An account of health systems resilience to emergencies in Africa: a scoping review

Abstract

Background

Healthcare systems across Africa continue to face a wide range of shocks. Using Ebola and COVID-19 as case studies, this study examines the various resilience strategies implemented in different countries and synthesises them in a way that can serve as a practical guide to make health systems in Africa more resilient for future emergencies.

Methodology

The study is a scoping review that synthesises evidence from peer-reviewed journal articles and grey literature, structured around a conceptual framework developed by the authors. We focused on various aspects of health system resilience during the Ebola outbreaks and the COVID-19 pandemic in Africa.

Key findings

This review identifies six key elements vital to health system resilience in Africa: strong leadership and governance, equitable social protection, digital health innovation, trusted community engagement, a sustainable and flexible workforce, and adaptable infrastructure. However, several gaps must be addressed to strengthen resilience against future health emergencies. While political commitment and coordination mechanisms improved integration and awareness, poor decentralisation, weak accountability, and fragmented governance undermined effectiveness. Social protection initiatives and digital tools enabled rapid responses but persistent inequities in access and data gaps hindered their reach. Telemedicine and workforce expansion showed adaptability but lacked sustainability. Community trust and local innovations supported resilience, yet their potential was curtailed by top-down strategies and insufficient institutional support.

Conclusion

This review emphasises the need for equitable, inclusive, and coherent strategies to strengthen resilient health systems in Africa. It calls for a shift from reactive, fragmented approaches to a long-term system-wide transformation grounded in inclusive governance, equitable social protection, robust digital health systems, a sustainable workforce, integrated and trusted community engagement, and adaptive physical infrastructure. Importantly, the review affirms that addressing deep-seated political, structural, and social inequities is crucial to ensuring resilience does not become an empty concept. The framework developed from this review provides a roadmap for policymakers to embed resilience as a core, institutional principle of long-term health system transformation, rather than a temporary emergency measure.

Supplementary information

The online version contains supplementary material available at 10.1186/s12992-026-01209-9.

Introduction

Healthcare systems across Africa continue to face a wide range of shocks [1–4], defined as a sudden and extreme change which impacts a health system [5]. These shocks range from acute and large-scale emergencies (such as the COVID-19 pandemic, Ebola Virus Disease (EVD), cholera outbreaks, natural disasters, and conflicts) to low-level chronic stressors, including non-communicable diseases (NCDs). Combined with the already overburdened and fragile health systems, these shocks have reinforced the critical need to strengthen resilience across African health systems to better prepare for and respond to public health emergencies [6, 7].

Although African healthcare systems regularly face diverse shocks, this review focuses specifically on EVD and COVID-19 due to their rapid spread, unprecedented scale, significant impacts, and their designation as Public Health Emergencies of International Concern [5, 8–12]. Unlike localised or routine disruptions, these crises created widespread turbulence across health, economic, and social systems, marked by high morbidity and mortality [8, 13–15].

The EVD outbreaks in West Africa (2014–2015) and the Democratic Republic of Congo (2018–2020) led to significant loss of health professionals, diversion and depletion of resources, and disruption of essential health services [1, 8, 16, 17]. COVID-19 further strained health systems, economies, and development worldwide [18–25]. These shocks overwhelmed emergency response capacities, inflicted lasting social trauma, and significantly eroded public trust in health institutions [8, 12, 15, 16, 22, 26]. Collectively, these crises exposed critical vulnerabilities and prompted significant policy and operational responses, making them valuable for examining the dynamics of health system resilience [9, 22, 27–30].

Resilience is a widely used concept across various sectors and disciplines [30]. It is commonly referred to as the capacity to recover quickly from a shock [27, 31–33]. In the context of health policy, the concept has evolved over the years, expanding from an initial focus on absorbing shocks to a more comprehensive model involving preparedness, adaptable management, and learning [9, 27, 32, 34]. The Expert Panel on Effective Ways of Investing in Health (EXPH) has equally defined health system resilience as “the capacity of a health system to (a) proactively foresee, (b) absorb, and (c) adapt to shocks and structural changes in a way that allows it to (i) sustain required operations, (ii) resume optimal performance as quickly as possible, (iii) transform its structure and functions to strengthen the system, and possibly (iv) reduce its vulnerability to similar shocks and structural changes in the future” [27], p.2.

In this definition, resilience is understood as distinct from health system strengthening, which De Savigny & Adam [35] described as efforts aimed at improving effectiveness, efficiency, and equity under normal conditions. Resilience, which is increasingly viewed as a dynamic system attribute rather than a fixed outcome, emphasises a system’s ability to prepare for, manage (absorb, adapt and transform) and learn from shocks, while sustaining essential functions such as governance, financing, and service delivery [5, 27, 30].

Kruk et al. [9] identify five core attributes that underpin resilient health systems. These include system awareness (health systems recognising their risks and capacities), integration (Coordinating health system strengthening, public health, including health security actions; intersectoral efforts and community engagement), diversity (Providing a broad range of services to meet diverse needs), self-regulation (Managing risks and responding to threats to minimise negative impacts), and adaptability (Learning from experience to adjust and improve). These attributes, together, enable health systems to anticipate, absorb, adapt, and transform in response to shocks, maintaining essential services while recovering swiftly to a stronger, more effective state.

Despite gaining traction in recent years, particularly following the EVD outbreak and the COVID-19 pandemic [15, 22, 36], the concept of resilience has not been without scrutiny. While often framed as an inherently positive concept and universally desirable, critics argue that resilience is a neutral capacity, one that can yield both positive and negative outcomes. It can, for instance, inadvertently sustain inequitable systems, reinforce existing disparities, or shift the burden of adaptation onto the vulnerable groups [15, 26, 37]. Thus, from this perspective, resilience should not be viewed as a one-size-fits-all solution for health emergency preparedness.

An important concern is that resilience efforts (i.e., strategies or interventions, such as workforce investments or digital health initiatives, aimed at strengthening resilience) tend to overlook underlying power dynamics, social contexts, and relational factors. This narrow focus can unintentionally shift burdens onto vulnerable populations, mask systemic weaknesses, and ignore the role of trust, agency, and decision-making in shaping resilient outcomes [26]. While resilience offers a useful systems-based lens for addressing health challenges, Topp [38] emphasises that it must be situated within its political context, as overlooking the power dynamics and intentions of health system actors risks diverting attention from necessary reforms to address longstanding health inequities.

These critiques point to a pressing need for resilience strategies that go beyond technical fixes to structural factors that enable effective responses. Health systems, as noted by WHO and other authors, are inherently complex and adaptive, deeply embedded within broader political, economic, and social ecosystems. They both shape and are shaped by sectors such as labour, trade, education, and the environment, making intersectoral collaboration critical for effective responses to shocks [14, 15, 22]. Evidence from the COVID-19 pandemic highlights how institutional fragmentation, governance constraints, social norms, and external pressures, such as sanctions, can hinder timely adaptation [15]. While countries that demonstrated effective governance, trusted leadership, evidence-based decision-making, and effective multisectoral coordination manage the crisis more successfully, fragmented systems with disjointed financing and governance struggled to respond effectively and suffered significant setbacks [22].

