience at all levels
following health system shocks (diversity). This (transformation). This means that health system
includes prioritization of routine health service recovery from any shock and building back better
continuity in tandem with emergency management is prioritized with required investments, moving
during and between shocks. away from the commonly seen “panic and neglect”
cycle.
Figure 3. Dividends of investing in health system resilience in terms of enhanced recovery,

performance and resilience following each shock event
Health system performance
Health security, universal health coverage, other SDG targets
Dividend of resilience investment

The next shock
Level 2 performance
Shock
Where we are at now:

COVID-19, humanitarian crises, etc.
e
nc
ie
Shock
sil
nt
Re
s t me t
nve emen
i c al i v
Typ pro
u a l im Level 1 performance
d
Gra
ry
ve
co
Stabilization
Re
What countries decide to do now

Time
4
Conclusion
4. Conclusion 35
The COVID-19 pandemic has demonstrated a priorities and resources, and political realities.
global lack of health system resilience, spanning The guidance contained within this product will
low- to well-resourced countries and systems. This help countries to develop a roadmap for building
has added impetus to the need to move beyond health system resilience. The development and
conceptual understanding to operationalization maintenance of health system resilience is a process,
of health system resilience, as demonstrated by and while it can take time to demonstrate the
recent experience with public health emergencies. benefits of investing in resilience in the context of
As countries move towards recovery, there is a need public health emergencies or large-scale shocks, the
for focused investment that recognizes current daily dividend of investing in and prioritizing health
and future fiscal constraints and the need for system resilience is apparent in the health system’s
efficient and effective use of all available resources. ever-increasing ability to respond to the day-to-day
Resilience-focused health system strengthening challenges with which it is presented. Given the
represents this smarter approach to resource use – evolving and expanding landscape of public health
one that aligns programme and platform planning challenges – climate change, ageing populations,
and investment to ensure wider benefits from rising rates of antimicrobial resistance, political
focused and targeted spending; one that identifies instability, and mass displacements – the building
and leverages all available resources, both within of health system resilience represents a worthwhile
and beyond the health system, to maximize their investment in healthier and safer populations as
efficient use for more effective outcomes; and one the foundation for stable and sustainable economic
that engages all stakeholders towards the common systems.
goal of promoting the highest attainment of health
possible for all within available resources.
It is clear that the application of resilience within
health systems is progressive and highly contextual.
It is also clear that resilience is not an inevitable
by-product of health system investment and
strengthening but must be deliberately developed
and nurtured across health system components. In
addition, resilience efforts must be contextualized,
taking account of population needs, country
36
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39
Annex. Template to guide

application of the resilience
roadmap
Below is a suggested template for applying the The template can be used by authorities, groups,
resilience roadmap. This template can be adapted focal points, units, and institutions responsible for
to suit national contexts, including the setting, leading and coordinating health system resilience-
stage of development and other contextual focused efforts at national and subnational levels. It
considerations. The template is intended to serve as is important that it represents the collective efforts
a comprehensive hands-on guide and record for the and situation from a whole system perspective
progression through the roadmap towards building rather than looking separately at different areas of
resilience. It can be used to facilitate stakeholders’ work, disciplines, or units. Text in italics explains the
discussions, inform planning as appropriate, guide suggested contents within each section, including
and inform actions, and help focus on and review some examples. Proposed indicators are included for
progress in building resilience, reflecting the various each section. An editable copy of the template can be
interlinked requirements across all stages of the downloaded here: https://cdn.who.int/media/docs/
roadmap. default-source/health-systems-resilience/template-
to-guide-application-of-the-resilience-roadmap.
docx.
[Title]
[Date]
Step 1: Prioritize resilience

A. Prioritizing health system resilience
This involves the identification of health system resilience as a strategic priority, for example, in a relevant
government statement, strategy, policy or equivalent.
Document or statement identifying resilience as a priority:
Health system resilience focal point, team, or equivalent:
B. Creating a shared understanding

