Table. Summary of Articles on COVID-19 and Health System Resilience .

First Author	Date Published	Objective or Purpose	Main Findings
Legido-Quigley64	March 2020	To describe the resilience of the Spanish health system during COVID-19 using the health system building blocks.	Long-term underinvestment had weakened health services, and financial resources were required to support regional responses. Coordination across levels and public compliance has been good but must be reinforced over time.
Gopichandran29	April 2020	To discuss the components for building health system resilience in India, based on the response to COVID-19.	Health governance and law must be systemically strengthened after underinvestment in public health and the public system to promote transparent communication. Disease surveillance and laboratory systems must be better coordinated and more robust. Clinical and public health human resources need to be developed.
Hsieh5o	April 2020	To describe the resilience of the Taiwanese health system during COVID-19.	Strong coordination between private and public sectors, good oversight, and clear, transparent communication aided in the response and in creating trust. Information was shared across sectors. Policies to promote community resilience were put in place.
Kirchhof63	May 2020	To compare the response to the COVID-19 pandemic in the United Kingdom and in Germany.	Centralized decision-making slowed the response and reduced flexibility. Localized decision-making increased innovation, speed, communication, and learning. Long-term underinvestment had weakened both systems.
Legido-Quigley8	May 2020	To outline core dimensions of three resilient health systems in Hong Kong, Singapore, and Japan during COVID-19.	Integrating services in the health system and across other sectors improved the systems’ ability to absorb and adapt to COVID-19. Trust in the health system and government was highly important but harmed by fake news and misinformation.
Peiffer-Smadja31	June 2020	To describe the key elements of a French hospital’s COVID-19–response.	The hospital needed to address the indirect effects of the outbreak on all departments, ensure committed and effective leadership, support healthcare workers, and organize communication with the public.
Hunte30	June 2020	To describe the resilience and responsiveness of Trinidad and Tobago’s health system during its response to COVID-19.	The system’s response was built on evidence-informed policy and interdependence. Governance, coordination, informed decision-making, and leadership were critical to the system’s resilience.
Garcia Elorrio68	June 2020	To discuss strategies for PHEwith focus on redesigning and strengthening health systems to make them more resilient.	The current COVID-19 pandemic presents an opportunity to adopt a comprehensive approach to quality of care that integrates quality planning, quality control and quality assurance with improvement science to achieve sustainable, large-scale adoption. As health systems start or continue to adopt these methods, it is important to assess their effectiveness rigorously, accompanied by proper management, accountability and governance systems and structures.
Dasgupta58	July 2020	To explore the impact of COVID-19 on sexual and reproductive health and rights through an intersectoral lens.	Restrictive policies, disruption of public health services for sexual and reproductive health, and reliance on private sector services have eroded trust and reduced community resilience.
De Ceukelaire39	July 2020	To learn from country responses to COVID-19 so far.	Integrated services and trust in the health system and government appear beneficial for resilience. Underinvestment in public health systems and increased privatization have hampered coordination, service delivery, and confidence in the system.
Sheehan9	July 2020	To identify lessons from COVID-19 to improve public health system preparedness for climate-related emergencies.	Cross-sectoral responsibilities need to be clearly delineated. Health information systems need to be responsive, targeted, and updated frequently. Enhancing community engagement can benefit preparedness. Health needs to be linked to economic and societal development. Leadership requires adaptive capacity and integration into planning.
Mazingi32	August 2020	To explore vulnerable points in surgical systems from past outbreaks and COVID-19.	Surgical infrastructure, the workforce, and service delivery are most vulnerable to shocks. Recommendations to improve resilience include improving telemedicine, maintaining surgical services through risk-based approaches to delivering services, and improving policies to support and protect the workforce.
O’Sullivan12	August 2020	To provide a commentary on the rural primary healthcare sector during the COVID-19 pandemic.	Pandemic policies and communication should be tailored to address rural risks and contexts. Primary healthcare is a staple of rural care and has benefited the response through adaptiveness, flexibility, local decision-making, resource management, and regional collaboration. COVID-19–related responses like telehealth may strengthen rural care post-pandemic.
Gupta13	August 2020	To better understand the extent of resilience in India’s health system.	Chronic underinvestment in public health and the public health sector have weakened the health system, hampered preparedness, and reduced trust and confidence in the system.
Etienne40	August 2020	To identify transformative changes in current approaches to health systems and development using lessons from COVID-19.	Health needs to be linked to economic and social development, followed by integrated policy and planning. Health systems should focus on equitable access to health services like primary care, and public health functions should be strengthened.