Building resilience, as highlighted by WHO, should, therefore, involve embedding adaptive capacities across all components of the health system to ensure the sustained delivery of quality services during crises. This includes strengthening governance, service delivery, and public health functions, while institutionalising mechanisms for effective coordination, continuous learning and improvement [39]. The WHO further advocates for resilience-building at individual, community, and system levels, emphasising the need for supportive environments, intersectoral coordination, and active civil society engagement [40]. A truly resilient system also requires an integrated approach that prioritises equity, financial protection, and the engagement of informal actors such as communities and families, while acknowledging the influence of governance, power dynamics, and the contributions of the private and voluntary sectors [14, 15]

Although several studies have examined health system resilience in Africa, they have nonetheless focused on resilience implications of specific emergencies (EVD or COVID-19) and, more importantly, have done so predominantly at the individual country level [11, 40–43]. While these studies offer valuable insights, their specificity and narrow contextual scope limit their utility for shaping broader, cross-national policy frameworks that enhance the resilience of health systems to withstand diverse shocks. The contrasting characteristics of EVD and COVID-19 further heighten the need for nuanced resilience strategies. EVD, which is primarily transmitted through contact with body fluids of symptomatic individuals, requires targeted containment strategies, including early diagnosis and isolation [12], whereas COVID-19, which spreads rapidly via aerosols, droplets, and direct contact, necessitates broad-based public health measures and strict societal compliance for control [44]. These differences provide a complementary perspective on resilience across different types of health emergencies.

This paper, thus, adopts EVD and COVID-19 as case studies to explore various resilience efforts implemented in different countries and synthesise them in a way that can serve as a practical guide for strengthening African health systems, thereby preparing them for future emergencies. The central research question guiding this review is: What resilience strategies were implemented in African countries during the EVD and COVID-19 crises, and how can these insights inform future emergency preparedness?

Conceptual approach

Several authors [1, 6, 27, 34, 45] have developed frameworks to strengthen health system resilience, but no universally accepted model exists. Despite this lack of consensus, many of them share overlapping elements that can be traced to the WHO health system framework [46], which serves as a foundational structure for understanding health systems and their responses to crises. However, existing frameworks have come under scrutiny for their limited capacity to holistically address the multifaceted and dynamic challenges posed by complex health shocks, such as the COVID-19 pandemic and the EVD outbreaks [45, 47]. These crises, as highlighted by Saulnier & Topp [26] and Witter et al. [15], have revealed the profound interdependence between health and other systems, demonstrating that resilience must extend beyond service delivery to encompass broader political, economic, and social contexts. A narrow focus on siloed metrics risks overlooking underlying vulnerabilities and the continuous, adaptive nature of health systems. This fragmented and unbalanced approach to resilience, termed ‘bad resilience’ by Saulnier and Topp [26], may yield short-term gains but ultimately incur greater long-term costs [39]. Lessons from the Ebola (2014–2016) and the COVID-19 pandemic underline the dangers of such an approach. To address these limitations and ensure a more holistic, context-sensitive approach to building a resilient health system, the current study employed a conceptual framework developed by the authors (see Fig. 1), based on a review of the existing literature (Table 1).

Fig. 1.

Conceptual approach for strengthening health system resilience to health emergencies

Table 1.

Description of elements in the conceptual framework

Elements	Description	Source
Leadership and Governance Domain
Leadership and Governance	The capacity to provide effective, participatory leadership with a clear vision, coordinated action across sectors, responsive organisational learning, and robust information and surveillance systems. It includes activating national emergency management mechanisms and engaging relevant ministries to oversee preparedness and response.	[32, 46, 47]
Policy & Societal Response Domain
Social and Economic Support	Economic and financial support to households, businesses, and markets to lessen the economic impact of the health crisis, as well as measures to protect the most vulnerable population.	[21]
Port of Entry Measures	Implementation of appropriate public health measures at points of entry, including screening for travellers, education on responsible travel behaviours before, during, and after travel; conducting case identification, contact tracing, and managing isolation and quarantine	[48]
Lockdown and Restrictions	A set of mandatory non-pharmaceutical measures designed to curtail the transmission of infections. These measures are applied to a general population and involve some restrictions on the established pattern of social and economic life.	[49]
Whole-of-society Approach	Engaging with non-governmental actors, including citizens and communities, health workers, civil society, and the private sector, to mobilise resources and share information.	[27]
Risk Communication and Community Engagement	The integrated process of disseminating timely, accurate information through multiple channels to educate the public on managing health threats, while actively involving community members and local leaders in the design and implementation of policies and services that affect their health	[27, 34]
Health System Response Domain
Public Health	Implementation of appropriate non-pharmaceutical interventions (surveillance, rapid response, case investigation, and laboratory diagnosis) and effective vaccination programmes to control or mitigate transmission.	[27, 34]
Health Service Delivery	Implementation of strategies to manage a surge in demand for both health and social services due to health emergencies, while continuing to provide other necessary healthcare services.	[27]
Human Resources	The availability of healthcare workers in sufficient numbers and with the appropriate training to respond to a surge in demand, as well as the governance mechanisms required to support change.	[47]
Health Information System (HIS)	HIS comprises data generation, compilation, analysis, synthesis, and communication to guide policy response decisions.	[41, 47]
Health Financing	Mobilising and ensuring the availability of sufficient financial resources within the healthcare system, that can be deployed and made available where and when needed during a pandemic.	[1, 27, 32]
Operational Support and Logistics	The availability of health facilities, beds, and well-maintained medical equipment and technology, as well as the presence of operational isolation centres. It also entails establishing robust logistical support and supply chain management for essential medicines, including PPE.	[45, 48]

The framework comprises two interconnected components: health system measures as well as policy and societal response measures anchored in leadership and governance (Fig. 1). The policy and societal response measures are broader, multisectoral interventions, which are essential for effective crisis management. They encompass social and economic support, lockdowns, port-of-entry (PoE) controls, a whole-of-society approach and risk communication and community engagement (RCCE). Their inclusion underscores the importance of coordinated societal efforts to enhance technical health responses. Health system measures are the traditional building blocks of health systems, which are adjusted in this paper based on literature and emerging evidence from the COVID-19 emergency response. The adjusted elements, which represent the core capacities required for system functionality and adaptability during crises, include public health measures, health service delivery, health financing, health information systems (HIS), human resources, and operational support and logistics.

At the centre of the framework is leadership and governance, which act as the coordinating hub across all system components and stakeholders, including healthcare providers, government agencies, communities, NGOs, and development partners. Effective leadership facilitates timely decision-making, resource allocation, and accountability [47]. This is vital for mobilising collective action, maintaining system performance, and addressing social determinants of health to enhance the ability of health systems to respond to emergencies [31, 32].

Methods

Design

A scoping review, based on a synthesis of published journal papers and grey literature, was used to explore the extensive literature on EVD and COVID-19 responses in Africa. This approach enabled us to thoroughly examine the subject and identify relevant materials from a wide range of sources, given the broad nature of the research topic [50, 51]. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Review (PRISMA-ScR) checklist [52], and the PCC (Population, Context, Concept) framework by the Joanna Briggs Institute (JBI) to generate the search terms [53, 54].

Eligibility criteria

The primary inclusion criteria were English-language papers that focused on health system resilience related to EVD and COVID-19. Other inclusion and exclusion criteria for the screening of materials are presented in Table 2. Only papers published in English from 2018 onward were considered. This time frame was chosen to capture papers that incorporated lessons learnt from both crises, while ensuring relevance to the current discourse on health system resilience.