This involves engaging and ensuring participation and support of relevant stakeholders in developing a
common understanding of and commitment to health system resilience, including amongst leaders across
all health system components and all levels of service delivery management, and representatives from
relevant government ministries and institutions, nongovernmental organizations, and communities,
as applicable.
Stakeholders identified through stakeholder mapping:
Key stakeholders trained or oriented:
Sectors represented and benefiting from training, orientation, and other competency-building
activities:
Service delivery levels and areas represented and benefiting from training, orientation, and other
competency-building activities:
Examples of suggested indicators: Evidence of health system resilience as a priority in national strategy,
policy or equivalent; % of subnational health authorities’ operational plans with health system resilience
identified as a priority; number of stakeholders trained; % of health facilities with management staff who
have undergone training on health system resilience; % of relevant partners with evidence of consideration
of long-term health system resilience in their programming.
Indicator Baseline Target Progress

Annex. Template to guide application of the resilience roadmap 41
Step 2: Identify the baseline and needs

A. Establish baseline capacities and priorities
This includes establishing the baseline human, financial, material, technical and political resources
available and needed to support health system resilience. This should be informed by population health
needs, priority health system risks and challenges, and resource and asset mapping.
The required information can be obtained from existing data sources. Critical information gaps can be
addressed through ad hoc data collection where the data are deemed essential to provide a comprehensive
picture of resources and needs.
Key priorities, needs, risks and challenges can be compared with identified strengths, critical capacities,
and opportunities to inform the current baseline, and what is required to build resilience.
Health system component What is required for resilience Status – showing current
– reflecting national and strengths and gaps
subnational priorities
Workforce, including community-

based
Financing
Service delivery – individual and
population health
Health information systems
Medicines, other medical
products, products, technologies,
and infrastructure
Governance and leadership,
including political support and
multisectoral engagement
Communities, people
Example indicators for this activity include resource mapping conducted; vulnerability and risk mapping
conducted; % of facilities with risk profiles; package of essential health services reflects population health
needs and services; % of facilities providing services according to local needs or package of essential health
services. More specific indicators should be chosen and developed based on identified gaps.
B. Agree objectives and identify targets

Identify objectives aligned with population and health system needs that address the gaps or weaknesses
in health system resilience identified above. These objectives should be SMART (specific, measurable,
achievable, relevant, and time bound) and directly address the gaps identified above.
Objective Target Timeline

Step 3: Adopt integrated planning and resourcing

This involves ensuring the realization of the common objectives identified above through integrating the
objectives and targets into relevant strategies, plans and resource mobilization processes. This requires
the review of existing plans and strategies and can be supported by the development of joint working,
workplans and budgeting. Examples of questions to consider are outlined in the table below.
Objective How will this objective Who needs to be What resources can
be addressed through engaged? be identified and
existing plans or allocated to support this
programmes? objective?
Example indicators for this activity include the following: health sector plan includes emergency activities;
health emergency management planning include a focus on routine health service continuity planning in
emergency contexts; and multisectoral plans for recovery from shock events include a focus on health sector
recovery and resilience building. Specific indicators chosen or developed should reflect identified objectives.
Step 4: Institutionalize resilience building

This involves integrating the roadmap activities with the key inputs and processes required to
institutionalize building health system resilience.
Examples of roadmap activities
How are activities embedded within

planning and resourcing processes?
How are activities embedded within
institutional structures?
What processes or mechanisms are in
place to ensure ongoing integration?
Are activities drawing appropriate
resourcing (for example dedicated
budget line)?
Are roles and responsibilities for resilience
defined across all relevant levels in relevant
strategies, plans and initiatives (essential
health services package, health sector,
health security, and disease-specific plans
and strategies)?
Is there a focal point or institution
identified with accountability for
resilience, with appropriate accountability
mechanisms and reporting structures?
Is the delivery of quality services prioritized
and supported in all contexts, including
in relation to service delivery and health
facility and service design (e.g., infection
prevention and control, occupational
health)?
Annex: Template to guide application of the resilience roadmap 43
Example indicators for this activity include: % of gross domestic product spent on health, public health, and
resilience; designated authority for coordinating health system resilience efforts; multisectoral structure for
emergency management with health system resilience as a function; health sector policy defines the roles
of primary care in delivering EPHFs; and % of facilities as part of collaborative networks. Specific indicators
chosen or developed should reflect identified objectives..
Step 5: Monitor and evaluate progress

