Abstract
Background
Middle East and North Africa (MENA) region has been one of the most significantly impacted by the COVID-19 pandemic. The escalating frequency and complexity of global health threats—from pandemics like COVID-19 to climate change-induced emergencies—have elevated the imperative for stronger and more resilient health systems in the MENA region and the world over. In this paper, we introduce a tool designed to offer a comprehensive and engaging approach to assessing health system resilience and emergency preparedness and response capabilities, and articulate the tool’s value add in the MENA region.
Methods
We developed the tool following a three-step approach consisting of (1) definition of purpose and scope of tool, (2) item generation and reduction and (3) testing for content and face validity given the MENA region’s context. The Health System Resiliency Analysis Framework was adapted as the guiding framework for tool development.
Results
The tool offers a comprehensive and adaptable approach to self-assessment of health system resilience, using a multisectoral platform that enables continuous learning and improvement. The novelty of the tool resides in its potential to yield practical priority actions that need to be considered at all levels. The current version of the tool includes five components: (1) financing arrangements; (2) governance arrangements; (3) health system resources, public health and service delivery; (4) data and information systems; and (5) political and socioeconomic context. Each of the components consists of various subcomponents (22 in total). Each subcomponent is assessed using a mix of quantitative and qualitative indicators (99 indicators in total). On that basis, each subcomponent is scored to reflect the maturity of the country’s capacity in that specific area.
Conclusion
The proposed tool will address the limitations of the existing assessment instruments. We invite others to contribute with additional real-life implementation of the tool.
Keywords: Health systems, Public Health, COVID-19, Global Health, Decision Making
WHAT IS ALREADY KNOWN ON THIS TOPIC.
WHAT THIS STUDY ADDS
We introduce a tool designed to offer a comprehensive and adaptable approach to self-assessment of health system resilience, using a multisectoral platform that enables continuous learning and improvement.
The tool can help countries minimise the impact of health shocks by assessing the existing capacities and capabilities of their health systems, pinpointing gaps and prioritising actions that need to be considered at all levels to strengthen overall resilience.
While the tool is tailored to the Middle East and North Africa region, it can be adapted to other regions.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The tool will be useful for researchers, governments and funders seeking to strengthen health system resilience and overall emergency preparedness and response capabilities.
Background
The COVID-19 pandemic has exerted immense stress on healthcare systems worldwide, testing their resilience.1 2 Even in the most developed nations, public health systems have been overwhelmed, struggling to cope with the surging demand for care, essential equipment, qualified staff and life-saving medication, and now vaccines.3 4 This pressure has resulted in disruptions in the provision of essential health services globally. The pandemic’s impact transcends immediate health outcomes, causing profound shock to economic and social systems.
The Middle East and North Africa (MENA) region has been one of the most significantly impacted by the COVID-19 pandemic. The region comprises higher-income countries, such as the Gulf Cooperation Council countries, and lower–middle-income countries, as well as fragile and conflict-affected settings such as Syria, Iraq, Djibouti, Yemen, Libya and West Bank and Gaza. While responses to the pandemic have been heterogenous across the MENA region, the pandemic has laid bare common weaknesses in health systems resilience and emergency preparedness. Countries in the region have had difficulty deploying surge capacity and adapting to evolving healthcare demands.5 For instance, 59% of countries reported having triaged patients, leveraging community health or moving toward home-based care, and less than 40% of countries have reported using telemedicine, extending prescription validity or recruiting additional staff.6 The pandemic has also created challenges in maintaining essential health services, with 74% of countries reporting disruptions to communicable disease treatment, 73% reporting disruptions to immunisation and 38% reporting disruptions to non-communicable disease treatment by September 2020.7 Furthermore, MENA countries have shown limited fiscal space to respond to the pandemic and lack of counter-cyclical health spending, with only 18% of governments removing user fees.8
While the COVID-19 pandemic is the most recent example of a health emergency in the MENA, the region continues to experience unprecedented health emergencies and conflicts.9 With more than 40 million migrants and a total of more than 127 million people in need of urgent humanitarian assistance, the MENA region has some of the world’s largest protracted conflicts, as well as frequent natural and human-made crises, outbreaks and climatic shocks.9 10 The escalating frequency and complexity of global health threats—from pandemics like COVID-19 to climate change-induced emergencies—have elevated the imperative for stronger and more resilient health systems against health emergencies in the MENA region and the world over.11 12
Despite the plethora of measurement frameworks and tools to help countries better prepare for health shocks, these have varied in their scopes, objectives and utility;13 many of the existing tools are too narrow in scope and measurements of resilience, often addressing a specific health shock (eg, Ebola, COVID-19), focusing on a specific health system building block (eg, service delivery or governance), examining a single dimension of the health system (eg, hospitals) or failing to account for the broader socioeconomic and political aspects of resilience building.14,23 The COVID-19 pandemic has further exposed weaknesses in emergency preparedness, response and recovery capacity in health systems that these existing frameworks and tools failed to predict, suggesting that other areas might merit greater weight in future preparedness and response efforts.24,28 Specifically, the pandemic has amplified the need to address the social, economic and political context in which responses occur and to develop pandemic preparedness, response and recovery plans that link policy actions across sectors and levels of care.17 29 30 It has also shed light on the crucial role of leadership, transparency and trust in crisis management.25 This underscores the need for tools that delve into not only the technical capacities but also the softer aspects of governance, social capital, power dynamics and public trust.25 31 Many assessments evaluated a piece of this region’s health system resilience such as hospital emergency planning. While tools have been used to examine absorptive, adaptive and transformative capacity of health systems in MENA,22 32 none were developed for or explicitly validated in this context.33 34
These shortcomings highlight the need for a novel tool that overcomes the limitations of existing frameworks and tools. In this paper, we introduce a tool designed to provide a more comprehensive and consultative approach to assessing health system resilience and emergency preparedness and response capabilities and articulate the tool’s value add in the MENA region.
Methods
The tool was commissioned as part of a World Bank project that aims to help countries in the MENA region better assess health system resilience and strengthen their preparedness and response to health emergencies. The development of the tool was led by a core research team including members from the MENA region (core team), with support from technical experts corresponding to the different components of the tool (ie, component leads) and a broader advisory group encompassing global and regional experts in resilience, health emergency preparedness and tool development.35
Definitions and conceptual framework
Health system resilience is a relatively nascent topic with diverse conceptualisations and varying definitions emerging over time.17 Some authors define resilience as an ability, capacity or capability, while others describe it as a process or a characteristic of complex adaptive systems.36 Despite these differences, they share a common core: regarding resilience as the degree of change a system can undergo while maintaining its functionality.11 For the purpose of this paper, health system resilience is defined as the ability of a health system to anticipate and prepare for potential shocks, absorb shocks, including the maintenance of essential functions during shocks, adapt and transform the system in ways that increase its long-term resilience to similar shocks in the future. A shock is defined as ‘a sudden and extreme change’ that impacts a health system, for example, pandemics, sudden climate events and natural disasters. It encompasses four phases: (1) preparedness; (2) shock onset and alert; (3) shock impact and response; and (4) short- and long-term recovery and learning.22
We adopt the definitions of absorptive, adaptive and transformative capacities from Blanchet et al:32 absorptive capacity refers to the capacity of a health system to continue to deliver the same level (quantity, quality and equity) of basic healthcare services and protection to populations despite the shock using the same level of resources and capacities. Adaptive capacity refers to the capacity of the health system actors to deliver the same level of healthcare services with fewer and/or different resources, which requires making organisational adaptations. Transformative capacity pertains to the ability of health system actors to transform the functions and structure of the health system to respond to a changing environment. To align with broader literature, we slightly refined these definitions and incorporated an additional dimension: preventive capacity:2237,39
Preventive: The capacity of a health system to proactively foresee the advent of a shock and minimise its potential future impact. This includes proactive planning and risk reduction strategies, preparedness training and system maintenance to reduce vulnerabilities before a crisis occurs.