Table 2.

Criteria for screening & selection

Inclusion

•Papers on health systems resilience representing Africa or with comparative analysis of countries in Africa with other continents. •Papers related to health systems with a focus on EVD or the COVID-19 pandemic in Africa. •Papers that discussed strategies for health emergencies or pandemic (EVD or COVID-19) preparedness and response in Africa

Exclusion

•Studies that are outside Africa or are global with no specific focus on Africa. •Studies not related to COVID-19 or Ebola •Studies that focus on Africa and COVID-19/Ebola, but not relevant to health system response/resilience •Study design not aligned with the review objectives (Studies whose methodological design does not provide analytical evidence on health system response strategies, including protocols, modelling studies without policy analysis, behavioural surveys, perception studies, and purely descriptive reports) •Limited alignment with the analytical framework: Studies addressing COVID-19 or Ebola impacts but not analysing response mechanisms within the predefined health system domains (e.g., governance, service delivery, human resources, financing, logistics, or health information systems). •Narrow service- or disease-specific focus: Studies focusing on a single health programme, disease area, or clinical service (e.g., maternal health, HIV services, vaccination uptake, ICU care) without examining broader health system response mechanisms. •Multiple reviews or studies reporting substantially similar interventions •Articles without access to the full text

Authors’ compilation, 2023

Information sources

We conducted a comprehensive literature search of peer-reviewed and grey literature on health systems preparedness and response to the COVID-19 pandemic and EVD between March 2023 and January 2024. Peer-reviewed articles were accessed from selected databases, including Google Scholar, PubMed, Scopus, and Health Source: Nursing/Academic Edition (EBSCOhost). We also searched for grey literature (i.e., unpublished materials) using the websites of national and international organisations, as well as Google Advanced Search. This approach ensured a more comprehensive evidence base by capturing relevant reports, policy documents, and evaluations that may not be indexed in academic databases. Additional hand searches of reference lists were conducted to identify relevant studies that may not have been captured through the database searches.

Search strategy

We adopted a three-stage process, as recommended in the JBI systematic review standard [53, 54], to identify records for the study. The first stage involved a limited search of existing reviews to determine the scope and extent of the literature on the study’s subject, using Google Scholar. This enabled the identification of databases and key search terms for the subsequent search strategy. In the second step, all the authors (MA, GAN, GAO, LY, and AAAB) searched across all included databases using the search strategy, which had been refined based on the keywords and index terms identified in the first step. The reference lists of the identified articles and reports were searched for additional sources in the third stage.

We developed the search terms in consultation with the literature and public health experts. The terms reflect the PCC framework as per the Joanna Briggs Institute’s recommendations [53, 54]. However, the strategy was slightly adjusted to align with the search capabilities of each database and website.

Population

The study focused on health systems in Africa, particularly at the national level, that were affected by the EVD outbreak and the COVID-19 pandemic. To ensure a comprehensive assessment of the phenomenon, studies comparing Africa’s health system with those of other continents were also considered.

Concept

The principal focus or concept examined in the review is health system resilience, which is described as the ability of health systems to prepare for, manage (absorb, adapt and transform) and learn from shocks [5].

Context

The context of this study refers to public health emergencies, specifically the COVID-19 pandemic and the EVD outbreak. The study examined the resilience of health systems to public health emergencies in Africa, referencing records of COVID-19 and EVD from various sources. Grey literature, including government reports, development partners’ reports, technical reports, and policy briefs, was assessed in relation to Africa’s response to both EVD and COVID-19, with an emphasis on the strategies adopted and the challenges faced in addressing the health crises. Empirical records from journal articles were consulted to establish gaps in the structural, operational, and leadership infrastructure of the continent’s public health emergency system.

Search terms

All the authors conducted comprehensive literature searches. The search queries were divided into three levels: Level 1 encompassed terms related to the health system, such as “healthcare system”, “health services”, “public health services”, “national health service”, public health infrastructure”. Level 2 included terms related to health system resilience, such as “resilience”, health system response, “emergency preparedness”, “health system capacity”, “surge capacity”, “shock”, “crises response:, “health security”, “system adaptation”, and “continuity of service”. Level 3 terms focused on COVID-19 and EVD, including “coronavirus,” “COVID,” “SARS-CoV-2,” “COVID-19,” “COVID-19 pandemic,” “COVID-19 response strategies,” “Ebola”, “Ebola Virus Disease: and EVD. We employed Boolean operators such as AND/OR to combine search terms. The search strategy also included truncation and wildcards to broaden the search.

Screening and selection process

The screening process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All records retrieved from the databases were merged into a single Microsoft Excel spreadsheet (version 2403), which captured key bibliographic details, including record number, source database, author(s), title, year, DOI, and abstract. Duplicate records were then identified and removed. The remaining records underwent title and abstract screening using a second Excel sheet designed for eligibility assessment. This sheet contained fields for record number, author, title, year, Africa check, crisis check, system response check, screening decision, and abstract to facilitate systematic evaluation against the study’s inclusion criteria.

Four authors (MA, GAO, LY, and AAAB) independently screened the titles and abstracts. Articles considered potentially relevant progressed to full-text review, where the same authors independently assessed eligibility. Disagreements were resolved through discussion, and unresolved cases were adjudicated by GAN. The overall study selection process is presented in the PRISMA flow diagram (Fig. 2).

Fig. 2.

PRISMA diagram illustrating selection of papers

Data items and the data charting process

We employed a framework synthesis approach [55, 56], drawing on our initial conceptual framework to guide data extraction and analysis. Using Microsoft Excel (version 2403), we created a spreadsheet that generated a matrix to systematically capture the characteristics of the included papers. These characteristics included the name (s) of the author(s), publication year, country, type of document, response strategies, and challenges. To ensure data accuracy and reliability, we employed the following to extract the data. Three authors (MA, GAO, and AAAB) independently extracted the data items using the extraction form. LY double-checked the information for each of the extracted items to ensure that they reflected the understanding of the framework. Discrepancies were resolved by discussion with GAN.

The framework’s three core domains (leadership and governance, health system functions, and policy and societal response) served as the overarching categories, with their sub-domains forming the basis for the thematic coding. Data from each included paper were organised under the framework’s domains and sub-domains. The extracted data were coded deductively using the framework’s predefined categories, while emerging sub-themes were derived through progressive inductive coding of the materials. The emerging subthemes were used to refine and expand the framework iteratively. All references were managed using EndNote 21.

Methodological quality appraisal

Given the exploratory nature of scoping reviews, we focused on mapping the findings onto the framework to uncover patterns, gaps, and relationships across the literature. We did not appraise methodological quality, as this is not typical of the standard scoping review methodology [57].

Analysis and synthesis

We employed both quantitative and qualitative analyses to synthesise the results. In the quantitative analysis, we used descriptive statistics (frequencies and percentages) to summarise the characteristics of the included papers (publication type, year, and geographical focus). For the qualitative analysis, we used thematic analysis [58]. The conceptual framework was used to structure the presentation of findings. For each element, we synthesised the implemented strategies and highlighted the challenges encountered in their implementation. In addition, illustrative examples from selected countries were provided to demonstrate the diverse approaches to addressing health crises. The data used to extract themes for the results is contained in Supplementary List 1 (SPL 1) attached to this paper.