This includes the proactive monitoring and evaluation of progress towards building resilience. This can
be done by leveraging and adapting existing data and at a minimum should represent all health system
building blocks, reflect resilience attributes, include a mix of input, process, output, outcome, and impact
indicators, and be measurable before, during, and after shock events.
Indicator Health system Baseline Target Progress

area
Indicators should be reviewed, revised, and adapted at regular intervals to ensure that they continually
align with targets and that they are reflective of and inform the process of building resilience through
addressing identified gaps.
World Health Organization
20 Avenue Appia
1211 Geneva 27
Switzerland
hsresilience@who.int
https://www.who.int/teams/primary-
health-care/health-systems-resilience

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Building health system

© World Health Organization 2024

How to use this technical product viii

2. Fundamentals of health system resilience 4

3. Building health system resilience: a roadmap for action 10

Annex. Template to guide application of the resilience roadmap 39

Figure ES.1 Roadmap for building health system resilience x

Figure 1. Roadmap for building health system resilience 11

Figure 2. Flowchart to support stakeholders in making decisions

Figure 3. Dividends of investing in health system resilience in terms

Table ES.1 Example scenario of country application of the roadmap

Table 2. Illustrative examples of actions and tools to support prioritizing

Table 3. Illustrative examples of actions and tools to support clarifying

Table 4. Illustrative example of actions and tools to support integrated

Table 5. Illustrative examples of actions and tools to support institutionalize

Table 6. Illustrative example of actions and tools to support monitoring and

Table 7. Summary of examples of actions to build resilience across the five

Table 8. Key stakeholders in building health system resilience 32

Box 1. Health system resilience attributes 5

Box 2. Operational definition of health system resilience 7

Box 3. Essential public health functions 8

Box 4. Key guiding principles 12

Box 5. Principles of a public health approach to health 13

Box 6. Promoting a common understanding of resilience in Liberia 15

Box 7. Using recovery to bridge current health sector policies and

Box 8. An integrated approach to pandemic policy development in

Box 9. Maximizing resource use for resilience: opportunities to leverage

Box 10. Applying a systems approach to strengthening collaboration

Box 11. WHO Health Systems Resilience Toolkit 25

Box 12. Example scenario of country application of the roadmap

EPHF essential public health function

How to use this technical product

Below is a summary of how to use the contents of this technical product.

Explore the roadmap for building Utilize the decision-making

Section 1 and 2 Section 3 Section 3 and Annex

Context Fundamentals of health system resilience

Building resilience is a continual process dependent

Figure ES.1 Roadmap for building health system resilience

Coordinated system wide and multisectoral joint working

Monitor and Identify the baseline

Institutionalize Adopt integrated

Building health system resilience: a This roadmap consists of five interconnected,

Roadmap steps Examples of actions

Step 4: Institutionalize establishes functional intersectoral accountability with funding to implement

1.1 Context Many efforts to improve health systems and services

Box 1. Health system resilience attributes

Box 2. Key starting points for building health system resilience

Health system Actions that support embedding consideration for resilience

Leadership and • Identifying a responsible entity or focal point for resilience

Health information • Ensuring comprehensive and integrated surveillance, assessment, and

Box 3. Essential public health functions

Type Health system stressors and shock events

Disease Environmental Economic Sociopolitical

Acute: New or re-emerging Sudden disasters, Sudden fiscal Political events

Chronic: New or re-emerging Effects of climate Progressive fiscal Political events

3.1 Introduction These are explained using a roadmap (Figure 1) that

Figure 1. Roadmap for building health system resilience

Coordinated system wide and multisectoral joint working

Monitor and Identify the baseline

Table 8. Key stakeholders in building health system resilience 32

Box 1. Health system resilience attributes 5

Box 2. Operational definition of health system resilience 7

Box 3. Essential public health functions 8

Box 4. Key guiding principles 12

Box 5. Principles of a public health approach to health 13

Box 6. Promoting a common understanding of resilience in Liberia 15

Box 11. WHO Health Systems Resilience Toolkit 25