Absorptive: The capacity of a health system to withstand and manage shocks while maintaining essential functions, using existing resources and capacities. Absorptive strategies enable the system to return to its original state or reduce the severity of the crisis without structural changes.
Adaptive: The ability of the health system actors to adjust and make incremental changes in system processes or structure to sustain service delivery. Adaptation involves absorbing additional demand or reduced supply by improving efficiency (eg, ‘doing more with less’) or reallocating resources to meet emerging needs. Adaptive strategies can be reflected in broadening of collaboration, reconfiguration of staff roles to enhance service delivery, telemedicine or reallocation of funds.
Transformative: The ability of the health system actors to implement long-term, fundamental changes in system structure and functions in response to major or recurring shocks. Transformative strategies lead to new models of operation, governance or service delivery to enhance future resilience (eg, universal healthcare, supply chain redesign, decentralisation).
Various frameworks have been identified for assessing resilience, pointing at the lack of conceptual maturity.39 40 For example, Hollnagel focused on the concept of resilience engineering and defined four resilient health system capabilities: anticipating, monitoring, responding and learning.41 Similarly, Kruk et al introduced the attributes of health system resilience, considering it as living organisms, characterised by awareness, diversity, self-regulation, integration and adaptability.18 Blanchet et al presented health system resilience capacities, including absorptive, adaptive and transformative capacities.32 A recent scoping review categorised health system resilience assessment approaches into three types: (1) system mapping, which examines core health system functions; (2) capacity-based, which focuses on resilience characteristics; and (3) strategy-based, which examines resilience strategies.40 In their review of published models, frameworks and theories, Foroughi et al noted that existing health system resilience frameworks typically focus on only one or two of the dimensions necessary for operationalising resilience.39 For example, Kruk et al, Hollnagel et al and Bruneau et al emphasised resilient system attributes, while Blanchet et al and Barasa et al examined resilience strategies and attributes, and Rogers focused on the phases of reaching resilience.39 To create a more comprehensive perspective, the authors developed a frame that combines all these core dimensions into one framework, centred on the WHO six-building-blocks.
The Health System Resiliency Analysis Framework by Foroughi et al was adapted as the guiding framework for the tool development (see online supplemental file 1).39 Unlike previous frameworks that focus on individual shocks or emergency response as entry point, this framework provides a health system-focused assessment. It was slightly modified to incorporate sociopolitical and cultural components influencing health systems.13 Recognising the importance of the resilience concept as a dynamic health system objective to achieve health system goals, the framework introduces resilient system attributes (also referred to as ‘intermediate objectives’) and health system goals. To define the boundaries of the analysis, the WHO health system’s building blocks serve as the foundational basis, with resilience conceptualised as a dynamic capability (comprising preventive, absorptive, adaptive and transformative capacities), through which health systems respond, recover and evolve in the face of health shocks. The analysis encompasses: components (broad system domains); subcomponents (conceptualised as resilience-enhancing strategies or key dimensions that shape resilience within each component); indicators (specific measures or assessment areas within each subcomponent), and; resilience capacities (the functional role of each indicator in system resilience, categorised as preventive, absorptive, adaptive or transformative).
According to the framework, resilience is linked to how well health systems function across the shock cycle, along the identified four components (derived from the WHO building blocks) frequently cited in the literature: governance and institutional arrangements, financing arrangements, data and information systems and health system resources, public health and service delivery. These components operate within broader political, social and cultural contexts, shaping system responsiveness and resilience over time. Additionally, the role of resilience enablers—strategies or mechanisms that strengthen absorptive, adaptive and transformative capacities—is recognised and reflected in the framing of the subcomponents (and operationalisation of indicators), contributing to a deeper understanding of resilience dynamics.
Process for tool development
The tool was developed using a standard multistep approach for instrument development, as described below:42
Step 1: definition of the purpose and scope
The project team defined the tool’s purpose and scope by aligning it with the study’s overarching goals and objectives. This definition was informed by the literature review as well as key insights from experts and policymakers (see step three for details on the consultation process). The following goals were taken into consideration:
Dynamically assess a country’s ability to prevent, detect and respond effectively to health shocks, including the ability to scale up and mobilise surge capacity, have built-in feedback loops to ensure continuous learning and adaptation to responses and maintain core services.
Create a multisectoral platform to implement the tool through consensus, using a combination of quantitative and quality indicators. The platform should be able to repeat and improve the assessment in an iterative manner.
Yield a practical, actionable list of priorities for stakeholders and policymakers to strengthen health system resilience, as well as emergency preparedness and response.
Step 2: item generation and reduction
This step followed a structured, iterative process to generate subcomponents for the identified components, define indicators for measuring these subcomponents and establish the scoring system for the tool.
A comprehensive review of the literature including for the MENA region and contextual analysis was conducted, with indicators selected based on their direct relevance to health system preparedness and resilience capacities. The guiding framework informed the selection and classification of indicators, ensuring a balanced representation of health system resilience. Two search strategies were employed: a broad search on resilience, health system and emergency preparedness, followed by targeted searches for each identified component. The following electronic databases were searched: Medline, Embase, Global Health and Scopus database. Additionally, key organisational websites (eg, WHO, World Bank, Joint External Evaluation (JEE) and States Parties Self-Assessment Annual Reporting (SPAR), Centers for Disease Control and Prevention, Global Health and Security Initiative (GHSI)) and Google Scholar were hand-searched for grey literature. From this process, 18 259 articles were retrieved. After removing duplicates, 7733 titles and abstracts were screened, and 110 full-text articles were selected for inclusion (online supplemental file 2). Based on existing literature and emerging evidence from the COVID-19 pandemic, we identified a broad range of assessment areas applied to various aspects of health system resilience. We also distilled a number of strategies for strengthening health system resilience or enabling a resilient response to a shock.22
The next step involved identifying key subcomponents within each health system component to ensure all relevant dimensions of resilience were captured. These subcomponents were framed as resilience-enhancing strategies or key dimensions that shape resilience within each component. 41 candidate subcomponents were initially identified from the included articles. These were reviewed to eliminate redundancies and merge similar ones, resulting in 22 subcomponents across the five identified components of the tool (online supplemental file 1).
Indicator generation for the subcomponents involved direct extraction of indicators from existing assessment tools and studies, modifications to existing indicators or development of new indicators building on lessons and attributes of health system resilience and pandemic preparedness relevant to MENA region. An initial compendium of 390 potential indicators for inclusion was developed. The indicators were grouped according to the health system components and subcomponents. Each indicator was also mapped to resilience capacities.
Indicator reduction occurred through three iterative rounds (online supplemental file 3). The first round eliminated redundant indicators or those that were conceptually irrelevant or unrelated to health system resilience. The second round involved assessing the remaining indicators against four criteria: measurability, validity, relative importance to MENA region and feasibility. These criteria were adapted from Al-Katheeri et al and subsequently revised based on discussion with the technical and broader advisory group.43 Indicators meeting all four criteria were retained automatically, while those meeting two or three were reassessed to ensure balanced representation across components, subcomponents, resilience capacities and relevance to MENA region. The third round involved further refinement, including rewording and combining those that were substantively related. This process generated a revised list of 109 indicators for inclusion in the tool. The 109 indicators included a mix of qualitative and quantitative indicators. To ensure consistency with the guiding framework, indicators within each subcomponent were categorised by their contributions to resilience capacities, with indicators mapped to preventive, absorptive, adaptive or transformative capacities as appropriate.