Results

Literature selection

The literature search yielded 3,161 citations (Fig. 2). After removing 407 duplicates, 2,754 unique records remained for title and abstract screening. From these, 303 records were considered potentially relevant and advanced to full-text review.

At the full-text screening stage, 207 studies were excluded based on the predefined eligibility criteria. Most were excluded because they did not align with the analytical framework, discussing COVID-19 or Ebola impacts without analysing health system response mechanisms across the core domains. Others were excluded due to a narrow focus on specific services or diseases, study designs not aligned with the review objectives (e.g., descriptive reports or perception surveys), or overlapping evidence that did not add new analytical insights. These exclusions ensured that the final set of studies remained closely aligned with the study objectives and analytical framework. Following this assessment, 88 articles met the inclusion criteria and were retained for the scoping review. All included studies were published from 2018 onwards.

Most of the included documents were journal articles or review papers (n = 81, 92.05%), while the remaining records (n = 7, 7.95%) were reports, policy briefs, or discussion papers (see Supplementary File SPL.2). Regarding geographical distribution, 40 studies (45.45%) covered multiple regions across Africa. The remaining studies focused solely on specific sub-regions: West Africa (n = 20, 22.73%), East Africa (n = 14, 15.91%), North Africa (n = 5, 5.68%), Southern Africa (n = 6, 6.82%), and Central Africa (n = 3, 3.41%) (see Supplementary File SPL.3).

African health systems response to EVD outbreaks and the covid-19 pandemic

In the following sections, we synthesise the narrative accounts detailing the strategies implemented and the challenges encountered by various African countries in responding to the EVD outbreak and the COVID-19 pandemic. These strategies and challenges are analysed through the lens of our initial conceptual framework (Fig. 1), which encompasses three core domains: leadership and governance, health system functions, and policy and societal response.

Leadership and governance

The review identified strong political leadership and effective governance as central to the effective response to EVD and COVID-19 in several African countries. High-level political commitment facilitated the formation of a national coordinating mechanism, including a presidential task force, national committees, and a multi-sectoral response team to ensure strategic oversight and coordinated action [11, 41, 58–68]. Most countries enacted legal and policy frameworks to support emergency public health measures, resource mobilisation and pandemic response financing [43, 60, 61, 64]. Crisis management structures, such as Emergency Operations Centres (EOCs), Incident Management Systems (IMS), and Rapid Response Teams, were also established or strengthened to coordinate surveillance, case management, and response activities [11, 41, 65, 69]. For Ebola, regional coordination was enhanced through collaborative frameworks, joint simulation exercises, workforce training, and targeted lockdowns in affected districts to limit transmission [70]. Strategic planning was further demonstrated through the development of national preparedness and response plans, including Ebola response strategies, COVID-19 national preparedness and response plans, and COVID-19 vaccine deployment frameworks, supported by efforts to mobilise resources and strengthen operational readiness [11, 41, 63, 65, 67, 69, 71].

Despite these efforts, limited emergency coordination capacity, delayed operational guidelines, fragmented data systems, and weak systems for tracking, monitoring, and evaluating resources, together with financial and human resource constraints, hindered timely and efficient response interventions in some countries during both crises [11, 63, 65, 70, 72]. Political dynamics also influenced response effectiveness. In some contexts, the politicisation of decision-making, widespread misinformation, and eroded public trust weakened compliance with public health measures [64, 65, 73, 74]. For example, a fragmented political environment complicated COVID-19 response efforts in Zimbabwe [73]. Armed conflicts and political instability across parts of Africa also hindered COVID-19 response efforts by exacerbating displacement, overcrowding, poor sanitation, and existing health system vulnerabilities [75]. In some contexts, pandemic responses became increasingly reliant on international actors and donor support, which influenced health planning and implementation priorities [71]. Weak decentralised governance systems and limited multisectoral coordination also undermined the effectiveness of COVID-19 responses [11, 74]. These findings reinforce the need for more resilient governance systems in future health emergencies.

Policies and societal response measures

Social and economic support

The COVID-19 and Ebola crises exposed deep-seated structural inequities across African countries, prompting resource mobilisation and socio-economic support strategies to protect the most vulnerable [66, 74, 76]. Governments mobilised financial resources through central banks and domestic financial systems, with additional support from multilateral and bilateral partners, development institutions, and private sector contributions [42, 60, 66, 73, 75–77]. Social protection measures included wage support, healthcare worker incentives, debt moratoriums, tax relief, utility subsidies, social grants, food assistance, and stimulus packages to support small businesses and health-related enterprises [42, 43, 49, 60, 64, 67, 74, 75, 78, 79]. Efforts to support vulnerable groups also involved collaboration with local authorities, community organisations, and non-governmental actors, along with the use of digital technologies and mobile platforms to facilitate the delivery of cash transfers and assistance to vulnerable populations, particularly informal workers [66, 74, 80].

However, the effectiveness of these interventions was constrained by several challenges, including limited financial resources, weak social protection systems, a lack of reliable beneficiary data, and bureaucratic inefficiencies. Further setbacks included inadequate economic stimulus packages, limited access to formal financial services, water scarcity, insufficient supply capacity, politicisation, corruption, conflict-related disruptions, and an unequal distribution of relief support [60, 72–74, 79]. Although women were disproportionately affected by lockdowns due to their concentration in informal employment and unpaid care responsibilities, many social protection and employment support initiatives did not adequately address their specific vulnerabilities [66].

Port of entries (PoEs)

To curb the importation of COVID-19, African countries implemented a combination of regulatory, operational, and technological measures at PoEs. Among these were border closures, mandatory quarantines, PCR testing, thermal screening, electronic health declarations, distributing information, education, and communication materials to raise awareness and support compliance with the WHO International Health Regulations [11, 43, 60, 61, 65, 67, 69, 74, 80–82].

Implementation approaches at points of entry varied across countries during COVID-19. For example, Rwanda required PCR testing on arrival and a 24-hour mandatory quarantine, while South Africa and Zimbabwe accepted prior test results without retesting [61]. Ghana also implemented screening, testing, quarantine, and isolation protocols at major ports of entry [43]. These measures were supported by strengthened infrastructure and operational systems, including testing laboratories, holding areas, logistics support, and targeted training for port health personnel [11, 43, 65]. However, several operational challenges emerged, including fraudulent test certificates, unofficial border crossings, limited isolation capacity, diagnostic delays, and disruptions to informal cross-border trade and livelihoods [61, 67, 74, 83].

For Ebola preparedness, cross-border collaboration was strengthened through regional coordination meetings, memoranda of understanding between neighbouring countries, and joint activities such as cross-border surveillance, information sharing, and simulation exercises to support early detection and response. Nevertheless, these efforts were often constrained by insecurity in border regions, weak coordination between national and subnational structures, and reliance on short-term outbreak-driven funding, which limited the sustainability of preparedness systems [84].

Lockdown and restrictions

Efforts to slow the spread of COVID-19 and Ebola infections led many African countries to adopt a raft of lockdown and restriction measures. These included declaring states of emergency, imposing full or partial lockdowns and night curfews, implementing social distancing policies, banning public gatherings, closing educational institutions, markets, and restaurants, restricting travel, enforcing hygiene protocols such as mask-wearing and disinfection of public spaces, and implementing isolation and quarantine procedures [59, 62, 63, 65, 71, 73, 79, 82, 84–88].

