Resilient health systems appraisal model. whole-of-system approach to health system resilience in fragile contexts: a best-fit framework synthesis

Abstract

Introduction

Fragile contexts are characterized by multiple simultaneous shocks combined with limited resources and inadequate institutional capacity to manage and respond effectively. These contexts account for 25% of the world population and are home to 72% of those living in extreme poverty, making resilient health systems essential to respond to the health needs of more than 2 billion people. This study aimed to develop a framework for the appraisal of health system resilience and subsequently inform the design of resilience building activities in fragile contexts.

Method

The study applied a Best Fit Framework Synthesis (BFFS) approach to adapt WHO health system building blocks framework for appraising resilience in fragile contexts. A two-stage synthesis was undertaken: a scoping review identified how health system performance and resilience have been assessed and measured in fragile, low-income contexts, and a desk review examined normative guidance and operational tools from global health agencies. An iterative, mixed deductive–inductive process was used to refine the framework and generate resilience domains, subdomains, and standards.

Results

The framework, the Resilient Health Systems Appraisal Model (ReHSAM), was developed through the identification and analysis of 918 indicators from peer-reviewed and normative sources. It comprises 17 domains, 45 subdomains, and 69 standards. Of the 69 resilience standards, 15 are newly introduced, meaning they were not articulated in existing frameworks and tools, and 30 are essential but under-studied. ReHSAM standards focus on the operational capacities that underpin health system resilience and guide context-specific, dynamic actions across the different administrative levels. ReHSAM articulated 69 attainable actions within each building block, bridging the gap between conceptual and operational aspects of health system resilience. ReHSAM provides a whole-of-system appraisal tool applicable across fragile and stable settings.

Conclusions

This study introduces the Resilient Health Systems Appraisal Model (ReHSAM), a whole-of-system approach for appraising health-system resilience. ReHSAM enables comprehensive assessment, cross-context comparison, and integration of resilience-building actions into health system operations. By translating resilience into universal yet context-adaptable standards, it provides a practical basis for bolstering health system resilience in both fragile and stable settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-025-00735-4.

Background

Health system resilience can be defined as a system’s capacity to absorb, adapt, and transform when exposed to shocks to retain control over its structure and functions [1]. With the growing demand for health systems to withstand stressors and crises while sustaining service functionality, health system resilience has become a central theme in health system research [2, 3]. Over the last decade, several conceptual frameworks have been developed to define and operationalize health system resilience in different contexts [4–6]. Evidence shows that managing health system resilience in low- and middle-income countries (LMICs) presents distinct challenges compared with high-income countries [7, 8]. Within LMICs, one key classification is the country’s state of fragility. Fragility is defined by the Organization for Economic Cooperation and Development (OECD) as the combination of exposure to risk and insufficient coping capacities of the state, system and/or communities to manage, absorb or mitigate those risks [9]. In 2025, 61 contexts were classified as fragile by the OECD. These contexts are home to 25% of the world’s population and 72% of people living in extreme poverty worldwide [10]. Health systems in these contexts face unique challenges that demand context-specific approaches to sustain performance and build resilience [11, 12]. The WHO 2025 Status of Health report further highlights persistent disparities in health outcomes both across and within countries underscoring the need for context-sensitive strategies to support health system performance and resilience [13]. The performance and resilience of a health system are interlinked, as the former focuses on how well a health system functions [14, 15], and the latter focuses on the system’s ability to function despite chronic stressors and shocks [1, 16]. In a way, a system needs to perform to be resilient. However, a health system does not need to be resilient to be qualified as performing.

Drawing on systems thinking and complexity theories, the building blocks are viewed as interdependent subsystems within a broader adaptive system [18–20]. The central hypothesis is that a health system can only be resilient if each of its building blocks demonstrates resilience. In this study, resilience is conceptualized as a process rather than an outcome, focusing on the resilience of each building block [21]. As outlined by Blanchet et al., resilience depends on four interlinked management capacities: Knowledge (to collect, integrate and analyze information), Uncertainty (to anticipate and cope with shocks), Interdependence (to manage multiple- and cross-scale dynamics and feedback), and Legitimacy (to govern and coordinate and through socially accepted and contextually adapted institutions) [1]. This paper is guided by three questions: (i) What standards define resilience within each of the WHO health system building blocks? (ii) To what extent are these resilience standards reflected in existing tools used to assess resilience in fragile contexts? And (iii) How can the WHO framework be adapted to incorporate these resilience standards?

This study aims to enhance and adapt the WHO building blocks framework [17] for the appraisal and design of health system resilience in fragile contexts, providing a structured basis for developing and implementing resilience building activities.

Methods

In view of the research questions and the study’s objective, a qualitative approach was employed and grounded theory was selected as it provides a theoretical explanation of a specific social phenomenon building on existing and new knowledge [22]. In view of the research questions and the study’s objective, the study applied the Best Fit Framework Synthesis (BFFS) approach to adapt and enhance the WHO health system framework [17]. The BFFS approach combines deductive development of an “a priori” framework derived from established theory with inductive refinement informed by empirical findings from the literature. This method is particularly suited to generating models that explain how complex systems, such as health systems, function under shocks and chronic stressors [23, 24]. BFFS offers a pragmatic and systematic approach to synthesizing evidence, identifying themes across diverse data sources, and developing frameworks that integrates both existing and emerging elements of the phenomenon under study [23, 25]. This approach was selected because it provides a rigorous yet flexible approach that is directly applicable to researchers and policymakers seeking to bridge the gap between conceptual and operational dimensions of health system resilience (Fig. 1).

Fig. 1.