Costa Font59	August 2020	To determine which characteristics of managed competition can make a difference in the management of a pandemic.	Regions in Italy that adopted a centralized model of managed competition appeared more resilient, through better and faster coordination, cooperation, and information sharing.
Meyer11	September 2020	To illustrate the importance of investments like telehealth for rural healthcare to support resilience during COVID-19.	Policy and services were quickly adapted during COVID-19 to enable telehealth care, but policy reforms are needed to address persistent challenges like access and affordability of care.
Chua10	September 2020	To present Singapore’s COVID-19 response using two health system resilience theories.	Clear leadership and governance allowed flexibility, maintaining health services. The government communicated quickly and transparently, made crisis financing available, and had a legal foundation to implement policies. Issues of trust and inclusiveness remain.
Collins14	October 2020	To highlight the overarching areas that need to be prioritized to enhance governments’ ability for effective prevention, alert, and response to emergencies to improve the health of their populations, so they become more resilient to health shocks.	Public health systems and public health capacities need to be strengthened and require greater investment. International and multisectoral coordination and solidarity could have improved preparedness and response. Health inequities should be reduced to prevent negative outcomes and improve community resilience. Sustained and appropriate communication can support community resilience and empowerment.
Lal15	October 2020	To assess lessons learned from deploying health information systems during COVID-19 and Ebola outbreaks to optimize preparedness and response actions.	Governance and coordination should be strengthened and aligned to global health agendas. Health systems infrastructure and resources should be built up and integrated into primary care. Community engagement can help improve information accuracy and trust and prevent misinformation.
Cuschieri27	November 2020	To summarize pandemic preparedness measures in Malta and the impact on routine services.	Malta and its sole acute hospital coped well with the first wave of COVID-19. The increased capacity will serve well for the anticipated combined annual influenza and the second wave.
Haldane90	December 2020	To argue for transformative resilience following COVID-19.	Health systems need to recognize their role in human systems and respond to crises in ways that protect the health system and other systems from harm in the future.
Lal89	December 2020	To understand how health systems with strong GHS and UHC policies fared during COVID-19.	Integrating GHS and UHC can improve interconnectivity between health system levels and actors. Broader funding pathways can help unify health systems. Joint health and development agendas can support resilience. Power dynamics should be included in resilience assessments.
Daszak46	February 2021	To review the US approach to pandemic preparedness and its impact on the response to COVID-19.	Authors identify six steps that should be taken to strengthen US pandemic resilience, strengthen and modernize the US healthcare system, regain public confidence in government leadership in public health, and restore US engagement and leadership in global partnerships to address future pandemic threats domestically and around the world.
Marshall26	February 2021	To examine care home management responses to COVID-19, considering their position in the health system.	Centrally organized responses led to resource constraints, additional work, and a lowered ability to make localized decisions in care homes. Resilience was a result of the ability of staff and teams to network to get around challenges brought by the centralized response.
Ahanhanzo34	March 2021	To explore if African countries have leveraged experiences from past epidemics to build resilience and response strategies.	West African countries continue to build resilience and responsiveness into the health systems. Coordination mechanisms have also improved across the region. There are gaps that might lead to overdependence on the global community to meet local needs.
Narwal66	March 2021	To derive lessons on resilience from patient safety issues during COVID-19 in India.	Inadequate resources and infrastructure from chronic underinvestment in public health systems, a lack of reliable data, and limited leadership and regulation impacted patient safety. Greater investment in the public sector may minimize future risks.
Hamadeh17	April 2021	To describe the current resilience mechanisms of the Lebanese public primary healthcare system, developed from earlier shocks.	The primary care system can work and share information collaboratively across sectarian lines and with multiple actors, and to work effectively with all population groups.
Pilevari43	April 2021	To describe the Iranian health system, with an emphasis on how resilience plays a role with the stressor of COVID-19.	Inefficiencies in the health system were detailed, with recommendations for equitable health financing, proper training of personnel and use of facilities, and strengthening intersectoral cooperation.
Romani44	April 2021	To compare and contrast the resilience of two different health systems in Italy during COVID-19.	The health system of one province appeared to have more resilience capacity, largely due to strengthening resources where strain was felt, diverting resources where feasible, and relying on a COVID-19 case dashboard to inform risk exposure levels continuously.
Alami16	June 2021	To assess systems preparedness and resilience towards emerging infectious diseases based on Palagyi framework.	Resilience and the ability to adequately respond to a systemic and global crisis depend upon preexisting system-level characteristics and capacities at both the provincial and federal governance levels.
Gebremeskel47	June 2021	To explore the role of community health initiatives in health system resilience in African countries.	Priority should be given to community-led health initiatives and health workers; ensuring reliable medical and diagnostic supplies; fostering evidence-based practice; and raising additional revenue to boost health system financing within the region, to boost health system resilience at the community level. All require stronger health system governance, including multisectoral collaboration within countries and regional collaborations.