Although intended to safeguard public health, compliance with lockdown measures encountered significant challenges across African countries due to severe shortages of personal protective equipment, limited access to water, sanitation and hygiene (WASH) facilities, food insecurity, and overcrowded living conditions [11, 65, 73, 75]. Cultural norms, limited health literacy, and mistrust of authorities further undermined adherence to public health measures [87], while informal workers frequently lost their livelihoods and were often compelled to violate restrictions in order to survive [60, 73, 76, 79]. Vulnerable populations, including women traders and low-skilled workers, were disproportionately affected because of structural inequalities, inadequate targeting of social support, and limited stakeholder engagement [66, 74, 76]. Compliance also varied across political contexts, with liberal democracies facing particular challenges in securing public adherence to restrictive measures [89].

The economic fallout of these restrictions triggered unemployment, social protests, and the gradual easing of lockdown measures in several countries [62, 63]. Lockdowns and prolonged school closures also restricted civil liberties, disrupted democratic processes, worsened mental health outcomes, and limited access to healthcare services. They further contributed to social unrest, gender-based violence, school dropouts, child labour, neglect and abuse, early marriage and teenage pregnancy [49, 59, 75, 86, 90, 91]. While digital learning initiatives partially mitigated educational disruptions, they also exacerbated existing inequalities in access to education [90]. In Egypt, strict containment measures were undermined by mass gatherings and weak enforcement mechanisms [89]. These findings highlight the importance of balancing public health protection with the broader social and economic implications of restrictive measures.

Whole-of-society approach

Africa’s COVID-19 and Ebola responses adopted a whole-of-society approach, involving government agencies, NGOs, CSOs, academia, health partners, the private sector, community leaders and professional bodies [40–42, 59, 63, 70, 74, 92]. RCCE strategies were strengthened through partnerships with CSOs and the use of digital platforms to disseminate public health information [92, 93]. WHO AFRO collaborated with NGOs, UN agencies, and community leaders to support outbreak interventions and strengthen response capacity in high-risk areas [41]. while ECOWAS coordinated regional efforts with international partners, including the Jack Ma Foundation and COVAX, to supply PPEs and vaccines to member states [59].

At the continental level, institutions such as the African Union and the Africa Centres for Disease Control and Prevention played a central role in facilitating information sharing, coordinating joint procurement of medical supplies, and mobilising diplomatic engagement with international partners [94]. Similarly, donor–community collaborations were instrumental during the Ebola response in West Africa, where partnerships involving local leaders, civil society organisations, and international actors strengthened community engagement and improved outbreak control and public health communication [95]. In Ethiopia, coordinated efforts led by the health sector facilitated the expansion of decentralised care and laboratory services across both public and private health facilities [41]. Similarly, in South Africa, Rwanda, and Zimbabwe, private sector actors contributed personal protective equipment, testing kits, and food support, while in Ghana, Nigeria, and Guinea, multisectoral partnerships helped establish national COVID-19 funds to finance infectious disease centres and essential supplies [42, 43, 63, 74].

Community-based initiatives further complemented national response efforts. In some contexts, churches made their multipurpose facilities available for conversion into COVID-19 isolation and treatment centres. Local innovations, including community mask production, rapid diagnostic testing initiatives, solar-powered hand-washing facilities, and informal public health messaging, also supported response efforts [43, 96]. In addition, NGOs, CSOs, religious organisations, and community leaders provided humanitarian assistance, including food aid and public health education, to vulnerable populations [42, 74]. Nonetheless, the absence of clearly defined epidemic governance frameworks and unclear roles for private and non-governmental actors sometimes limited the effectiveness of multisectoral coordination during emergency responses [41, 63]. Community non-compliance, stigma, and misinformation also hindered adherence to response measures [70]

Risk communication and community engagement (RCCE)

Several countries employed diverse communication platforms, including social media, radio, SMS alerts, infographics, billboards, national broadcasts, and mobile information vans to deliver timely updates and counter misinformation during the COVID-19 pandemic [10, 61, 64, 65, 74, 85, 90, 93, 97]. These communication efforts were reinforced through RCCE working groups, social mobilisation initiatives, strategic partnerships with non-governmental organisations and mobile service providers, targeted messaging for vulnerable populations, and community engagement through trusted influencers and survivor testimonies [11, 42, 65, 74, 85, 92, 93, 95, 98].

In the Ebola response, risk communication was strengthened through radio programmes, social listening approaches, and community engagement activities to address misinformation and improve public awareness [70]. Community engagement strategies involved partnering with community-based organisations and local leaders to support risk communication, promote prevention behaviours, facilitate contact tracing and safe burials, and improve utilisation of health services during the Ebola response [99]. Community education, survivor integration, local participation in healthcare delivery, and community-based surveillance also helped build trust and improve case detection and reporting [13, 95, 100]. Evidence from past outbreaks further demonstrates that large-scale community engagement and real-time data collection can be effectively implemented during health emergencies when adequately resourced, well-structured, and integrated into formal health systems [101].

Despite these efforts, several barriers limited the effectiveness of RCCE during outbreak responses. Poor community compliance, stigma, and suboptimal engagement contributed to resistance to control measures, risky cultural practices, and underreporting of suspected cases during the Ebola response [70, 99]. Misinformation, rumours, conspiracy theories, inconsistent messaging, and limited resources further weakened risk communication during both EVD and COVID-19 responses [65, 85, 93, 95, 101–103]. Limited community involvement in decision-making and longstanding distrust of government institutions also reduced adherence to public health measures [13, 99, 104], while political corruption in some settings undermined compliance with COVID-19 directives [93]. Cultural beliefs, stigma [70], limited access to reliable information, and weak digital infrastructure further constrained public cooperation [90, 105]. In addition, RCCE efforts largely overlooked vulnerable groups, particularly persons with disabilities, limiting equitable access to health information. Weak health systems, limited workforce capacity, and poorly defined roles among partners hindered effective RCCE coordination (Adebisi, Rabe, & Lucero-Prisno III, 2021b) [93].

Health system response

Public health functions

The public health response to COVID-19 and EVD in Africa encompassed a wide range of interventions, including strengthening surveillance, expanding laboratory capacity, and deploying vaccines. Many countries leveraged lessons from previous outbreaks and existing surveillance systems to reinforce their COVID-19 response strategies [106, 107]. Epidemiological surveillance was strengthened through the establishment of new coordination centres, the integration of COVID-19 case definitions into the IDSR system, and the development of SOPs for contact tracing. Community-based surveillance mechanisms and rapid response teams were trained to support entry-point screening and decentralised house-to-house contact tracing in vulnerable communities. Digital tools, including DHIS2, SORMAS, CommCare, Sense Ebola Follow-ups, and handheld sequencing devices, were deployed to support surveillance, case management, contact tracing, real-time reporting, and disease modelling during both EVD and COVID-19 responses [13, 42, 43, 59, 61, 65, 67, 69, 74, 85, 92, 100, 108]. In South Africa, epidemiological data and sentinel surveillance systems were used to guide hotspot interventions, integrate COVID-19 data into existing platforms, and support modelling for response planning [85]. Surveillance and research activities, including sero-surveillance and operational studies, were also expanded to understand transmission dynamics, post-COVID conditions, and vaccine effectiveness [59, 62, 109]. Similarly, Egypt adapted its acute respiratory infection (ARI) surveillance system to monitor circulating respiratory viruses and inform clinical management and control measures during the pandemic [110].