Adapted Best Fit Framework Synthesis (BFFS) process for the development of the Resilient Health Systems Appraisal Model. The figure, developed by authors, illustrates the sequential phases of the BFFS approach used in this study: (1) development of an a priori framework from Blanchet’s et.al. and WHO health system building blocks; (2) scoping review to identify empirical indicators of health-system performance and resilience in fragile, low-income contexts; (3) thematic mapping and development of a priori framework; (4) inductive refinement of domains through integration of recent normative guidance; and (5) generation of the final conceptual framework for resilience appraisal and planning

A scoping review was conducted to examine how the performance and resilience of the health system has been assessed and measured in fragile, low-income contexts [26]. A scoping review methodology was chosen to assess the extent of the available evidence and then to highlight the gaps in measuring the resilience of health systems in fragile low-income contexts [27]. The review included studies that proposed, collected, analyzed, and reported indicators to assess and measure health system performance or resilience at any level of the system (national, subnational, or facility levels). Only countries classified in 2022 by OECD as fragile and low-income were included [9]. Studies also had to take a whole-of-system approach, defined as looking across health system building blocks [17] or functions [28] to account for the interdependence of health system components; therefore, studies that focused on the resilience of a single building block [17] or function [28] were excluded. Peer-reviewed original research articles published in a scientific journal during a ten-year period between January 2014 and April 2024 in English were included. There was no limitation on study design. The science databases EMBASE, PubMed, and Web of Science were searched in July 2024. Database-specific search strings were developed using key words for health system performance or resilience, measurement and fragile contexts. After removing duplicates, 1 847 articles were identified, 267 were reviewed for full text and eighteen included. The studies were screened by title, abstract, and full text by the first author using Covidence Systematic Review Software (Covidence) [29]. Although quality assessment is not required for scoping reviews, one was conducted for the included studies to ensure transparency and strengthen confidence in the included evidence [30].

A structured desk review of five tools from health agencies was then conducted. We employed purposive sampling as the goal is not to collect exhaustive data but rather to extract information directly linked to the research questions [22]. We sampled the documents based on the work of UHC2030 Technical Working Group on Health System Assessment [31]. As the framework is structured around the WHO’s building blocks framework, two tools were deemed relevant for inclusion in the review: WHO handbook on monitoring the building blocks of health systems [32] and the USAID health system assessment tool [33]. Noting the relevance of health security to resilience, the State Party self-assessment annual reporting tool was included [34]. Two additional tools, developed by WHO, were added: Health system performance assessment framework which is a tool for measuring the performance of health system [15] and WHO Health System Resilience Indicators [35].

Data was extracted from 23 documents: 18 from the scoping review and five from the desk review. Data analysis and coding were completed manually. Among the eighteen articles included in the scoping review, eight used Kruk’s framework [36], four used Blanchet’s framework [1, 37–40], and two used other frameworks. To develop the coding framework, WHO’s building blocks framework and Blanchet’s frameworks were chosen (Table 1). The process of data extraction and coding led to the development and addition of three new themes (Table 2) and (Fig. 2).

Table 1.

The coding framework

Building block	The domains and the associated (Resilience Management Capacity)	Definitions
Leadership and governance	1. Vision and strategic direction (Legitimacy, Interdependence)	Clear long-term goals and policy direction.
	2. Oversight and participation. (Legitimacy, Interdependence)	The right to health, management at subnational level and users’ engagement in decision-making.
	3. Accountability (Legitimacy, Knowledge, Interdependence)	Systems and processes to ensure transparency, answerability, and corrective action
Health workforce	4. Health workforce planning (Knowledge, Uncertainty)	Planning of health workforce to meet health system needs
	5. Production (Legitimacy, Uncertainty, Interdependence)	Health workforce education and licensing
	6. Management (Legitimacy, Knowledge, Interdependence)	Distribution of health workers their payments and systems in place to support, and retain health workforce
Health Information system (HIS)	7. HIS Governance and management (Legitimacy, Knowledge, Interdependence)	Structures and processes for overseeing, coordinating, and regulating HIS functions.
	8. Data-driven decision making (Knowledge)	Use of data to guide policies and planning
Access to essential medicines	9. Governance (Legitimacy, Knowledge)	Regulating, procuring, and monitoring medical products vaccines and technologies
	10. Availability (Knowledge, Interdependence, Uncertainty)	Access to essential medicines, medical products, vaccines, and technologies.
Health systems finance	11. Revenue raising and resource pooling. (Legitimacy, Knowledge, Uncertainty)	How to generate, mobilize, and pool funds
	12. Purchasing (Legitimacy, Knowledge, Uncertainty, Interdependence)	How to allocate funds to services
Health service delivery	13. Governance and management (Legitimacy, Interdependence)	Structures and processes for organizing and managing delivery of health services
	14. Access and availability (Knowledge, Uncertainty, Interdependence)	access to essential health services

Table 2.

New concepts from the thematic analysis

Building block	Concepts for coding (Domains)	Definitions
Governance and leadership	Implementation and management (legitimacy, uncertainty, knowledge) (35 indicators) (15, 35, 41–44)	Ministry of Health (MoH) capacity to execute policies and strategies and manage resources (legitimacy)
Health products and supply chain management (previously Access to essential medicines)	Supply chain management (Legitimacy, Uncertainty) (12 indicators) (33, 35, 44–47)	Systems for procurement, storage, distribution, and tracking of health products.
Health system finance	Capacity of public institutions (Legitimacy, Knowledge, Uncertainty) (28 indicators) (32–35, 37, 42–46, 48)	National systems for budgeting, disbursement, and accountability of health funds

Fig. 2.

Conceptual model illustrating the iterative process of the Best Fit Framework Synthesis (BFFS). Two-column schematic linking WHO health-system building blocks and Blanchet resilience capacities on the left to emergent resilience domains on the right, with bidirectional arrows indicating iterative BFFS mapping; a lower box shows three additional domains added to the original coding framework

Framework components: domains, subdomains, and standards

The indicators were classified according to the health system building blocks as defined in the source document. Coding was conducted to identify emerging concepts and to examine relationships between them. The resulting concepts were organized as domains within each building block [22, 49]. Literature defines a domain by its main object of interest, kind of knowledge, and people and groups involved in it [50]. Although indicators were aggregated at the domain level, subdomains were retained to enhance clarity and ensure replicability, reflecting the specific focus of the indicators. Standards, defined as benchmarks for evaluating specific domains [51], were derived from evidence in peer-reviewed literature and normative guidance, ensuring alignment with both conceptual and operational dimensions of health system resilience. The interconnected domains and subdomains, organized across the six building blocks, reflect the structure of the health system as conceptualized in the WHO Health System Framework [17]. Analysis of the 918 indicators informed the development of the conceptual framework (Table 3) and (Additional file 1).

Table 3.