Scoring systems were developed at two levels: the indicator level and the broader subcomponent level (online supplemental file 4). The scoring scales at each level were intentionally designed to provide measurable understanding of how far existing capacities and competencies can be stretched or scaled up in anticipation of and in response to shocks.
Step 3: testing for content and face validity
In order to establish content and face validity of the tool, we sought inputs from two groups of stakeholders.
First, the project team shared a beta version of the tool, including a preliminary list of candidate indicators, with selected international experts in health system resilience and pandemic preparedness (via World Bank network). We asked participants to reflect on the overall comprehensiveness of the tool, discuss whether or not each subcomponent and indicator should be retained in the tool, suggest refinements and modifications to the subcomponents and indicators as well as nominate new indicators or merging of similar ones. Participants also reflected on the utility of the proposed scoring system.
Second, the team invited policymakers and stakeholders from the MENA region to solicit feedback on the preliminary tool. Specifically, two consultative workshops were conducted in Jordan and the West Bank and Gaza. Each workshop was facilitated by representatives from the core team and a focal lead identified for each country. Each workshop lasted half a day and was attended by 12–15 multidisciplinary stakeholders purposively selected from different ministries, national entities for disasters/crises preparedness and response, statistical departments, healthcare organisations, universities, non-governmental organisations and intergovernmental organisations. The same version of the tool was administered in both workshops. Participants were divided into smaller working groups, corresponding to the different components of the tool. Each working group was asked to provide their collective inputs on the (1) clarity of the indicator and its scoring scale; (2) relevance of the indicator to their context; and (3) feasibility (ie, data availability). They were then asked to reflect on the tool as a whole. Members of the research team took thorough notes of all the discussions.
The inputs received from the two groups were consolidated into one document and divided into general and component-specific feedback. Using the results of the feedback, additional refinements were made to the tool. Some indicators were reworded, and others merged, resulting in a final set of 99 indicators. The 22 subcomponents were retained with minor refinements to their wordings to capture the non-health sector role in preparedness and response to health system shocks. More in-depth elaborations for some of the indicators were subsequently captured as subindicators, with yes/no responses. Additional options to add qualitative information through qualitative support questions (that are not scored) were introduced to allow users to qualify and frame the discussion on the indicators.
There was a general consensus to retain both scoring levels (indicator and subcomponent levels) in the tool as well as provide flexibility for users to decide on the scoring approach (metrics vs consensus based) that best fits their context.
Patient and public involvement
Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Results
Below, we present the current version of the tool, organised as follows:
Purpose, scope and function.
Component, subcomponents and indicators.
Scoring system.
Action plan development.
Implementation considerations.
Purpose, scope and functions
The emergency preparedness and health system resilience assessment tool—here referred to as the EPSRA tool—offers a comprehensive and adaptable approach in assessment of health system resilience, using a multisectoral platform that enables continuous learning and improvement. It is specifically aimed for use against shocks that have significant health impacts. It can help countries minimise the impact of health shocks by assessing the existing capacities and capabilities of their health systems, pinpointing gaps and prioritising actionable recommendations to strengthen overall resilience. While the tool is developed for the MENA region, it can be adapted to other regions.
The tool is designed to be implemented as a country self-assessment exercise, initiated by national authorities with support from the World Bank and completed through intensive and active form of consultation with stakeholders through in-depth exchange of views and information, leading to joint analysis and decision-making. A user manual provides a step-by-step guidance on using the tool, as well as contextual considerations for its adaptation (available on request from first or corresponding author). Acknowledging the nuances across countries, the tool is not designed to compare countries but to inform policy discussions within a given country. Additionally, it does not seek to assess health system performance in a ‘business-as-usual’ scenario, rather its ability to respond on short notice to any given large-scale health shock. An overview of the key functions of the tool is provided in online supplemental file 5.
Countries using the tool can expect to generate a detailed assessment report with key findings for each component, a visual scorecard as a living document for ongoing monitoring and evaluation (M&E) of progress over time and a prioritised action plan for strengthening systems resilience that can be incorporated into the country’s national policies and strategies through a multistakeholder collaborative approach. Thus, findings can serve as both a starting point and a platform for future policy dialogue and reform efforts.
Online supplemental file 6 provides a comparison of EPSRA tool with other assessment tools, adapted from the scoping review by Tran et al which compared the breaths of 14 selected epidemic risk assessment toolkits.13 First, the EPSRA tool covers all the system components—allowing for assessment of the impact of system-wide factors, such as governance and institutional arrangements, on the health system’s ability to prevent, detect and respond to shocks. It also incorporates components reflecting the broader political, community and sociodemographic factors influencing health systems functioning. In doing so, it emphasises not only the tangible aspects of health systems but also the country contexts. Second, unlike other tools like the Global Health Security Index, the proposed tool adopts a participatory approach to assessment which yields several benefits including the opening up of a discussion platform to reach consensus on responses, the possibility of approaching subcomponents from different angles, the opportunity for participants to take part in developing plans and actions to fill existing gaps, the improved relevance and accuracy of the data and the enhanced ownership and sustained capacity for country-level self-assessments. Third, the tool yields practical, actionable priority recommendations that countries can address to strengthen health system resilience and broader emergency preparedness and response.
Components, subcomponents and indicators
The five system components that make up the current version of the tool include: (1) financing arrangements; (2) governance and institutional arrangements (including government leadership); (3) health system resources, public health and service delivery; (4) data and information systems (including surveillance systems); and (5) sociopolitical and cultural environment. Each of the components consists of various subcomponents. Each subcomponent is assessed using a mix of quantitative and qualitative indicators and, on that basis, scored to reflect the maturity of the country’s capacity in that specific area. The full version of the tool is available on request from the first or corresponding author.
Financing arrangements (four subcomponents; 16 indicators): Resilience in financing is a critical aspect of a country’s ability to respond to health emergencies, as unexpected shocks can increase the demand for health spending while decreasing government income. This component focuses on a government’s capacity to plan for and mobilise additional resources in the event of emergencies and other health shocks. It includes four subcomponents: (1) availability of contingency appropriations, (2) financing arrangements for surge capacity during emergencies, (3) financing arrangements for maintaining essential services and (4) the availability of social protection mechanisms to protect vulnerable populations.
Governance and institutional arrangements (six subcomponents; 20 indicators): Strong governance and leadership are critical to the functioning of all other aspects of the health system, involving stakeholders across the government, private sector, civil society and other stakeholders. It includes six subcomponents: (1) presence and maturity of policies and strategies for emergency preparedness, response and recovery, (2) organisational structures and mechanisms to respond to emergencies, (3) regulatory and oversight capacity, (4) informed decision-making processes, (5) management and institutional capacity for implementation and evaluation and (6) community engagement, communication and outreach capacity,
Health system resources, public health and service delivery (four subcomponents; 35 indicators): This component assesses the ability of the health system to deliver quality care while responding to health shocks and maintaining essential health services. It includes four subcomponents: (1) service delivery and system organisation for surge capacity and maintenance of essential services, (2) functional and reserve capacities of health workforce, (3) functional and reserve capacities of physical resources and (4) public health functions
Data and information systems (six subcomponents; 19 indicators): This component focuses on the availability and maturity of data and information systems relevant to the health sector, across different stakeholders and existing data-sharing protocols. It includes six subcomponents: (1) framework and operational procedures for data and information systems, (2) infrastructure and capacity to support information systems, (3) presence and maturity of key data sources, (4) presence and maturity of early warning and surveillance systems, (5) flow of data and data integration across sectors and (6) existence and use of knowledge management systems for the dissemination of information.