Hasan18	June 2021	To synthesize the evidence on integrated health service delivery during COVID-19 in LMICs.	Organizational integration across health system levels and building blocks can strengthen intersectoral coordination. Alternative service delivery mechanisms can support innovation to ensure uninterrupted routine care services.
Bashier41	June 2021	To present opinions and expectations about the anticipated changes in the future of public health at the global, regional, and national levels, based on a need for better governance and stronger and more resilient health systems.	Coordination and collaboration among countries and stakeholders in different multilateral and global initiatives, as well as of evidence-based solutions and a strengthened health workforce, are critical to resilience. Agencies, systems, and individuals must be resilient enough to cope with any expected changes.
Haldane28	June 2021	To review COVID-19 responses in 28 countries using a health systems resilience framework.	Resilient health systems were considered to have comprehensive responses that integrated health with social and economic considerations, adaptive capacity within and beyond the health system to meet the needs of communities, preserved functions and resources within and beyond the health system to maintain pandemic-related and other care, reduced vulnerability to catastrophic losses in communities, and continually learned and adjusted.
Kwon20	July 2021	To provide approaches to strengthen health financing and resilience, based on the impact of COVID-19 in Asia and the Pacific.	Sufficient resources, fast and flexible funding mechanisms, multisectoral cooperation, and adequate public health funding supports the system’s ability to prepare for and respond to health emergencies. Innovative financing can mitigate risks.
Smaggus38	July 2021	To investigate how government actions in New South Wales, Australia and Ontario, Canada related to health systems resilience.	Both governments focused on reactive resilience, while fostering proactive resilience could be more beneficial to society. Having a proactive vision of resilience and acknowledging the complexity of health systems could improve resilient performance in healthcare.
Phillips48	August 2021	To explore information asymmetries during COVID-19 and how they pertained to the UK government’s decision-making.	In times of uncertainty, actors of different levels and sectors looked to acquire new information to minimize errors in decision-making. Most innovation occurred in management and organization, rather than radical innovations.
Fiske79	August 2021	To discuss critical ethical concerns in COVID-19 pandemic response, as they relate to building resilient health systems.	Healthcare system resiliency hinges on ‘ethics by design’. Key ethical concerns are the distribution of scarce resources; research ethics; structural inequities; and solidarity and social cohesion. Health systems need to proactively integrate ethical considerations into their design and operation, and ethicists need to be a part of pandemic response.
Amul35	August 2021	To discuss key policy responses in Southeast Asian countries’ approaches to COVID-19, including resilience.	Countries with existing resources, infrastructure, and future resilience plans were at an advantage during COVID-19. Workforce and multisectoral cooperation were critical to the most successful responses.
Balqis-Ali56	August 2021	To explore public perspectives on health systems’ response towards COVID-19, and to identify gaps for health systems strengthening by leveraging on WHO health systems’ building blocks.	Since all building blocks influenced service delivery during COVID-19, with governance having a cross-cutting effect on the response, addressing macro-level problems with short and long-term strategies may help support resilience capacity.
Hodgins19	September 2021	To assess innovations and changes created during COVID-19 in children’s health services in Australia.	Health systems values of equity, integration, and support of the workforce shaped the response. Non-hierarchical governance structures, responsiveness, and a clear vision supported innovation and change.
Burke25	September 2021	To examines whether and how the Irish government’s pandemic response contributed to health system reform and increased resilience.	Crisis can open a window of opportunity for transformative changes, which can be utilized to initiate or continue reform implementation, as was the case of Irish Slaintecare reform during the COVID-19 pandemic.
Plagg91	September 2021	To illustrate the regional differences in response to and outcomes of COVID-19 in Lombardy and Veneto, Italy.	Flexible health services allowed for the greatest success in containing exposure and mitigating risk, as well as having a strong primary healthcare sector with good coordination of care between primary and secondary/tertiary levels of care.
Sundararaman36	September 2021	To reflect on what makes for resilient and prepared health systems.	Five design features—organization of primary healthcare services, planned surge capacity, robust surveillance integrated with health management information system, ability to scale-up production domestically, and a government that recognizes the importance of health systems that are adaptive—may create resilience capacity.
Khalili65	October 2021	To identify directions to address and support interprofessional resilience at all levels of healthcare.	Team resilience is critical to organization-level and system resilience, by optimizing collaboration and information sharing, and supporting the well-being of the workforce.