Resilient health systems appraisal (ReHSA) framework: final structure of six WHO Building blocks, seventeen domains, and forty-five subdomains of health-system resilience

Building block	Domains (n = 17)	Subdomains (45)
Leadership and governance and	1) Vision and strategic direction	Explicit vision. Policies and guidance documents.
	2) Implementation and management	Funding health sector priorities. MoH management and leadership capacities. Intersectoral collaboration for health. Fragmentation.
	3) Oversight and participation.	The Right to Health. Decentralization. Participation of service users in decision-making
	4) Accountability	Accountability within government. Accountability to citizens. Mutual Accountability
Health workforce	5) Health workforce planning	Health workforce strategy and data Functional surge capacity Dependance on donor funding for health sector wages
	6) Health workforce production	Quantity of health workforce production Quality of health workforce production
	7) Health workforce management	Health workforce wages Distribution of health workforce In-service training Managing health workforce absenteeism
Health information system	8) Health information system governance and management	National Health Information System Surveillance System Core Health Indicators
	9) Data-driven decision making	Data-driven decision making for financial resource allocation Data- driven decision making for health workforce allocation Data– driven decision making for health products allocation
Health products and supply chain management	10) Governance	Governance of health products Public Procurement Systems
	11) Supply chain management.	Storage of health products Timeliness of distribution Quantification capacity
	12) Availability	Availability of Essential Medicines
Health financing	13) Planning and revenue raising.	Health financing policy and decision making Revenue raising Pooling revenues
	14) Purchasing access and financial protection	Purchasing, providers’ payments and conditions of access Financial protection
	15) Capacity of public institutions	Public Financial Management (PFM) Funding to respond to shocks and emergencies Systematic tracking of Health Spending
Health service delivery	16) Governance and management	Planning and strategy Management of service delivery
	17) Access and availability	Health Benefit Package Service availability and readiness

Results

The Resilient Health Systems Appraisal Model (ReHSAM) conceptualizes a resilient health system as one which each of its interlinked building blocks demonstrates resilience. ReHSAM comprises 17 domains, 45 subdomains and 69 standards across the six building blocks. Themes derived from 918 indicators were aggregated into domains (n = 17) and subdomains (n = 45). The 69 resilience standards were developed through the synthesis of evidence from peer reviewed literature and global normative frameworks. Each standard represents a recommended and attainable action that contributes to the resilience of its respective domain and building block. Collectively, the standards focus on the operational components of the health system, encompassing actions that are context specific and dynamic across national, subnational, and local levels [52, 53].ReHSAM retains the nomenclature of the WHO building blocks framework [17], except for Access to Essential Medicines, which, based on the thematic synthesis has been reframed as Health Products and Supply Chain Management to reflect the broader processes required to ensure the availability and delivery of health products—including medicines, vaccines, diagnostics, medical devices, and protective equipment-to the point of care [56].

During the thematic analysis, the largest share of indicators was related to service delivery (37%), followed by leadership and governance (19%), health products and supply chain management (12%), health information system (11%), health workforce (11%), and health financing (10%). The following sections present the detailed domains, subdomains, and corresponding standards that constitute the ReHSAM framework.

Leadership and Governance

ReHSAM outlines four domains, twelve subdomains, and 21 resilience standards (RS) for resilient leadership and governance (Table 4). Overall, 175 indicators were categorized under this building block.

Table 4.

Resilient health systems appraisal model (ReHSAM): recommended standards of resilience (n = 69), number of supporting indicators, and alignment with existing global frameworks