Sociopolitical and cultural environment (two subcomponents; nine indicators): This component assesses the broader context within which a health system operates, focusing on the political, sociocultural and macroeconomic environment that can influence a health system’s resilience and response to health shock. It includes indicators related to the following two subcomponents: (1) sociopolitical environment and (2) sociocultural risks.
The EPSRA tool comprises 99 indicators, which fall under two types:
Qualitative indicators provide high-level descriptions of systems and are rated on a 4-point Likert scale. The descriptive scales reflect ascending requirements of capability levels.
Quantitative indicators are captured numerically and assigned a value from 1 to 4 relative to national targets or international reference points, using the same 4-point scale mentioned above.
Each indicator is mapped to a specific subcomponent within a health system component and further categorised by its contribution to resilience capacities. Online supplemental file 7 provides an overview of the characteristics of the included indicators.
Tables15 provide a detailed overview of the indicators and their subcomponents, organised by component (for table 3, the subindicators have been removed for brevity; the full version is available in online supplemental file 8).
Table 1. Financing arrangements: subcomponents and indicators.
| Subcomponents | Indicators and subindicators | Source of data | Resilience capacities | |||||
|---|---|---|---|---|---|---|---|---|
| Extracted | Modified | Proposed | Preventative | Absorptive | Adaptive | Transformative | ||
| 1. Contingency appropriations earmarked for emergencies (including health emergencies) | 1. Does the government have a national strategy, policy or legislation to allow for emergency financing? 1.1. Are health systems integrated into the broader emergency/disaster risk financing policy, strategy, commitment or plan? |
√ | √ | √ | ||||
| 2. Does the government have contingent funds for use during national emergencies? 2.1 If funds exist, how liquid/accessible are they? Are there established administrative steps to trigger their mobilisation? 2.2 If funds exist, where are they housed? 2.3 Does the Ministry of Health (MoH) have a fund of its own? |
√ | √ | √ | √ | ||||
| 3. Available contingency funds for emergencies as a percentage of total government annual outlays in the previous year. 3.1 If available, how much of this is earmarked for the MoH? |
√ | √ | √ | √ | ||||
| 4. Does the government have a comprehensive plan for contingent liability spending? If available: 4.1. Was it developed in consultation with all interagency stakeholders, who must now be fully aware of its existence and its implications for their own operations? 4.2. Are there any robust tools to measure/anticipate potential spending liabilities? |
√ | √ | √ | √ | ||||
| 2. Financing arrangements for surge capacity during emergencies | 5. Are there formal provisions to reallocate funds during an emergency to meet changing needs? | √ | √ | √ | ||||
| 6. Do health authorities at the national and subnational levels exercise control over the allocation within their own budgets? 6.1 Do cost centres and health facilities have some autonomy over their own budget allocations? 6.2 Is this part of a broader system-wide decentralisation of financial management? |
√ | √ | √ | √ | ||||
| 7. Do procurement/purchasing policies include provisions and clear guidelines for undertaking flexible procurement in the case of national emergencies? | √ | √ | √ | |||||
| 8. Does the country participate in credit risk financing mechanisms (national, regional or international), that cover disasters? 8.1. If yes, do these mechanisms specifically include coverage for health crises? |
√ | √ | √ | |||||
| 9. Does the government have recourses to aid or humanitarian funding that can be mobilised during national emergencies? | √ | √ | √ | √ | ||||
| 10. Are there accountability systems/mechanisms in place to track, monitor and report on the financial allocations used during emergencies (at national and subnational levels)? | √ | √ | √ | √ | √ | |||
| 3. Financing arrangements for maintaining essential services | 11. Core financial indicators: 11.1. Public spending on health (as a share of total government spending). 11.2. Out-of-pocket payments as a share of total health spending. 11.3. Level of donor funding as a share of total health spending. |
√ | √ | √ | √ | |||
| 12. Percentage of health spending allocated to primary care as a share of total government health spending? | √ | √ | √ | √ | ||||
| 13. Are there well-defined, clear and transparent financial arrangements to ensure the non-stock-out of essential medicines and commodities? | √ | √ | √ | √ | ||||
| 4. Social protection mechanisms to protect the most vulnerable populations | 14. What percentage of the population is covered by health insurance (public vs private) or publicly financed health services? 14.1 Are these coverages adequate by international standards? As per WHO, universal health coverage consists of (1) % population coverage (2) service coverage and (3) financial coverage. 14.2. Is there an adaptive plan or strategy in place to progressively achieve and improve universal health coverage, considering evolving health needs and challenges? |
√ | √ | √ | √ | |||
| 15. Are there social protection programmes/systems that can be adapted and scaled up rapidly in times of crisis? If available: 15.1 How rapidly can the payment system/support be scaled up during emergency responses? 15.2 Is the health sector coordinated with the social protection sector? 15.3 Which type of social protection programmes (cash transfers, subsidies, in-kind transfers, public works, pensions, etc) are available? |
√ | √ | √ | |||||
| 16. Coverage of social protection and welfare programmes (% of population). 16.1. If available, what is the coverage among population below the US$1.9 per day poverty line? |
√ | √ | √ | √ | ||||
Table 5. Sociopolitical and cultural environment: subcomponents and indicators.
| Subcomponents | Indicators and subindicators | Source of data | Resilience capacities | |||||
|---|---|---|---|---|---|---|---|---|
| Extracted | Modified | Proposed | Preventative | Absorptive | Adaptive | Transformative | ||
| 1. Stable and supportive sociopolitical environment | 1. Government Effectiveness index. | √ | √ | √ | ||||
| 2. Political stability and absence of violence index. | √ | √ | ||||||
| 3. National poverty headcount ratio. | √ | √ | ||||||
| 4. Corruption perceptions Index. | √ | √ | ||||||
| 5. Proportion of migrant populations that have legal recognition in the country. 5.1. If legal recognition exists, does it enable access to housing, jobs and healthcare? |
√ | √ | √ | √ | ||||
| 2. Reduced sociocultural vulnerabilities | 6. Population density. | √ | √ | |||||
| 7. Adult literacy rate. | √ | √ | √ | |||||
| 8. Social cohesion index. | √ | √ | √ | √ | ||||
| 9. ICT development index (includes access to internet and mobile phones, mobile network, etc). | √ | √ | √ | |||||
Table 3. Health system resources, public health and service delivery: subcomponents and indicators.