Laboratory capacity was expanded and strengthened through decentralised testing, deployment of mobile laboratory units, leveraging existing diagnostic platforms such as GeneXpert, adopting rapid diagnostic tests (RDTs), training of laboratory personnel, and engaging public–private partnerships to scale testing and procure supplies [11, 42, 61, 62, 69, 72, 85, 92, 107]. In some countries, including Senegal and Nigeria, locally developed rapid test kits were introduced, and GeneXpert platforms, initially deployed for multidrug-resistant tuberculosis, were repurposed to support COVID-19 diagnosis [59].

Vaccination strategies involved structured rollout plans, prioritisation of high-risk populations, community outreach initiatives, awareness campaigns using community radio in local languages, task-shifting within existing community health worker (CHW) networks, integration of COVID-19 vaccination with existing immunisation campaigns, and advocacy by political leaders to increase public trust in vaccination programmes [68, 92, 111]. In the Democratic Republic of Congo, ring vaccination strategies used during Ebola outbreaks were adapted into broader community vaccination campaigns due to sociocultural barriers, with local engagement contributing to improved trust and containment [100].

Notwithstanding the measures implemented, surveillance and contact tracing remained constrained by fragmented reporting systems, shortages of trained personnel, overwhelming caseloads, inaccurate contact information, community resistance, stigma, delays in case confirmation, limited genomic sequencing capacity, poor digital connectivity, and logistical barriers [13, 65, 102, 107, 112]. Laboratory services also faced major challenges, including global shortages of reagents, weak specimen transport systems, prolonged turnaround times, and limited diagnostic capacity [42, 43, 60, 61, 63, 71, 74, 85, 106].

In São Tomé and Príncipe and Cabo Verde, limited testing capacity during the early stages of the pandemic delayed case confirmations and contributed to higher cumulative attack rates [82]. Access to COVID-19 vaccines was further constrained by vaccine nationalism, funding limitations, delayed deliveries, and supply chain disruptions. Vaccine hesitancy was fuelled by concerns about safety and side effects, the rapid development of vaccines, misinformation circulating on social media, and mistrust in vaccine sources and government authorities [62, 63, 112–116]. In Ghana, high-level political leadership supported vaccine acquisition and efforts to strengthen local vaccine production capacity [68]. However, public concerns emerged regarding a vaccine procurement deal perceived as overpriced [74, 115].

Service delivery

Essential health services, including HIV care, malaria and tuberculosis treatment, antenatal care, family planning, and routine immunisation, experienced significant disruption during the COVID-19 pandemic and Ebola outbreaks across many African countries. These disruptions were largely driven by movement restrictions, increased healthcare costs, and widespread fear of infection among patients and healthcare workers [41, 61, 65, 69, 71, 77, 117]. In post-conflict countries such as Liberia and Sierra Leone, heavy-handed containment measures during the 2014 EVD outbreak, particularly quarantines and movement restrictions, intensified fear, mistrust between communities and healthcare providers, and weak communication within already fragile health systems, thereby undermining public trust and creating significant barriers to maintaining essential health services [77].

To mitigate these challenges, several African countries implemented multi-level coordination mechanisms and governance committees to oversee the continuity of essential health services during the COVID-19 pandemic. Some countries, such as Uganda, also recruited, redeployed, and incentivised health workers to strengthen the health workforce and sustain service delivery. [118]. Many countries also adopted digital health and telemedicine solutions to maintain service delivery during the COVID-19 pandemic. These tools supported remote consultations and helped reduce physical contact between patients and healthcare providers [65, 105, 118–120]. However, telemedicine adoption faced several barriers in many African settings. These included poor internet connectivity, limited skilled personnel, weak digital infrastructure, regulatory gaps, and high operational costs [105, 117, 119–122]. Rural areas also experienced unequal access to these technologies [121]. The pandemic also exposed major equity gaps. Persons with disabilities faced serious barriers in accessing health services and information, as most countries lacked targeted policies or reasonable accommodation measures to address their specific needs [123, 124]. Many disability-related services were not classified as essential during lockdowns. These included medication delivery, rehabilitation services, assistive technologies, and sign language support [124]. Although some countries introduced sign language interpretation in public health broadcasts, broader accessibility needs remained unmet [123].

At the onset of the COVID-19 pandemic, many countries also faced critical gaps in clinical case management capacity, including shortages of trained healthcare personnel, intensive care unit beds, oxygen supply, ventilators, and essential medical equipment [11, 41, 42, 65, 69, 92, 117], which were compounded by other health emergencies like yellow fever, cholera, measles, and floods [11]. In response, several countries established dedicated isolation and treatment centres, deployed specialised clinical teams, reassigned healthcare personnel, and developed case management guidelines and standard operating procedures. Community-based care approaches were also introduced to reduce pressure on health facilities and maintain access to essential services [42, 43, 62, 65, 74, 117]. The WHO and its partners supported the development of oxygen infrastructure, training, and cost reduction, while regional platforms facilitated peer learning in triage and clinical care [92]. Public-private partnerships further expanded treatment infrastructure and improved rural access [43, 62, 74]. In Liberia, Ebola case management integrated psychosocial support through Social Reconnection Groups and community surveillance [100].

At the health facility level, IPC measures for COVID-19, including patient screening, triage protocols, improved ventilation systems, national IPC strategies, and healthcare worker training, were implemented to reduce healthcare-associated transmission of COVID-19 [61, 69, 125, 126]. However, these efforts were undermined by persistent shortages of personal PPE, weak adherence to IPC protocols, and global supply chain disruptions [11, 65, 74]. Inadequate WASH infrastructure within some health facilities further compromised IPC implementation during the pandemic [65, 127].

Human resources

Shortages of healthcare personnel, compounded by the incessant brain-drain surge, inadequate PPEs, increased workloads, and high levels of occupational and mental stress were reported in most African countries during the early phase of both the COVID-19 and EVD outbreaks. There were also issues involving poor working conditions, low pay, limited training on infectious diseases, fear of spreading the virus to loved ones, community attacks, and social stigma, especially among those previously infected [41, 73, 75, 77, 86, 90, 91, 102, 112]. To mitigate these challenges, several countries implemented workforce surge strategies, including the recruitment and deployment of additional health workers and volunteers to support case management, surveillance, and contact tracing activities [11, 42, 77, 128]. For example, Guinea enlisted approximately 2,950 health workers during the 2014–2015 Ebola outbreak to strengthen response capacity [77, 112]. Similarly, Ghana recruited more than 45,000 health workers during the COVID-19 pandemic, representing an estimated 35% increase in public-sector health workforce capacity [128]. Capacity-building initiatives were scaled up to strengthen workforce preparedness and response readiness in areas such as RCCE, IPC, surveillance, field epidemiology, laboratory diagnostics, home-based care, safe and quality service delivery, and mental health support [43, 92, 129]. These efforts were often complemented by incentive packages, insurance schemes, and recognition programmes aimed at improving workforce motivation and retention [60, 128]

Health information system (HIS)

African countries employed diverse approaches to generating and reporting health data, with most capturing core metrics such as confirmed cases, recoveries, and deaths during both COVID-19 and EVD. Many countries adopted digital tools, including mobile health (mHealth) applications, DHIS2 platforms, SORMAS, and geographic information system (GIS) technologies, to enhance transparency, facilitate real-time reporting, and support coordination of outbreak responses and spatial monitoring during the pandemic [10, 61, 108, 130, 131]. In several settings, these digital tools were integrated into existing disease surveillance systems to strengthen epidemic monitoring, spatial analysis, and decision-making for response [85, 132]. In addition, some existing platforms such as DHIMS2 and SORMAS were reconfigured with COVID-19 modules to support real-time surveillance, vaccination monitoring, and data-driven planning [121].