Domain	Subdomain	Resilience Standard (RSn)	Indicators (n)2	Evidence sources3	Alignment with Existing frameworks 4	Comment
1.Leadership and Governance
1.1. Vision and strategic direction	1.1.1. Explicit Vision	1. National strategy is developed based on inclusive process, sound situation analysis and includes explicit goals, funding priorities, budget, and monitoring framework (RS1)	17	[15, 32, 35, 37]	WHO-JANS (attribute.1, 2)
	1.1.2. Policies and Guidance Documents	2. All strategic priorities are supported by comprehensive policies, guidelines, and plans. (RS2)	48	[32, 33, 35, 41, 42, 44, 45, 48]	WHO-JANS (attribute 3)
1.2. Implementation and Management	1.2.1. Funding Health Sector Priorities	3. All priorities of the national strategy are sufficiently funded. (RS3)	1	[43]		NEW
		4. All priorities of the subnational strategies are sufficiently funded. (RS4)	1	[43]		NEW
	1.2.2. MoH management and leadership capacities	5. The organizational structures of the federal and state ministries of Health are strategically designed to achieve the objectives set in the national health policy. (RS5)	1	[43]	WHO-JANS (attribute 12)
		6. All managerial positions (director-Level roles) at the national and subnational levels are filled (RS6)	0			NEW
	1.2.3. Intersectoral collaboration for Health	7. Relevant multisectoral policies and legislation are fully implemented at both national and subnational levels and funding from other sectors is allocated to health (RS7)	29	[15, 34, 35, 42, 44, 48]	WHO-JANS (attribute 6)
	1.2.4. Fragmentation	8. All subsector and subnational plans are fully aligned with the health sector plan (RS8)	3	[41, 42]	WHO-JANS (attribute 7,10)	Under-studiedᵃ
		9. The flow of Development Assistance for Health (DAH) to subnational levels or subsectors aligned to national needs and priorities (RS9)	0		WHO-JANS (attribute 13)	Under-studiedᵃ
1.3. oversight and participation	1.3.1. The Right to Health	10. The government has adopted legislation that safeguards the Right to Health, including provisions for access to healthcare services, nondiscrimination, and the provision of essential medicines to all. (RS10)	4	[15, 34, 35]		NEW
		11. The right to health is realized and monitored through various national mechanisms (RS11)	18	[15, 33, 34, 44, 45, 62]	WHO-JANS (attribute 6)
	1.3.2. Decentralization	12. Subnational authorities have power over budget allocation (RS12)	5	[35, 42, 43, 45, 48]		NEW
		13. Subnational authorities have power over health products management (RS13)	1	[35]		NEW
		14. Subnational authorities have power over recruitment and dismissal of health workforce personnel and management positions within ministries of health. (RS14)	1	[43]		NEW
	1.3.3. Participation of service users in decision-Making	15. Community groups (e.g., patient associations) participate in health-related decision-making at the national and subnational levels (RS15)	11	[33–35, 42, 45, 46, 62]		Under-studiedᵃ
		16. Civil society organizations (e.g., trade unions, professional associations) participate in health-related decision-making at the national and subnational levels (RS16)	3	[33, 37]		Under-studiedᵃ
1.4. Accountability	1.4.1. Horizontal Accountability (Accountability within Government)	17. Government-led mechanisms for financial accountability are in place, and reports are regularly published by government agencies. (RS17)	3	[33, 47, 62]	WHO-JANS (attribute 13)	Under-studiedᵃ
		18. Government-led performance accountability mechanisms are fully operational, with regularly published reports. (RS18)	4	[33, 35, 65]	WHO-JANS (attribute 14,16)	Under-studiedᵃ
	1.4.2. Vertical Accountability (Accountability to Citizens)	19. The mechanisms for vertical financial and performance accountability at national and subnational Levels are fully operational, with regular reports published. (RS19)	18	[15, 32, 33, 35, 41–45, 48, 62]		NEW
	1.4.3. Mutual Accountability	20. National systems for transparent financial reporting of DAH from all recipients at the national and subnational levels are in place and functional. (RS20)	3	[33, 48)]		Under-studiedᵃ
		21. Reports from 100% of DAH recipients are made available on a public platform (RS21)	4	[37, 41, 44, 65]		NEW
2.Health workforce 5
2.1. Health workforce planning	2.1.1. Health workforce strategy and data	22. Evidence-based national health workforce plan exists, meets criteria, regularly updated and a mechanism for regular workforce planning and review is in place. (RS22)	5	[15, 32, 33, 37]		Under-studiedᵃ
		23. A fully functional and up-to-date health workforce information system is in place (RS23)	3	[32, 33]		Under-studiedᵃ
	2.1.2. Functional surge capacity	24. There is a functional, fully funded roster of rapid response teams for emergency response. (RS24)	17	[15, 34, 35, 37, 41, 42, 44–46]
	2.1.4. Dependance on donor funding for wages	25. Reliance on domestic financing for health workforce’s pay. (RS25)	0			NEW
2.2. Health workforce production	2.2.1. Quantity of health workforce production	26. Health workforce production meets need and address skill mix imbalances. (RS26)	11	[32, 33]		Under-studiedᵃ
	2.2.2. Quality of health workforce production	27. A national accreditation body evaluates preservice training institutions and ensures adherence to quality standards. (RS27)	3	[15]		Under-studiedᵃ
		28. Incentives and selection criteria for preservice training are responsive to the health system’s needs. (RS28)	0			NEW
2.3. Heath workforce management	2.3.1. Heath sector wages compared to other government sectors	29. PayScale and non-wage benefits are competitive and attract and retain qualified health workers. (RS29)	11	[33, 35, 43, 47, 65]		Under-studiedᵃ
	2.3.2. Distribution of health workforce	30. Equitable distribution of the health workforce based on needs (urban/rural, population density, health status, health risks). (RS30)	27	[15, 32, 33, 44, 47, 62, 65]	WHO-JANS (attribute 11,12)
	2.3.3. In-service training	31. There are accredited in-service and continuing education programs that address learner needs and enhance service provision. (RS31)	20	[15, 32, 33, 35, 37, 41–43, 45, 65]
	2.3.4. Managing health workforce Absenteeism	32. A system in place to track and manage health workforce absences in the public sector (including addressing the underlying causes) (RS32)	3	[43, 65]		Under-studiedᵃ
3.Health Information System
3.1. Health information system governance and management	3.1.1. National Health Information system	33. National Health information system meets criteria, functional and responsive to health sector needs (RS33)	60	[15, 32, 33, 35, 37, 43, 47, 62]	WHO-JANS (attribute 15)
	3.1.2. Surveillance system	34. Surveillance systems are integrated, digital and provide real-time, high-quality data to guide routine monitoring, emergency response, and health policy decisions (RS34)	15	[32, 34, 35, 37, 42, 44, 47, 62]	WHO-JANS (attribute 15)
	3.1.3. Core Health Indicators	35. The country has core health indicators that are regularly updated and used to assess system resilience and performance at national and subnational levels. (RS35)	4	[33, 41, 47]	WHO-JANS (attribute 15)	Under-studiedᵃ
3.2. Data-Driven Decision Making	3.2.1 Data-Driven Decision Making for Financial Resource Allocation	36. Data informs allocation of financial resources, multiyear planning and forecasting at the national and subnational levels. (RS36)	20	[33, 35, 42, 44, 45, 48]	WHO-JANS (attribute 16)
	3.2.2. Data-Driven Decision making for Health Workforce Allocation	37. Data informs allocation of health workforce, multiyear planning and forecasting at the national and subnational levels. (RS37)	2	[32, 33]		NEW
	3.2.3. Data-Driven Decision Making for health products allocation	38. Data informs allocation of health products, Ulti-year planning and forecasting at the national and subnational levels. (RS38)	2	[32, 45]		NEW
4.Health Products and Supply Chain Management
4.1. Governance	4.1.1. Governance of health Products	39. Comprehensive National Policy that sets clear standards for medicines, vaccines, and health products, and includes multiyear planning (RS39)	30	[15, 32, 33, 35, 43, 45, 47]
		40. The National Regulatory System meets criteria and functions at national and subnational levels. (RS40)	20		WHO Global Benchmarking Tool [77]
	4.1.2. Public Procurement System	41. Public Procurement systems meet national and international standards with transparency and accountability. (RS41)	11	[33, 47]	MAPS [91]	Under-studiedᵃ
4.2. Supply Chain management	4.2.1. Storage of Health Products at National and Subnational levels	42. Medical stores at national and subnational levels comply with WHO good storage practices. (RS42)	5	[33]		Under-studiedᵃ
	4.2.2. Timeliness of Distribution to Respond to Health Emergencies	43. Timely distribution to meet needs and system in place to ensure products are available in the event of a health emergency. (RS43)	7	[33, 35, 44–47]		Under-studiedᵃ
	4.2.3. Quantification capacity	44. A quantification system is in place with the necessary capacities to forecast and plan the supply of health products in response to present and emerging needs. (RS44)	0			NEW
4.3. Availability	4.3.1. Availability of Essential Medicines	45. National Essential Medicines List (EML) aligns with the health priorities of the country and is regularly updated. (RS45)	14	[15, 32, 35, 37, 43, 65]
		46. Drugs in the EML available at national and subnational levels. (RS46)	2			Under-studiedᵃ
		47. No stock out in drugs listed in the EML at national and subnational levels. (RS47)	21
5.Health systems financing
5.1. Governance, Revenue raising and Pooling	5.1.1. Health financing policy	48. Health financing policy is guided by UHC goals and informed by high-quality health financing data (RS48)	8	[33, 35, 37, 43, 44, 65]	WHO-HFPM (Q:1.1, 1.3)	Under-studiedᵃ
	5.1.2. Revenue raising	49. Reliable funding sources throughout the duration of the planning cycle (RS49)	24		WHO-HFPM (Q:2.2,2.3, 2.4)
		50. Plans and actions are in place to reduce dependency on External Development Assistance for Health (DAH). (RS50)	0			NEW
	5.1.3. Pooling revenues	51. Effective structure and mechanisms for pooling revenues and efficient redistribution of funds. (RS51)	6	[15, 43]	WHO-HFPM (Qs 3.2,3.3,3.4)	Under-studiedᵃ
5.2. Purchasing, access and financial protection	5.2.1. Purchasing, providers’ payments and conditions of access	52. The allocation of resources to providers is informed by population health needs, adjusted for provider performance, and aligned to the health service objectives. (RS52)	3	[15, 33, 37, 45, 65]	WHO-HFPM (Q4.1, 4.3)	Under-studiedᵃ
		53. Health benefit entitlements are clearly defined, universally applied, and designed to ensure access for populations in need. (RS53)	7		WHO-HFPM (Q5.1,5.5)	Under-studiedᵃ
	5.2.2. Financial Protection	54. Population covered by health insurance to ensure access to essential health services without financial hardship. (RS54)	4	[15, 62, 92]		Under-studiedᵃ
		55. Out-of-pocket health expenditures are minimized, effective fee exemptions are in place, and informal fees are eliminated (RS55)	15	[15, 32, 33, 35, 44, 47, 62, 65]
5.3. Capacity of Public Institutions	5.3.1. Public Financial Management (PFM) System	56. Health budget formulation allows for flexible spending and providers’ payments are structured to reward output and performance. (RS56)	8	[33, 43, 45]	WHO-HFPM (Q6.1,6.2)	Under-studiedᵃ
		57. Budget process is consultative and transparent, based on dialogue between Ministries of Health and Finance and includes a clear multiyear budgeting framework (RS57)	0		WHO-HFPM (Q6.3)	Under-studiedᵃ
	5.3.2. Funding to respond to shocks and emergencies	58. Domestic financing for responding to emergencies is in place and allows for timely response. (RS58)	15	[34, 35, 37, 42, 44–46, 48]	WHO-HFPM (Q7.3,7.4)
	5.3.3. Systematic tracking of Health Spending	59. Timely, accurate, and comprehensive data on resource flows and health expenditures is available. (RS59)	5	[32, 33]	WHO-HFPM (Q6.5)	Under-studiedᵃ
1. Health service delivery
6.1. Governance and Management of health services	6.1.1. Planning and strategy	60. Service delivery planning is data-informed, employs balanced service delivery, and ensures continuity of services during emergencies (RS60)	34	[15, 33, 41–45, 47, 62, 65]	WHO-JANS (attribute 11)
	6.1.2. Management of operations	61. Public and private health providers operate within a fully integrated system. (RS61)	0		WHO-HFPM (Q7.2)	Under-studiedᵃ
		62. Performance monitoring at primary, secondary and tertiary levels. (RS62)	21	[15, 35, 37, 42, 44, 45]
		63. Systems in place to ensure quality of service at facilities level. (RS63)	68	[15, 33–35, 41–45, 47, 48, 62, 65, 84]
		64. Mechanism in Place for regular supervision of health facilities. (RS64)	1	[65]		Under-studiedᵃ
		65. Equitable distribution of health facilities to support Universal Health Coverage (UHC). (RS65)	19	[32, 33, 35, 37, 41, 42, 44–48, 65]
6.2. Access and Availability	6.2.1. Health Benefit Package	66. Explicit health benefit package, comprehensive, regularly updated, and aligned with needs. (RS66)	0		WHO-HFPM	Under-studiedᵃ
		67. All elements or components of the health benefit package are being executed or operationalized within a health system. (RS67)	157	[15, 32–35, 37, 41, 42, 45–48, 62, 65, 84, 85]
	6.2.2. Service availability and readiness.	68. Health services are brought closer to people (RS68)	1	[65]		Under-studiedᵃ
		69. Maintaining the delivery of essential health services in an equitable and effective manner even in times of crisis. (RS69)	35	[15, 32, 33, 45, 47, 65, 85]