| Subcomponents | Indicators* | Source of data | Resilience capacities | |||||
|---|---|---|---|---|---|---|---|---|
| Extracted | Modified | Proposed | Preventative | Absorptive | Adaptive | Transformative | ||
| 1. Service delivery and system organisation for surge capacity and maintenance of essential services | 1. Is there a regularly updated national surge capacity preparedness plan for healthcare systems? Surge capacity has four elements (4S): staff (medical personnel, doctors, nurses, pharmacists); stuff (equipment, supplies); structures (hospitals, community health centres, laboratories); and systems (successful coordination and management of various levels of the healthcare system). |
√ | √ | √ | √ | |||
| 2. For each of the 4S elements, how has the country managed to expand surge capacity specifically during the COVID-19 pandemic? | √ | √ | √ | |||||
| 3. How quickly can surge capacity be scaled during emergency responses (irrespective of the mechanism used) | √ | √ | √ | |||||
| 4. Is there a country-specific list of essential health services that should be maintained by health facilities in the event of service disruptions during emergencies? | √ | √ | √ | |||||
| 5. For each of the services below, were there disruptions? 5.1: Vaccinations. 5.2: Antenatal visits. 5.3: Chronic care follow-ups. 5.4: Renal care—dialysis. |
√ | √ | √ | |||||
| 6. Are there national level mechanisms for both monitoring the ongoing delivery of core services and deployment of human and capital resource reserves in the event of service disruptions? | √ | √ | √ | |||||
| 7. To what extent can digital health technologies (eg, telemedicine, mobile health apps) be used to expand service delivery during emergencies? | √ | √ | √ | √ | ||||
| 8. Are there national medical crisis standards of care in place that can be implemented during an emergency? | √ | √ | ||||||
| 9. Is there a national quality improvement agency/council responsible for supporting quality management activities during emergencies? | √ | √ | √ | √ | √ | |||
| 10. Is there a national and functional referral system in place, with clearly defined policies for triage, transfer/transportation, communication and diversion during emergencies to enable effective referrals and counter-referrals? | √ | √ | √ | √ | ||||
| 11. To what extent is the role of primary healthcare integrated and explicitly recognised in emergency responses? | √ | √ | √ | √ | √ | |||
| 12. What mechanisms or agreements are in place to integrate and leverage private sector in service provision, including for surge capacity and maintaining essential services during emergencies? | √ | √ | √ | √ | ||||
| 13. Are there policies or mechanisms to link the humanitarian system (UN agencies, International Red Cross/Red Crescent Movement, NGOs, donor agencies, etc) with the national public service delivery system to reduce fragmentation and mount a unified and effective response? | √ | √ | √ | |||||
| 14. What processes exist at the national and subnational levels to integrate or coordinate service provision for vulnerable and at-risk populations, including migrant workers, refugees and homeless populations during an emergency? | √ | √ | √ | √ | ||||
| 15. What support mechanisms are available for protecting the health workforce during emergencies (eg, helplines and counsellors, safety of staff, access to healthcare, etc)? | √ | √ | √ | √ | ||||
| 2. Functional and reserve capacities of human resources for health | 16. Is there a national health workforce plan (which has been updated in the past 5 years)? Considerations of a mature plan: considers recruitment, retention, performance improvement and capacity building of the health workforce (at both national and subnational levels). |
√ | √ | √ | ||||
| 17. Is there a national plan or agreement in place for rapidly scaling up health workforce during emergency response/health shock events (ie, workforce surge plan/agreement)? Considerations for mature plan: includes agreements for entry of foreign health workers; considers task-shifting guidelines; accelerated credentialing, licensure and indemnification of health workers; and public-private partnerships. |
√ | √ | ||||||
| 18. Is there an adequate number and geographical distribution of skilled health workforce in the country (public and private sector)? | √ | √ | √ | √ | ||||
| 19. Does the country have standing reserve workforce capacity that can be seconded during a public health emergency without disruption to core service delivery (eg, unemployed health workers, trainees, non-health personnel, retirees, community workers)? | √ | √ | √ | |||||
| 20. What protocols exist for training the health workforce during emergencies? | √ | √ | ||||||
| 21. Is there capacity to conduct rapid assessments on the availability, capacity and distribution of the health workforce during emergencies and to initiate rapid training mechanisms for key capacities based on these assessments? | √ | √ | √ | |||||
| 3. Functional and reserve capacities of physical resources | 22. Is there a regularly updated map of the health service delivery system (hospitals, primary care centres, clinics, pharmacies, laboratories and imaging centres, etc)? | √ | √ | |||||
| 23. Health facilities per capita: 23.1 Emergency beds per capita. 23.2 Hospital beds per capita. 23.3 ICU beds per capita (including ventilator availability). 23.4 Primary healthcare/clinic density. |
√ | √ | √ | √ | √ | |||
| 24. Bed occupancy rate (inpatient ICU, emergency). | √ | √ | ||||||
| 25. Are the majority of healthcare services in the country provided by non-governmental organisations (NGOs), charitable organisations or international organisations (eg, MSF, ICRC)? | √ | √ | √ | |||||
| 26. Is there a stockpile of critical medical and laboratory supplies (eg, medical countermeasures, medicines, vaccines, medical equipment, PPE, reagents, blood) for national use during emergencies? | √ | √ | √ | |||||
| 27. Is there a national plan or agreement in place for the manufacturing, procurement and distribution of medical and lab supplies (eg, medical countermeasures, medicines, vaccines, equipment, PPE) during emergencies? | √ | √ | √ | √ | √ | |||
| 28. Is there a national laboratory that serves as a reference facility and is subject to external quality assurance review? | √ | √ | √ | √ | ||||
| 29. Is there a plan in place to rapidly authorise or licence laboratories to supplement the capacity of the national public health laboratory system and scale up testing during a public health emergency? | √ | √ | √ | |||||
| 30. Is there a national plan or agreement in place to sustain the supply of external lifeline services (ie, water supply, electric power supply and gas supply) for healthcare facilities during emergencies? | √ | √ | √ | |||||
| 4. Effective public health functions | 31. Are there national plans and protocols for testing, contact tracing, isolation and surveillance (active/passive, syndromic/sentinel surveillance; zoonotic; genomic) that can be activated and scaled up during emergencies? | √ | √ | √ | √ | |||
| 32. Are there national plans and protocols for non-pharmaceutical public health interventions (eg, social distancing measures, hygiene practices) that can be activated and scaled up during emergencies)? | √ | √ | √ | √ | ||||
| 33. Are there national plans and protocols for Infection Prevention and Control (IPC) that can be activated and scaled up during emergencies? | √ | √ | √ | √ | ||||
| 34. Trained field epidemiologists per 200 000 people. | √ | √ | ||||||
| 35. Is there a dedicated IPC focal point responsible for infection prevention and control? | √ | √ | ||||||
The subindicators have been removed for brevity; the full version is available in online supplemental file 8.
DHS, Demographic and Health Surveys; ICRC, International Committee of Red Cross; ICT, Information and Communication Technology; ICU, intensive care unit; MSF, Medecins Sans Frontier/Doctors Without Borders; PPE, Personal Protective Equipment.
Table 2. Governance and institutional arrangements: subcomponents and indicators.