Despite these innovations, reporting on critical information such as comorbidities, hospital capacity, and response measures was often inconsistent across countries [130]. While some countries exceeded international reporting standards by incorporating indicators of healthcare preparedness and response capacity, others struggled with fragmented reporting systems and limited interoperability across platforms. These challenges were further compounded by poor data quality, duplication of reporting processes, limited standardisation, and the parallel introduction of multiple digital systems by different partners [77, 85, 121]. Persistent difficulties in data generation, transmission, analysis, and use continued to hinder timely and effective public health action across the region [7]. Weak health information systems also limited visibility into supply chains, health facility capacity, and emerging disease hotspots, thereby delaying interventions during the COVID-19 and EVD outbreaks [10]. Furthermore, the rapid deployment of digital technologies during the response raised concerns about privacy breaches, misinformation, data inaccuracies, and the potential for stigma [133]. This underlines the need to strengthen governance and trust in health data systems.

Healthcare financing

Countries adopted multiple resource mobilisation strategies to finance the COVID-19 response, including external financing from development partners (e.g., the World Bank, the IMF, and the AfDB), reallocation of domestic public funds through budget realignment and stabilisation funds, and mobilisation of private-sector contributions through public–private partnerships and national COVID-19 trust funds [41, 42, 74, 134]. The private sector and development partners supported key interventions, including isolation measures, the provision of PPEs, and the procurement of essential medical commodities [59, 74]. However, the absence of pre-existing contingency financing mechanisms, limited fiscal reserves, and the need to rapidly reprogram budgets created significant uncertainty and challenges in mobilising sufficient resources to respond to the pandemic [134].

Operational support and logistics

Both crises revealed critical gaps in health systems infrastructure and logistical support across many African countries. Stock-outs of essential medicines, severe shortages of PPE, limited ICU and oxygen capacity, and fragile infrastructure, including inadequate WASH facilities, ambulance services, and weak digital health infrastructure, were widely reported, particularly during the early phases of the Ebola and COVID-19 outbreaks [7, 11, 41, 65, 77, 85, 86, 90, 127, 135]. Over-reliance on imported supplies, limited local production of PPE and vaccines, weak forecasting systems, and procurement inefficiencies contributed to delayed access to essential resources [61, 85, 92]. Balancing COVID-19 and non-COVID-19 healthcare demands further exacerbated supply constraints and increased the risk of healthcare worker exposure [11].

To address these challenges, countries implemented a range of operational and logistical strategies. These included expanding health infrastructure capacity by scaling up testing laboratories, procuring ventilators and medical equipment, constructing specialised infectious disease facilities, and initiating new hospital infrastructure projects to strengthen preparedness for future health emergencies (Novignon & Tabiri, 2022). Existing treatment infrastructure was also repurposed, including the establishment of oxygen plants, promotion of local PPE production, and stockpiling of essential medical commodities [43, 117]. Global platforms such as the UN COVID-19 Supply Portal enabled the WHO African Region to secure over 106 million PPE items, 105 million test kits, and other critical equipment [92]. Ethiopia, with support from the WHO, procured essential supplies internationally after local assessments revealed limited domestic availability, supplemented by donations from the private sector and bilateral partners [11]. Countries also leveraged digital tools for planning, coordination, and real-time monitoring, including electronic logistics management systems such as eELMIS in Uganda [136], COVID-19 Connect and DATCOV in South Africa [85], and broader platforms such as DHIMS2, SORMAS, and CommCare [42, 108, 137]. Innovations such as locally produced PPE, solar-powered oxygen systems, drone-based delivery, and contact-free WASH devices were also deployed to address supply shortages and expand service delivery capacity (Ngongoni, 2021).

Revised framework

Based on the findings of this review, the initial conceptual framework (Fig. 1) was refined to better capture the dynamic and interconnected factors shaping health system resilience in Africa during public health emergencies. While the original framework provided a general representation of resilience components, it did not fully reflect the empirically derived structures of pandemic response systems identified across the reviewed studies. The revised framework (Fig. 3), therefore, presents a more integrated resilience model that organises resilience strategies into three interconnected domains (leadership and governance, policy and societal response measures, and health system measures), supported by enabling systems and contextual factors that shape emergency response capacity. These elements illustrate how coordinated governance, responsive health system functions, and inclusive societal measures interact to strengthen health system resilience during public health emergencies.

Fig. 3.

Revised Conceptual Approach for Strengthening Health System Resilience to Health Emergencies

Within the leadership and governance domain, four key subcomponents were introduced: political leadership and commitment; multisectoral and decentralised coordination; legal and policy frameworks; and transparent monitoring and evaluation systems. These elements reflect recurring governance challenges identified during the Ebola and COVID-19 responses, including delayed emergency activation, fragmented coordination across sectors and local levels, politicisation of health decisions, and donor-driven agendas that sometimes undermine nationally led strategies [11, 64, 65, 73]. Strengthening these governance structures reinforces the central role of leadership in enabling accountability, coordination, and timely decision-making during health emergencies.

The social and economic support component was broadened to emphasise targeted financial protection measures and collaboration with local actors to ensure that vulnerable populations are not excluded from relief interventions [60, 73, 75]. These measures highlight the importance of integrating social protection systems into public health responses to mitigate the disproportionate impact of crises on marginalised populations. Similarly, the lockdown and containment measures component was refined through an equity lens to acknowledge the social consequences associated with stringent restrictions. Evidence from several African settings points to significant challenges, including economic hardship, mental health strain, gender-based violence, and disruptions to child welfare and livelihoods during prolonged lockdowns [49, 59, 75, 86, 90, 91]. These insights informed the integration of social safeguards within containment strategies in the revised framework.

To further strengthen societal resilience, the framework formalises the role of non-state actors under a whole-of-society approach. This adjustment recognises the contributions of community organisations, civil society groups, and private sector actors in resource mobilisation, community engagement, and service delivery during health emergencies [40–42, 59, 63, 92]. In addition, the RCCE component was strengthened to incorporate culturally sensitive messaging, community-led engagement mechanisms, trusted local influencers, and strategies for managing misinformation and rumours. These additions respond to documented challenges related to misinformation, stigma, and distrust during outbreak responses [13, 65, 100, 101, 138].

The health system measures domain was also refined to reflect the operational realities observed during COVID-19 and Ebola responses, while remaining aligned with the WHO health system building blocks. Within public health functions, the revised framework highlights the importance of community-based approaches in surveillance, testing, and vaccination campaigns. Evidence from several African countries demonstrates that community health structures and decentralised surveillance systems played a critical role in early detection, contact tracing, and vaccine delivery [42, 59, 61, 85, 92, 108]. Similarly, the service delivery component was refined to emphasise maintaining continuity of essential health services through inclusive delivery approaches and digital innovations that helped minimise disruptions during the COVID-19 and Ebola outbreaks [65, 105, 117, 119].