¹RS(n): Resilience Standard and its reference number in the ReHSAM.

²Indicators (n): number of indicators supporting each domain (from 918).

³Evidence Source(s) refers to studies or documents identified through the scoping and desk reviews (full reference list in Supplementary File 1)

⁴Alignment with existing frameworks (e.g., WHO-JANS) indicates conceptual correspondence beyond the reviewed literature.

⁵Health managers responsible for overseeing the operations at facility level are included under Health Work Force. Health managers, responsible for overseeing the operations at district and national level, are part of the leadership and governance building block. Standards for Community Engagement are categorized under governance and those for Community Health Workers under Health Workforce building block.

WHO-JANS: Joint Assessment of National Health Strategies and Plans (JANS): Joint Assessment Tool,2013. World Health Organization [81].Att: Attribute

Understudiedᵃ :A standard is classified Under-studied if it’s supported by ≤13 indicators across all reviewed sources.

MAPS: The Methodology for Assessing Procurement System

WHO-HFPM (n) : WHO Health Financing Progress Matrix (question number) [82]

Vision and strategic direction include strategic directions, structures and processes to achieve the health system’s goals. ReHSAM introduces two resilience standards (RS): a national strategy document that meets predefined criteria (RS1) and a comprehensive set of policies, guidelines, and plans designed to implement the vision (RS2). 65 indicators were classified under this domain [15, 32, 33, 35, 37, 41, 42, 44].

The implementation and management domain focuses on the resources and systems needed to implement and manage health sector plans. This includes adequate funding at national and subnational levels (RS3, RS4), Ministry of Health’s (MoH) management capacity (RS5, RS6), intersectoral collaboration (RS7), and addressing fragmentation within the health system (RS8, RS9). A total of 35 indicators were classified under this domain [15, 34, 35, 41–44, 48], with none assessing MoH management capacity (RS6) or fragmentation in planning and service delivery (RS9). RS6 was introduced to address gaps identified in the literature, recognizing limited MoH capacity contributes to fragmented service delivery and weak resilience during emergencies [15, 20]. MoH size, structure, and responsibilities vary based on institutional mandate and political context [57]. RS9 highlights the importance of MoH stewardship in promoting a country-led approach to Development Assistance for Health (DAH) [58].