| Subcomponents | Indicators and subindicators | Source of data | Resilience capacities | |||||
|---|---|---|---|---|---|---|---|---|
| Extracted | Modified | Proposed | Preventative | Absorptive | Adaptive | Transformative | ||
| 1. Presence and maturity of policies and strategies for emergency preparedness, response and recovery | 1. Are there up-to-date, comprehensive and multisectoral strategies and policies for emergency preparedness, response and recovery? If available: 1.1. Do these provide a broad framework for coordination and collaboration across sectors, ensuring a cohesive and comprehensive approach to emergencies? 1.2. Are there specific strategies and policies for emergency preparedness, response and recovery within the health sector? 1.3. Is the health sector and health system preparedness integrated into the national emergency policies and strategies? 1.4. Do these cover all the phases of an emergency (preparedness, response and recovery)? 1.5. Have these been activated and acted on during the last emergency (eg, COVID-19)? |
√ | √ | √ | √ | √ | ||
| 2. Are there established links/relationships with regional and global health authorities (including reporting arrangements and division of responsibilities) during emergencies? | √ | √ | ||||||
| 3. Does the Ministry of Health have agreements (formal or informal) with other government ministries for collaboration and coordination on crisis response? | √ | √ | √ | |||||
| 2. Organisational structures and mechanisms to respond to emergencies (including coordination of activities across government and key stakeholders) | 4. Is there a system for conducting risk assessments to determine the national risk profile of the country and prioritise actions in case of an emergency? | √ | √ | |||||
| 5. Is there explicit and recognised organisational leadership to steer the overall emergency response? If available: 5.1. Does it include health emergencies? 5.2. What form does the leadership take? 5.3. Does the authority shift to the military or police in crisis response? 5.4. Is there a national incident command structure that can be rapidly activated during an emergency response? 5.5. Are there provincial (or district-level) emergency operations centres, with the capability for situational awareness and rapidly scaling up capacity as required during an emergency response? |
√ | √ | √ | |||||
| 6. Is there explicit and recognised leadership for steering the health sector response? 6.1 Is the MoH perceived as the nation’s foremost leader in health, by other central government departments, local government health authorities and non-governmental actors? |
√ | √ | √ | √ | ||||
| 7. Are there formal mechanisms or processes (eg, President’s Office, Joint Committee, Ministerial Tables) for the MoH to regularly interact and engage with other government agencies on cross-cutting issues and policies? If available: 7.1. Does it include representatives from all relevant sectors? 7.2. Is there a designated chair(s) of these mechanisms, with clearly defined role and responsibilities? 7.3. Are there incentives (eg, political/reputational/financial) for cross-ministry/department working? |
√ | √ | √ | √ | ||||
| 8. Is there a well-defined, full-time Emergency Preparedness and Response Unit within the MoH that provides a health intelligence function and oversees/coordinates other partners responsible for data and intelligence? | √ | √ | √ | √ | ||||
| 3. Institutional capacity for regulation and oversight | 9. Is there regulatory capacity in-country for the approval, importation and oversight of therapeutics, vaccines and other medical countermeasures needed to respond to emergencies? | √ | √ | √ | ||||
| 10. Is there a National Public Health Institute (NPHI) or an equivalent entity (eg, national public health agency, country CDC) responsible for the oversight of public health in the country? | √ | √ | √ | √ | ||||
| 4. Evidence-informed and transparent decision-making | 11. Are there mechanisms in place to support evidence-informed decision-making? If available: 11.1. At the national level? 11.2. Specifically, at the health sector level? 11.3. Are there established linkages between the government and the scientific community (including subject matter experts) to carry out essential research during emergencies? 11.4. Are there functional systems for developing, clearing, translating and disseminating national guidance and technical documents during an emergency? 11.5. Does the MoH/health authority earmark funds for knowledge translation and evidence-informed policymaking |
√ | √ | √ | ||||
| 12. Is there a formal system in place to hold public officials and non-state actors accountable for decisions and policies related to emergency response? | √ | √ | √ | √ | ||||
| 5. Management and institutional capacity for implementation and evaluation | 13. Are health officials trained in health protection and emergency preparedness and response? If available: 13.1 Does it include senior position? 13.2 Does it involve all types of personnel (eg, medical, administrative, etc)? |
√ | √ | √ | ||||
| 14. How frequently are national emergency simulation exercises, drills and joint planning activities conducted with the health sector? 14.1: Within the health sector, are simulation exercises, drills and joint planning activities conducted at all relevant levels, including public health, primary care, hospitals and long-term care etc.? |
√ | √ | √ | √ | ||||
| 15. Have any comprehensive and expert-informed assessments been conducted to take stock of the country’s response to the most recent public health emergency (eg, COVID-19 across the pandemic cycle)? | √ | √ | √ | |||||
| 6. Community engagement, communication and outreach capacity | 16. Is there a coordination structure for civil society/community and voluntary organisation that can be leveraged and scaled up during emergencies? | √ | √ | √ | ||||
| 17. Are there pre-established communication protocols and channels for timely communication and exchange of information during emergencies? If available: 17.1 Are there clear channels of communication between health sector actors and other sectors during emergencies? 17.2 Are there established systems within the health sector to facilitate communication among hospitals, health care systems, public health entities, communities and health authorities (e.g., MoH) during emergencies? 17.3 Have the communication protocols been implemented or tested through actual emergency or simulation exercises and updated in the last 12 months? |
√ | √ | √ | |||||
| 18. Are there information feedback loops (eg, capturing feedback, appeals, public sentiment through community leaders, civil society and patient groups) during and after emergencies, that are linked to government decision-makers? | √ | √ | √ | √ | ||||
| 19. Civil Society Participation Index. | √ | √ | ||||||
| 20. Voice and Accountability Index. | √ | √ | ||||||
CDC, Centers for Disease Control and Prevention; MoH, Ministry of Health.
Table 4. Data and information systems (including surveillance systems): subcomponents and indicators.
| Subcomponents | Indicators and subindicators | Source of data | Resilience capacities | |||||
|---|---|---|---|---|---|---|---|---|
| Extracted | Modified | Proposed | Preventative | Absorptive | Adaptive | Transformative | ||
| 1. Framework and operational procedures for data and information systems | 1. Is there a functional health information system (HIS) (this includes electronic medical record (EMR), electronic health record (EHR), practice management software, master patient index, etc)? If available: 1.1. Is the HIS electronic, hybrid or paper-based? 1.2. Does the HIS function effectively during crisis situations? |
√ | √ | √ | √ | |||
| 2. Is there a legal framework for the HIS? 2.1. Is it well-established and evolving? |
√ | √ | √ | √ | ||||
| 3. Are there protocols for data management in the health sector (this includes a written set of procedures or operating frameworks for data collection, storage, cleaning, quality control, analysis, presentation and sharing with target audiences, both in times of crisis and non-crisis)? 3.1 If applicable, are there essential datasets, such as case files and individual health records, identified for collection across different phases of emergencies? 3.2. Are there harmonized data collection tools with minimum data quality standards for emergency response and essential health services, including harmonized data entry systems? |
√ | √ | √ | √ | ||||
| 4. Are there national-level data privacy laws to safeguard personal and sensitive information, including during emergencies? 4.1. If available, are these applied within the health sector? |
√ | √ | √ | |||||
| 2. Infrastructure and capacity to support information systems | 5. Is there adequate infrastructure (power, ICT connectivity, hardware) for a functional HIS? | √ | √ | √ | √ | |||
| 6. Is there sufficient capacity for data management and analytics (including conducting routine data analysis, interpreting data and translating findings into possible actions)? 6.1. At the health sector level 6.2. At the national level (beyond health sector) 6.3. Is there a centralized body responsible for undertaking needs assessment and overseeing capacity building/training on data management and analytics? |
√ | √ | √ | √ | ||||
| 3. Presence and maturity of key data sources | 7. Of the core data needed, which of the below are available and routinely updated:
|
√ | √ | √ | √ | |||
| 8. Is there a national citizen database or social registry in place for identifying vulnerable populations for social protection/welfare? 8.1. If available, is it regularly updated? |
√ | √ | √ | √ | ||||