Larson67	October 2021	To describe lessons learned from COVID-19 about strengthening vaccination programs.	Routine vaccination should be prioritized as an essential health service. Access can be expanded by providing services through non-traditional vaccinators and alternative sites. Strengthened data systems can improve program performance. Building trust and confidence can improve uptake and reduce misinformation.
Tokalić81	October 2021	To examine how Croatia and Bosnia and Herzegovina dealt with COVID-19 in terms of health systems resilience, following their recent wars and natural disasters.	Croatia and Bosnia and Herzegovina had health systems that learned from and adapted to previous shocks of war and natural disasters. Strategies included an integrative homeland security system, plans on how to mobilize healthcare workers as needed, and learning how best to improvise in circumstances when there is a lack of resources.
Martin76	November 2021	To explore the influence of health system governance on community care staff during COVID-19 in England.	The central control over resources and priorities led to limited control over resources, limits on decision-making, and a lack of a voice for community staff transitioning to the crisis. Collective belief in individual and organizational capacities may support transitions.
Leslie55	November 2021	To examine competing resilience-focused responses to COVID-19 in Canada.	Stakeholders had competing visions on how to achieve resilience. Integrating and including all stakeholders in centralized planning should be a priority.
Orhan42	November 2021	To examine how to reduce the impact of NCDson health systems in the European Union in light of COVID-19.	COVID-19 has created momentum to develop policies to build resilience towards NCDs. National-level policies had weaknesses in protecting the Union from cross-border threats. Multi- and cross-sectoral collaboration is expected to lead to resilience.
Riccardo52	November 2021	To examine a COVID-19-monitoring tool implemented in Italy and its direct and indirect effects.	While the tool was able to detect cases and increase precautions quickly to mitigate COVID-19 exposure, it faced public criticism for being too sensitive. Public forum question-and-answer sessions held by the government helped reduce criticism.
Aristei54	January 2022	To overview the policies, regulatory frameworks, and legislation on health emergency management at the European and global level.	Crises highlight existing gaps in cooperation and collaboration within both horizontal and vertical levels, as well as regulatory conflicts.
Singh23	January 2022	To catalog the responses of Member States of the WHO Regional Office for South-East Asia on lessons learnt throughout the pandemic.	16 topic areas were identified as the most important lessons learnt during the pandemic. The importance of long-term oriented thinking on behalf of policy makers was highlighted as fundamental to strong health systems.
Thomson33	January 2022	To explore the resilience of health financing policy to economic shocks by reviewing policy responses to the 2008 financial crisis and COVID-19 in Europe.	Countries with social health insurance schemes fared worse in both the 2008 financial crisis and COVID-19 in health systems management and financing. Health financing sources should be diverse, health sector funding should increase, and systems should learn from previous health financing shocks.
Karamagi80	February 2022	To develop methods to measure inherent and targeted resilience, using data from 47 African countries.	Both capacities are necessary to address predictable and unpredictable shocks. Inherent resilience was low across countries, with transformative capacity least developed.
Øyri21	February 2022	To analyze the situated, structural, and systemic resilience Norway’s health system had in its COVID-19 response.	While the Norwegian government faced criticism for relatively modest COVID-19 precautions, it had adaptive ability to shift resources within health systems.
Mustafa49	February 2022	To assess the extent that preparedness plans integrate essential health service continuity.	Emergency plans lacked local stakeholder engagement in planning, and few plans included maintenance of essential health services. Plans lacked quality of care considerations and plans to monitor capacity for essential service functionality.
Shaw22	February 2022	To describe the resilience of a newly developed digital-health tool implemented during COVID-19.	Cohesiveness supports a strong response to large-scale threat like COVID-19. The ability to adapt depends on intersectoral collaboration and tolerated innovation.
Arsenault53	March 2022	To assess the immediate effect of the pandemic on 31 health services in 10 countries.	Many health systems failed in regard to capacity to absorb stress and perform at the same level, and being responsive to preexistent needs. Countries must strategically address this incapacity for future emergencies.
Burau24	March 2022	To analyze the adaptive, absorptive and transformative capacities of the health workforce during the first wave of the COVID-19 pandemic in Europe and to assess how health systems prerequisites influence these capacities.	Regardless of health system prerequisites, the health workforce in different countries was able to actualize absorptive, adaptive and transformative capacities in COVID-19 pandemics.
Turner69	March 2022	To examine how responding to COVID-19 has influenced personal and organizational resilience among health system leaders.	COVID-19 spurred changes within the health sector and had unexpected and positive and negative effects on adaptive capacity at different levels.

Abbreviations: COVID-19, coronavirus disease 2019; WHO, World Health Organization; PHE, Public health emergencies; GHS, Global health security; UHC, Universal health coverage; NCDs, Noncommunicable diseases; LMICs, Low- and middle-income countries.