The Oversight and Participation domain consists of three subdomains: the right to health, decentralization, and service users’ participation in decision making. The right-to-health includes legislation and national mechanisms for monitoring health rights (RS10, RS11). Decentralization refers to the transfer of authority for health service delivery from the central MoH to subnational entities, aiming to reduce inefficiencies and meet local needs [59, 60]. ReHSAM assesses decentralization through subnational autonomy over financial resources, health products, and health workforce, as reflected in RS12, RS13, and RS14 [61]. Only seven indicators were identified under this area—five addressing financial autonomy, one workforce autonomy, and one autonomy over health products. Service users’ participation in decision making is reflected in RS15 and RS16. Overall, 43 indicators were classified under oversight and participation [15, 33–35, 37, 42–46, 48, 62].

Accountability means that both individuals and institutions are answerable for their actions, decisions, and performance [63]. Accountability is core to resilience as it ensures transparency and drives continuous improvement. This domain includes three subdomains and five resilience standards (RS). Horizontal accountability, RS17 and RS18, involves internal checks and balances within the government. Vertical accountability, RS19, relates to government-citizen relationships. Mutual accountability, RS20 and RS21, is defined as reciprocal obligations between health donors, MoH, and other national actors for transparent results and financial reporting [64]. 32 indicators were classified under this domain, but there are only seven assessed mutual accountabilities [15, 32, 33, 35, 37, 41, 42, 44, 45, 47, 48, 62, 65].

Health workforce

Health workforce (HWF) refers to all individuals engaged in actions whose primary intent is to enhance health [17]. ReHSAM standards for a resilient HWF involve adapting and transforming HWF policies and systems to address the current and future needs. ReHSAM introduces three domains, 9 subdomains, and 11 Resilience Standards (RS). 100 indicators were categorized under this building block (Table 4).

Health workforce planning involves an evidence-based strategy (RS22 and RS23), surge capacity (RS24), and reliable domestic financing for HWF pay (RS25). Effective HWF governance is critical for improving healthcare delivery [66]. Data on HWF stocks, flows, demand, education, financing, expenditures, working conditions, and distribution are essential for planning and sound policy making [67, 68]. The surge capacity was the most studied subdomain; however, none of the indicators assessed the sources of funding for HWF remuneration. HWF remuneration is a significant part of health expenditures in low- and middle-income countries with high dependence on external assistance [69, 70]. Relying on domestic resources for HWF remuneration is a key strategy for attaining a resilient HWF, thus justifying RS25. 25 indicators were classified under HWF planning [15, 32–35, 37, 41, 42, 44–46].

Health workforce production focuses on systems and processes to generate sufficient, competent, and sustainable health workforce [71]. Resilient HWF production entails a stable supply that is responsive to population health and learners’ needs. In fragile contexts both the quantitative expansion and qualitative improvement of HWF production present significant challenges [72]. This domain includes three resilience standards: RS26, on the quantity and mix of production; RS27 on the quality of preservice training; and RS28 on the learners’ selection criteria and incentives [73]. Responsive HWF production, for example, may facilitate the enrollment of learners from rural areas or provide support to reduce dropout rates [73]. However, no indicators identified in the literature assessed RS28. Overall, the HWF production domain is the least studied, with only 14 indicators categorized under it [15, 32, 33].

Health workforce management encompasses various aspects of managing HWF, including remuneration, nonwage benefits, distribution of HWF, in-service training, and management of absenteeism [15, 32, 33, 35, 37, 41–45, 47, 62, 65]. RS29 calls for competitive pay, adequate nonwage benefits and decent and safe working conditions [74]. Only one indicator assessed measures to protect HWF during emergencies [45]. The equitable distribution of HWF, RS30, requires data to inform it and system to enforce it [71]. In-service training, RS31, is a key strategy for enhancing health workforce performance, retention, and adaptability [70, 71]. Managing absenteeism, RS32, is essential for efficiency and service continuity [71]. Only three indicators were related to the absence management system.

Health Information Systems

Health Information System (HIS) is a cross-cutting building block that manages data drawing from both population-based and facility-based data sources [33]. A resilient HIS has the capacity to collect and analyze diverse information from multiple sources, anticipate shocks, and provide feedback to inform actions [6, 75]. The ReHSAM framework presents two domains, six subdomains and six resilience standards (RS). A total of 103 indicators were classified under this building block (Table 4).

HIS governance and management include three subdomains and three corresponding standards (RS). Governance includes the structures and systems to steer and coordinate, and management involves the processes to operate and use the resources. RS33 is a national health information system that meets criteria [75]. RS34 concerns the establishment of a functional and effective surveillance system, defined as a system for collecting, analyzing, and disseminating health data to guide public health actions [75, 76]. Fifteen indicators were categorized under RS34, all focused on infectious disease surveillance, highlighting a notable gap in population health surveillance [32, 34, 35, 37, 42, 44, 47, 62]. RS35 pertains to core health indicators that are regularly updated and used to assess health system resilience and performance. Only four indicators were categorized under RS35 denoting limited attention to routine monitoring of health system performance [33, 41, 47]. 77% of the indicators under HIS are categorized under this domain [15, 32–35, 37, 41–44, 47, 62].

Data-driven decision-making involves the use of quality data to guide policies, strategies, interventions and resource allocation. This includes real-time data for decision-making (RS34) and monitoring core indicators (RS35). It also includes the system’s ability to forecast future needs. RS36, RS37, and RS38 pertain to data-driven decision-making. Among the 24 indicators classified under this domain [32, 33, 35, 42, 44, 45, 48], only three examined the health system’s capacity to forecast future needs [42, 44].

Health products and supply chain management system

The ReHSAM introduces three domains, six subdomains and nine resilience standards (RS) under this building block (Table 4). A total of 110 indicators were classified under area, with 95% (n = 93) extracted from the desk review [15, 32–35], indicating that this building block remains under studied in the peer reviewed literature.

Governance of health products refers to the policies, laws, regulations, and institutional structures that oversee, finance, and regulate the pharmaceutical sector to coordinate actors and ensure the safety and quality of health products [15]. This domain includes two subdomains: governance and public procurement systems. RS39 is a comprehensive national drug or pharmaceutical policy that meets criteria and incorporates multiyear planning as well as legislation that regulates manufacturing, trade, and use of health products. RS40 refers to the capacities of the national regulatory system [77], while RS41 pertains to a public procurement system that meets national and international standards. A total of 61 indicators were categorized under this domain [15, 32, 33, 35, 43, 45, 47].