9. Of the system-wide data, which of the below are available and routinely updated:
|
√ | √ | √ | √ | ||||
| 4. Presence and maturity of early warning and surveillance systems for timely detection of shocks | 10. Are there functional indicator-based surveillance (IBS), event-based surveillance (EBS) and Early Warning, Alert and Response Systems (EWARS) in place? If available: 10.1. Is a list of priority diseases, conditions and case definitions for surveillance available? 10.2. Are surveillance data linked to health information systems? 10.3. Are surveillance data systematically and regularly reported to the relevant sectors and stakeholders? 10.4. Are there institutional arrangements to channel information for action (protocols, contingency plan to implement, coordination mechanisms, etc)? |
√ | √ | √ | √ | |||
| 11. Does the EWAR/syndromic surveillance have the monitoring and alert capacity? 11.1. Are baseline estimates, trends and thresholds for alert and action defined at community level for primary events? 11.2. Is timely reporting is received from at least 80% of units? 11.3. Are values exceeding thresholds used for action at the primary response level? |
√ | √ | √ | |||||
| 12. Are the surveillance systems regularly assessed and updated and used for action? 12.1 Are surveillance results disseminated to all relevant stakeholders in a timely manner? 12.2. Are surveillance systems assessed on key surveillance attributes: date of last assessment; timeliness and completeness of surveillance reports |
√ | √ | √ | |||||
| 13. Are there mechanisms in place to enable the surveillance system to adapt to working in emergencies? | √ | √ | ||||||
| 14. Are health risk assessments, simulation exercises and/or forecasting scenarios for a variety of hazards (eg, climate event, conflict, refugee crisis, biohazard, financial crisis) conducted routinely and have they prompted decision making? | √ | √ | √ | |||||
| 5. Effective and timely flow of data and data integration across sectors | 15. Is there an integrated database (for emergency and routine data), across institutions and sectors? 15.1. Is there a One Health platform for human-animal-environment interface? |
√ | √ | √ | ||||
| 16. Are the data systems interoperable across databases/institutions/sectors? | √ | √ | √ | |||||
| 6. Existence and use of knowledge management systems to collect, integrate and disseminate different forms of knowledge and information | 17. Is there a knowledge management (KM) team and portal that integrates health and health-related information resources from different sectors (horizontal) and levels of governments (vertical)? 17.1. At the national level (not just health)? 17.2. Specifically at the health sector level? |
√ | √ | √ | √ | √ | ||
| 18. Are there real-time dashboards to track the public health emergency and progress on intervention(s)? | √ | √ | √ | |||||
| 19. Is there a system for monitoring and evaluation (M&E) of the health system performance (including health services and public health functions) during emergencies, with embedded feedback and learning mechanisms? If available: 19.1. Are evaluations conducted on a regular basis? 19.2. Are methods and results of evaluations publicly reported? 19.3. Does MoH have in-house technical expertise and/or experience in M&E? |
√ | √ | √ | √ | ||||
MoH, Ministry of Health.
Scoring system
As indicated earlier, there are two levels of scoring for the tool: indicators and subcomponent levels, respectively (online supplemental file 4).
Indicators level
Qualitative indicators are directly assigned a score of 1–4 based on their descriptive scales which reflect ascending requirements of capability levels. For the quantitative indicators, numerical scores are generated and subsequently assigned a value from 1 to 4 relative to national targets or international reference points (with 1=least desirable and 4 most desirable). Subindicators with Yes/No responses are assigned a score between 0 and 0.5 (No=0; Yes=0.5).
Subcomponent level
A country’s maturity level in a specific subcomponent is defined across the following scale:
Beginning, indicating either the complete or relative lack of country response capacity for the specific subcomponent, including but not limited to a lack of policy initiatives to fulfil the specific pandemic preparedness and response (PPR) function.
Developing, indicating initial efforts to make progress toward fulfilling that specific function, with some gaps regarding complete policy formulation and substantial gaps regarding policy implementation.
Expanding, indicating substantial progress within that subcomponent, with relatively complete policy formulation and some gaps in implementation.
Mature, indicating full maturity within that subcomponent with regard to both design and implementation of relevant policies and initiatives.
Users may opt for a consensus-based or metrics-based approach to decide on the maturity level of the country in a specific subcomponent. Under the metrics scoring system, the average score of the indicators (and subindicators) within a subcomponent is generated. This average score is then translated into the subcomponent maturity level based on predefined scoring ranges. Under the consensus-based approach, the working group reviews the qualitative and quantitative data for each subcomponent and reaches a consensus on the maturity level.
Acknowledging the nuances inherent in the development process, it is not recommended to generate an aggregate singular score for each component or a final singular score for the whole tool as this may mask the areas for priority action as well as provide a potentially false sense of development of the system; rather, the scores within each subcomponent can serve as guides which allow users to have a quick snapshot of where a country stands in relation to the development of its health system. The scores also enable users to monitor a country’s progress over time.
A visual presentation of the scoring system for the subcomponents is provided in online supplemental file 4.
Action plan development
As part of developing the action plan, stakeholders engage in critical reflections on the results, identifying key areas requiring improvement and prioritising actions accordingly. The action planning process begins at the subcomponent level, where potential areas for improvement are identified, taking into consideration current gaps and desired conditions for capacity expansion. Based on the prioritised actions within each subcomponent, a consolidated plan is generated, outlining the specific recommendations the country should undertake to enhance its preparedness and response capacity, along with the responsible entities, supporting partners and timeline.
An example of an action plan development template is provided in online supplemental file 9.
Implementation considerations
When implementing the EPSRA tool, careful consideration of its design and contextual factors is crucial for effective implementation and interpretation of outputs (see online supplemental file 10). The tool is intended as a self-assessment tool for the country, initiated by national authorities with support from the World Bank. While it is primarily designed for national-level assessments from a health systems lens, it can also be adapted for use at subnational levels, especially in countries with highly decentralised public sectors. Here, it is recommended to use the tool to score a province or region rather than the entire country.
The implementation process requires intensive and active stakeholder consultation, involving in-depth exchange of views and information to facilitate joint analysis and decision-making. For technical and/or logistical reasons, it is recommended to fill the tool by component areas. A small, diverse working group should be assembled to complete each component, followed by a cross-component validation meeting. To ensure the process is evidence-based, it is advisable to distribute a brief booklet containing background information to participants before consultation meetings.
The team’s core competencies should encompass public health, health systems and emergency preparedness and response. It is crucial to emphasise the assessment’s intersectoral nature and involve experts from various ministries and sectors as necessary. Ideally, the assessment team should include the following:
Focal coordinating lead: Responsible for overseeing the entire implementation process, following up on the assessment and action plan and coordinating across the different stakeholders. This lead could be a representative from the Ministry of Health or another entity responsible for emergency preparedness and response.
Component leads: One for each component, tasked with leading work on their respective components. These leads should possess the necessary expertise, experience and legitimacy to convene key stakeholders and complete the tool related to their component.
Multidisciplinary working groups: These groups, comprising 6–8 members per group, will engage in in-depth discussions and consensus-building to complete the tool. Members should represent various disciplines with a focus on the assessment’s intersectoral nature.
The assessment process consists of three phases: preparatory, assessment and postassessment (see online supplemental file 10). On average, completing the assessment process takes 6–10 weeks. This estimate includes 2–3 weeks for preparatory work, 2–4 weeks for data collection and analysis and up to 3 weeks for consolidating, validating and disseminating the report and action plan. This time frame can be implemented consecutively or spread out over a period of 1 year.