Supply chain management involves three subdomains: storage, timeliness of distribution, and quantification of health products. Only 12 indicators assessed this domain [33, 35, 44–47]. Medical stores, RS42, play a crucial role in ensuring availability and quality of health products [78]. Five indicators were categorized under RS42 [33]. Only seven indicators assessed RS43, the timely distribution of health products [33, 35, 44–47]. None of the indicators assessed RS44 which is the quantification capacity [33]. Supply chain system resilience remains under-researched, despite recent crises exposing significant weaknesses even in stable, high-income countries [5, 79, 80].

The availability of health products is defined as the extent to which supplied items meet demand. it is shaped by supply, access, and affordability [15, 56]. ReHSAM uses availability of essential medicines as a proxy for health products availability. RS45pertains to National Essential Medicines List (EML), which aligns with health priorities and guides public sector procurement, donation programs, and reimbursement decisions. RS46 concerns the availability of essential medicines at the national and subnational levels while RS47 addresses the absence of stock outs across these levels. Stock out often reflect systemic gaps across multiple areas-from inadequate data on health needs to delays in products delivery to points of care. A total of 37 indicators were categorized under this domain [15, 32, 33, 35, 37, 43, 65].

Health Systems Financing

Health financing is defined as the mechanisms and processes through which funds are generated, allocated, and utilized to ensure delivery of health services [15]. It is a cross-cutting function that involves raising revenue, resource pooling, and the purchase of goods and services to ensure access to effective public and personal health care [14, 23]. This building block includes three domains, eight subdomains and twelve resilience standards (RS) (Table 4). 95 indicators were categorized under health finance with a balanced distribution between the three domains.

Planning and revenue raising: Planning is the process of designing, organizing, and allocating financial resources within the health system. It involves setting priorities, forecasting needs, mobilizing funds, and allocating funds to achieve health system goals [15, 81]. ReHSAM focus is to reduce fragmentation and promote equitable, efficient use of resources. Revenue raising is the process of collecting funds to finance health services [15]. RS48 relates to evidence-based health financing policy aligned with universal health coverage goals while RS49 focuses on enhancing the reliability of funding sources. RS50, newly introduced by REHSAM, requires the development of plans to reduce reliance on external Development Assistance for Health (DAH) and gradual transition to domestic financing [58]. RS51 concerns the effective pooling of revenues to enhance equity, strengthen financial risk protection, and reduce inefficiencies [15, 82]. 38 indicators were categorized under this domain, with none examining plans for a gradual transition from donor funding [15, 32, 33, 35, 37, 43, 44, 47, 62, 65].

Purchasing, access, and financial protection: Purchasing refers to the strategies used to allocate financial resources to healthcare providers for delivering services, and serves as a tool to influence provider behavior, service quality, efficiency, and equity [15, 82]. Access is defined as the ability to obtain timely and appropriate healthcare services. Access is contingent upon affordability, availability, acceptability, and equity in the distribution of health services [15]. Financial protection ensures that individuals can access healthcare services without experiencing financial hardship [15]. RS52 is strategic purchasing which involves the use of financial incentives to achieve health system objectives [82]. RS53 is explicitly defined health benefits packages which are universal in nature. ReHSAM introduces two standards under financial protection, RS54 and RS55. 29 indicators were classified under this domain [15, 32, 33, 35, 37, 44, 45, 47, 62, 65].

The capacity of public institutions to effectively govern, finance, and deliver health services is crucial for equity, efficiency, and financial protection [83]. ReHSAM presents three subdomains and four related resilience standards (RS). RS56 and RS57 focus on health budget formulation and execution processes [82]. RS58 is the ability to swiftly mobilize and distribute funds during public health emergencies. RS59 is a functional system for tracking health spending. 28 indicators were categorized under this domain [32–35, 37, 42–46, 48].

Health service delivery

The focus of this building block is the organization and delivery of health care services. This requires managing different inputs to address population health needs [15, 17]. The delivery of health services depends on multiple building blocks as well as actors and institutions within the health system. ReHSAM presents two domains, four subdomains and ten resilience standards (RS). A total of 335 indicators were classified under this building block (Table 4).

Governance of health services refers to the mechanisms, policies, and processes that guide the planning, organization, and operation of health services to ensure that they are effective, equitable, and responsive to population needs [15]. The management of health services encompasses the day-to-day implementation and coordination of health services [15]. ReHSAM presents six resilience standards (RS): evidence-based planning of health services (RS60), integrated service delivery (RS61), health management information systems (RS62), quality of care (RS63), regular supervision of health facilities (RS64) and equitable distribution of health facilities (RS65). 142 indicators were categorized under this domain. Only one indicator assessed mechanisms for regular supervision (RS64) and none evaluated integration between public and private providers [15, 32–35, 41–48, 62, 65, 84].

Availability and access are essential for effective and equitable health care delivery. Availability ensures that sufficient health facilities and resources exist to meet population needs [15]. Access refers to individuals’ ability to obtain needed services without financial, geographic, or social barriers [56]. Availability of health services is influenced by various interconnected elements, such as the presence of facilities, infrastructure, and distribution of inputs. Four resilience standards (RS) are included under this subdomain. RS66 is a comprehensive health benefit package that is regularly updated based on population health needs [15]. RS67 is the implementation of all components of the health benefit package. Access to health services is also influenced by distance to facility and sociocultural factors [15, 56]. Bringing services closer to people (RS68) and continuous delivery of health services during crises (RS69) are the two last standards which are also an output of multiple intersecting standards. 193 indicators were categorized under this domain [15, 32–35, 37, 41, 42, 44–48, 62, 65, 84, 85].

Discussion

This study addressed three central questions. First, it identified the standards that define resilience within each of the health system building blocks producing 69 resilience standards across 17 domains and 45 subdomains. ReHSAM articulates attainable actions to bolster resilience capacities. Second, it examined the representation of these standards in existing literature and tools on health system resilience in fragile contexts. Of the 69 standards, 15 are newly introduced and 30 are essential but understudied, revealing key gaps in current frameworks. Third, it demonstrated how the WHO building blocks framework can be adapted through the Resilient Health Systems Appraisal Model (ReHSAM)- a structured, whole-of-system approach that operationalizes resilience through measurable and context-adaptable standards to appraise, compare, and track resilience over time [12, 86].

ReHSAM innovation lies in three areas, it defines both the “what” and the “how” of resilience, integrates best practices from peer-reviewed literature and normative guidance into a single, cohesive framework, and identifies critical evidence gaps, drawing attention to understudied and novel areas of health system resilience that help bridge the gap between the conceptual and operational domains (Table 4).

Although ReHSAM is organized by the six building blocks, it is not a linear representation of the health system [17]. Rather, it provides a framework for understanding resilience as a dynamic, interdependent process and for designing resilience-building interventions without being constrained by the system’s complexity (Table 4) [6, 12].

Health system, as a complex adaptive system, requires continuous learning to build and sustain resilience [6, 24]. The literature presents a wide array of conceptual frameworks and tools for health system performance and resilience in fragile contexts [15, 32–35, 37, 41, 42, 44–48, 62, 65, 84, 85]. This diversity, while valuable, limits comparability, cross-country learning [87] and the ability to scale up what works [36, 42, 86, 88]. Importantly, even the most recent guidance on health system resilience indicators does not delineate specific domains or standards across the building blocks.

The analysis in this study demonstrates that resilience standards are universal across contexts, though their attainability is shaped by available resources, institutional capacity, and contextual constraints. Although ReHSAM was developed from the perspective of fragility, its standards are applicable for both fragile and stable settings, recognizing that pathways and thresholds for achieving resilience differ. By articulating globally relevant yet contextually adaptable standards, ReHSAM bridges equity and conceptual gaps between global guidance and country realities, offering a structured yet flexible, whole-of-system approach to appraising health-system resilience. ReHSAM harmonizes resilience assessment across contexts, providing a common foundation for appraisal and a practical framework for context-sensitive implementation in both fragile and stable settings.

Drawing on findings of this study, we propose three critical shifts to advance the operationalization of health system resilience in fragile contexts:

First, support the agency and capacity of national actors: agency refers to the actor’s ability to make decisions and act [89]. For example, MoH’s agency is reflected in its leadership and policy setting role (RS1, RS2, RS9, RS39, RS40, RS48, and RS60), local governments demonstrate agency through autonomy over resources management (RS12, RS13, RS14), and community agencies are expressed through active engagement in health decision making and response. Capacity refers to the resources needed by actors to exercise their agency as reflected in multiple standards: MoH capacity (RS5, RS6), health sector funding (RS3, RS4, RS7, RS25, RS26, RS49, RS58), and reduced dependence on DAH (RS9, RS50). In fragile contexts, the MoH’s agency and capacity are usually weakened by various factors which prompts donors, humanitarian organizations, and local institutions to take on responsibilities usually done by national authorities and resources [5, 10, 24]. ReHSAM standards listed here support reinstating authority to health ministries by enhancing their capacity to govern, coordinate, and facilitate dynamic interactions within the health system [1].

Second, accountability is an enabler of resilience especially in fragile contexts where governance structures are often weak and trust in institutions is limited [5, 90]. National governments are responsible for health services for all (RS10, RS11). Effective governance [5, 24], as reflected in multiple resilience standards, relies on accountability (RS17-RS21), inclusive decision-making (RS16), and strategic resource allocation (RS22, RS23, RS33-RS38, RS46-RS47, RS51-RS56, RS59, RS62, RS65, RS66, RS68, RS69). Furthermore, community engagement (RS15, RS19) enhances social accountability, builds trust, and aligns health services with local needs [5, 24].

Third, there is a critical need to transform the operating model from a centralized, top-down approach to decentralized and local governance structures (RS8, RS9, RS12-RS14). This is to enable national and local actors to make timely and context-sensitive decisions [5, 11, 24]. The key elements of this transformation are the adoption of flexible approaches like task shifting (RS69), adaptive supply chains (RS41-43), on-the-job training (RS31, RS63), and a shift from input- to output-based funding (RS56, RS57,RS61) to align resources and incentives with health system goals [83].

Study limitations

The main limitation of this study relates to the scoping review cut-off date of April 2024. This is mainly due to the iterative nature of the Best Fit Framework Synthesis (BFFS) process. Although the search was rerun in April 2025 and additional publications were identified, a full re-analysis was not feasible within the study’s scope and timeline. This limitation is methodologically acceptable, as the BFFS seeks conceptual saturation rather than exhaustive coverage [23, 54, 55]. Although additional indicators from articles published after the scoping review cut-off date may not have been captured, this is likely to have influenced the extent of identified evidence gaps rather than the formation of the framework. The framework’s structure and domains, grounded in established health system and resilience frameworks and supported by peer-reviewed evidence, ensure methodological and scientific rigor.

Conclusion

This study presents the Resilient Health Systems Appraisal Model (ReHSAM), a whole-of-system framework for appraising health system resilience in fragile contexts. The model comprises 69 standards across the six-health system building blocks, including 15 proposed standards that extend existing frameworks. ReHSAM focuses on the standards and management capacities that underpin health system resilience. The actions necessary to implement the standards are context-specific and dynamic across national, subnational and local levels of the health system. ReHSAM enables the assessment and tracking of resilience, facilitates cross-context comparison and learning, and supports the prioritization and implementation of actions that bolster the resilience of health systems in both fragile and stable settings.

Abbreviations

BFFS

Best Fit Framework Synthesis

DAH

Development Assistance for Health

HIS

Health Information System

HWF

Health workforce

LMICs

low- and middle-income countries

MAPS

The Methodology for Assessing Procurement Systems

MoH

Ministry of Health

OECD

The Organization for Economic Cooperation and Development

ReHSA

Resilient Health Systems Appraisal Model

RS

Resilience Standard

SC

Supply Chain

UHC

Universal Health Coverage

USAID

United States Agency for International Development

WHO

World Health Organization

WHO-HFPM

WHO The Health Financing Progress Matrix

Author contributions

MELB and KB conceptualized the research objectives and methods. MEL and KB defined the search strategy. MEL ran the search. MEL screened titles and abstracts. MEL screened full texts, completed the analysis, and drafted the standards, and KB was involved in the resolution of conflicts on the inclusion of papers against the set criteria and the refinement of the framework elements whenever needed. MEL drafted the whole manuscript in continuous dialogue with KB. KB provided substantial support in the thematic analysis and development of the framework. All authors provided contributions to the discussion and the subsequent revisions of the manuscript.

Funding

Open access funding provided by University of Geneva. No funding was received.

Data availability

All data generated or analyzed during this study are included in this published article and its supplementary information files.

Declarations

Ethics approval and consent to participate

Not Applicable, the study doesn’t report on or involve the use of any animal or human data.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.