Discussion
In today’s global context, extreme shocks are becoming more common; the next emergency, whether it is an economic fall-out of the pandemic, an environmental or refugee and migration crisis or another pandemic, is just around the corner.22 Countries must not wait to prepare for it, but should rather build on the lessons learnt from the COVID-19 pandemic to strengthen their health systems in order to ensure better resilience and sustainability.30 Resilient health systems were able to cope more effectively with the impact of COVID-19, provide stronger protection for citizens and mitigate the impacts of COVID-19; consequently, increasing health system resilience will improve responses to future public health emergencies.4 Assessing the resilience of a health system is difficult but a necessary first step to prepare for the next health emergency. It can help countries understand how various leverage points within and outside of the health system can enhance its preparedness and ability to maintain performance during an emergency or shock.44
The proposed EPSRA tool responds to the general consensus on the importance of health system resilience and the need to establish new and adapted tools that address the limitations of existing tools as identified in the scientific literature related to health system resilience assessment. Moreover, it builds on key emerging challenges and lessons learnt from the COVID-19 pandemic to predict a country’s ability to scale up surge capacity and launch an effective response. The tool is designed to enable national health authorities and partners to identify gaps, build on existing capacities and engage in meaningful and informed discussions to yield practical, actionable sets of country priorities for strengthening health system capacity to prevent, detect and respond to future shocks that have significant health impacts. The scoring mechanism reflects the maturity of the country’s response mobilisation capacity in that specific subcomponent and thus can provide measurable understanding of how far existing capacities could be stretched or scaled up in anticipation of and in response to different shocks. Countries can customise the tool to their needs by omitting items that may not be applicable to their settings. Countries can also extract relevant indicators from the tool to formulate the M&E framework for national pandemic preparedness and resilience strategic plans.
By highlighting areas where investments could be made that would result in improving the health system prior to, during and after the health emergency or shock, the tool can help channel limited resources to areas of highest priority. It can also promote intersectoral coordination and collaboration in the development and implementation of the health sector response. Using this tool is particularly relevant in the MENA region where the unprecedented scale of health emergencies creates an urgent need to focus on strengthening health system resilience in that region.9
Since the development of our framework in 2022, the field of health system resilience assessment has evolved substantially, with several notable contributions advancing conceptual frameworks and measurement approaches. Recent work by Witter et al has reconceptualised health system resilience by emphasising power dynamics, social values and equity considerations that were previously underexplored.31 Copeland et al conducted a scoping review highlighting the need for empirical studies that operationalise resilience beyond theoretical frameworks.36 Zhong et al introduced innovative quantitative approaches for measuring resilience through longitudinal analyses of service disruptions across multiple shocks.45 Tonga et al provided a comprehensive categorisation of assessment approaches, identifying gaps in current methodologies.40 Our EPSRA tool contributes to this evolving landscape by offering a practical, context-sensitive approach that bridges theoretical concepts with actionable assessments. Unlike many recent frameworks that remain conceptual, our tool operationalises resilience assessment through a multisectoral, participatory process with concrete indicators mapped to specific resilience capacities. The tool’s value-add lies in its comprehensive scope addressing both health system functions and sociopolitical contexts, its regional validation in the MENA context where such tools are scarce and its practical orientation toward generating actionable priorities rather than just measuring performance. This was also evident in the way that the tool was used to inform successful Pandemic Fund applications in Jordan, West Bank and Gaza and Tunisia. All three countries that implemented the tool secured Pandemic Fund (PF) grants based on the assessment findings.
Strengths and limitations
As a key strength of this study, a multidisciplinary team developed and validated the tool using a standard methodology, with input from experts in health system, resilience and tool development. The guiding framework and tool provide a deeper analytical understanding of health system resilience and offer initial guidance for countries and stakeholders in operationalising and assessing health system resilience against shocks. This constitutes a significant attempt towards addressing the challenges of translating or operationalising resilience capacities into practical tools that health system actors can employ in response to crises.36 Additionally, extensive regional consultative meetings with policymakers and stakeholders further enhanced the validity and relevance of the tool to the MENA region. While some indicators may not be applicable in all settings, we aimed to address this by adopting an inclusive approach in selecting the final set of indicators.
Despite our attempt to define health system resilience, we recognise the complexity of the term and the various existing interpretations which can make it challenging to fully capture its multifaceted nature. In particular, the concepts of adaptation and transformation remain underdeveloped in the empirical literature, limiting their operationalisation.36 While most of the existing quantification frameworks primarily focus on resilience to a single disruption, Zhong et al recently extended this approach by incorporating multiple disruptions in health services, attempting to disentangle the compounded effects of successive shocks.45 Our proposed tool is designed to assess resilience across different types of shocks (eg, pandemics, natural disasters) rather than to specifically track health system responses to successive waves of a single disruption. Further testing is needed to explore its applicability in that context. Additionally, due to the short time frame for the study, we could not review all articles published on resilience beyond the health sector. Consequently, the team prioritised articles based on relevance to the framework and study objectives. It is also important to note the geographical bias in the literature, with a predominant focus on North America and Europe.
While we aimed to enhance the tool’s comprehensiveness by encompassing different health system components and the wider system, we acknowledge the limitations in exploring the interconnectedness of these components and subcomponents within a complex system. This falls under the domain of complex systems science methodology, which is beyond the scope of this study.46
Another potential limitation relates to the lack of concordance on definitions, varying methodology and limited empirical grounding of some indicators. In particular, indicators derived from gaps and lessons during the COVID-19 pandemic would benefit from further validation. Despite these challenges, the iterative process employed in selecting indicators, along with extensive discussions with experts and consultative meetings with stakeholders, played a crucial role in validating indicator selection and definitions. Furthermore, developing scoring scales that reflect the maturity of a country’s response required consideration of regional and international standards while recognising that benchmarks may need to be adapted to specific contexts. Additionally, despite our attempt to stratify indicators by subcomponents and contribution to resilience outcomes, these distinctions were not always clear-cut. To reduce ambiguity, we cross-checked with existing literature and relied on continuous input from subject matter experts during the coding process. Data availability and quality can also pose significant constraints to tool implementation, as some indicators depend on data that may not routinely be collected or may be difficult to access in parts of the MENA region. Adopting a mixed-methods approach, including stakeholder consultations and tailoring the tool to fit available data, can help address these issues. To support future use, more comprehensive data on the tool’s feasibility, cost and comparative performance could help evaluate its practical utility and inform decisions about its role in assessing health systems’ responses to future shocks, including its applicability to successive disruptions.
In terms of next steps, we plan to implement the tool in additional MENA countries. This will provide an opportunity to further test its feasibility and refine its use, while generating insights into how it can support health system resilience in diverse contexts.
Conclusion
The proposed EPSRA tool addresses a gap in the scientific literature. We believe the tool will be useful for researchers, governments and funders seeking to strengthen health system resilience in their contexts. It enables identification of gaps and facilitates collaborative discussions to prioritise actions for strengthening health system capacity and capability to prevent, detect and respond to future emergencies that have significant health impacts. We encourage other countries and regions to use the tool and conduct further testing within their own contexts as a contribution to further refining the tool and expanding its utility in dynamic crisis environments.
Supplementary material
Acknowledgements
We would like to thank the stakeholders and experts for their valuable inputs and contributions. We would also like to acknowledge Ms Najla Daher, Ms Noor Ataya and Ms Nour Kalach from the American University of Beirut for their support with data analysis and synthesis. We would also like to acknowledge the World Bank team for their overall support.
Footnotes
Funding: This publication is based on research funded by the World Bank. Grant no - NA.
Provenance and peer review: Not commissioned; externally peer reviewed.
Handling editor: Valery Ridde
Patient consent for publication: Not applicable.
Ethics approval: Not applicable.
Data availability free text: All data relevant to the study are included in the article or uploaded as supplementary information. The full version of the tool is available upon request from the first or corresponding author.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Data availability statement
Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.
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Data Availability Statement
Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.