Given the pressures experienced by frontline health workers, the human resources for health component was reframed as workforce sustainability to emphasise measures that protect and retain the workers during public health emergencies. Accordingly, the component was expanded to include psychosocial support, occupational safety measures, incentives, and workforce capacity-building initiatives to address burnout, mental stress, fear of infection, and stigma experienced by healthcare workers during the pandemic [41, 73, 75, 77, 86, 90, 91, 102, 112]. Complementing this, the HIS component was refined to prioritise data interoperability and real-time reporting capabilities. These improvements address persistent challenges identified across several African countries, including fragmented reporting systems, limited integration of digital platforms, and weak analytical capacity [7, 77, 85, 130]. The finance domain highlights the importance of emergency resource mobilisation and health financing reforms to support rapid response, maintain essential health services, and reduce reliance on external funding during public health emergencies

Furthermore, the operational support and logistics segment was reframed as health infrastructure readiness and operational support. Under this component, we added two key elements: robust supply chain and emergency facility readiness. These additions respond to documented gaps in supply chain management, procurement inefficiencies and infrastructure limitations, including ICUs, medical equipment, ambulances and WASH facilities in tackling case surges during health emergencies [7, 11, 41, 42, 61, 85].

Finally, across all domains, the revised framework integrates several cross-cutting elements that strengthen its coherence and policy relevance. At the centre of the framework are equity, inclusiveness, and coherence, which function as guiding principles across all response domains. Equity ensures that underserved and vulnerable populations are prioritised, inclusiveness promotes broad stakeholder engagement through multisectoral collaboration, and coherence supports alignment between national, regional, and global health strategies. In addition, digital health and data systems operate as foundational enablers that support surveillance, service delivery, logistics coordination, and evidence-based decision-making across the framework. The model also incorporates a contextual layer capturing broader resilience enablers and constraints, including public and institutional trust, community legitimacy, domestic financing, local production capacity, innovation, and workforce flexibility. These contextual factors can either strengthen or constrain health systems’ ability to absorb shocks and maintain functionality during crises.

Discussion

Drawing on diverse sources, including policy documents and academic literature, the review identifies a wide range of resilience-building efforts and persistent challenges. These insights informed a revised conceptual framework (Fig. 3) grounded in the five core resilience attributes proposed by Kruk et al. [9]: awareness, diversity, self-regulation, integration, and adaptability. These attributes reflect the system’s inherent capacity to absorb, adapt, and transform in response to shocks, while resilience strategies refer to the tangible actions taken to reinforce these capacities. The discussion illustrates how specific strategies enhance attributes across different contexts, while also highlighting critical gaps that require further attention.

The findings highlight the central role of strong leadership and effective governance in strengthening health system resilience. High-level political commitment and the establishment of multisectoral committees led by top political leaders, together with operational structures such as EOCs, IMS, and Rapid Response Teams, significantly improved system integration, situational awareness, and timely crisis response [41, 43, 58–60, 63, 64]. These findings align with WHO guidance emphasising trusted leadership, early threat detection, and multisectoral coordination as key components of effective crisis mitigation [22]. Nonetheless, governance responses were not uniformly effective. In some contexts, decentralisation challenges, systemic fragmentation, politicised decision-making, misinformation, declining public trust, and weak accountability mechanisms undermined governance effectiveness [64, 65, 73, 74]. Such constraints limited system adaptability and self-regulation, and thus emphasise the need for sustained political commitment, transparency, accountability, and inclusive governance reforms.

To address these gaps, the revised framework emphasises decentralised coordination, robust legal and policy frameworks, and transparent monitoring and evaluation mechanisms as core strategies for strengthening resilience. From the perspective of Kruk et al.‘s [9] resilience attributes, these elements enhance integration by promoting coherence and coordination across national, regional, and local levels, reducing fragmentation and duplication. Decentralised governance structures further enhance diversity by enabling locally tailored responses suited to contextual needs and capacities. Transparent monitoring systems support self-regulation by reinforcing oversight, accountability, and continuous learning. These strategies contribute to a more adaptive and responsive system capable of anticipating, absorbing, and responding effectively to future health emergencies.

In parallel, social and economic support mechanisms played an important role in mitigating the socioeconomic consequences of pandemic control measures. Many African countries implemented social protection programmes to cushion the effects of lockdowns and movement restrictions [42, 43, 74]. Collaboration with local authorities, civil society organisations, and NGOs, often supported by mobile technologies, facilitated the rapid delivery of financial assistance to vulnerable populations [66, 74]. However, weaknesses in data systems, limited access to formal financial services, inequitable distribution of relief support, and governance challenges, including corruption and politicisation, exposed significant gaps in equity and diversity within these interventions [60, 73, 75].

These challenges reflect Kruk et al.’s [9] argument that resilient health systems must address a broad spectrum of societal needs rather than narrowly targeting specific population groups. This does not imply that targeted interventions should be avoided; rather, they should be embedded within inclusive and flexible systems. Targeted social protection enhances equity, while diverse and adaptable systems enable responsiveness to varying needs. Within the revised framework, targeted financial safety nets strengthen self-regulation by protecting vulnerable groups during crises, while collaboration with local actors enhances adaptability, diversity, and integration in service delivery. These strategies build trust, improve responsiveness, and contribute to what Kruk et al. describe as the “resilience dividend.” Without this balance, resilience efforts risk deepening existing inequalities instead of strengthening overall system stability [26].

One of the most significant challenges identified in this review was the limited ability of health systems to maintain essential services during crises. According to Kruk et al. [9], self-regulating systems should be able to isolate health threats while maintaining routine health services and minimising broader societal disruption. However, many countries experienced severe disruptions in essential services, including HIV care, tuberculosis and malaria treatment, and immunisation during both Ebola outbreaks and the COVID-19 pandemic [41, 61, 117].

While telemedicine provided alternative service delivery pathways, it also exposed structural inequalities related to poor internet connectivity, limited infrastructure, shortages of skilled personnel, and regulatory constraints [105, 119, 122]. Similar inequalities emerged in other sectors, such as education, where digital learning widened pre-existing disparities [90]. These experiences reinforce concerns that resilience strategies lacking an equity lens risk perpetuating structural inequalities [26, 37]. The revised framework, therefore, promotes inclusive service delivery and equitable digital innovation by expanding digital infrastructure in underserved areas, strengthening digital literacy, subsidising access to digital tools, and developing inclusive regulatory frameworks to ensure that digital technologies enhance rather than restrict access to care.

The whole-of-society approach also played a critical role in mobilising resources and expanding response capacity. Multisectoral collaboration involving governments, donors, NGOs, civil society organisations, private sector actors, and community leaders helped strengthen infrastructure and mobilise resources for crisis response [40–42, 59, 63, 92]. However, these collaborations were mostly ad hoc rather than institutionalised, limiting long-term sustainability. As Kruk et al. [9] emphasise, effective integration requires formal governance structures, legal frameworks, and clear communication channels to enable flexible mobilisation of resources during crises. In their absence, collaboration remains fragmented and difficult to sustain. Formalising the role of non-state actors, as proposed in the revised framework, will strengthen integration, foster trust, and enhance the adaptability and responsiveness of service delivery.

RCCE were also central to effective outbreak responses. RCCE strategies relied on multiple communication channels, including radio, television, social media, and community engagement initiatives, often supported by NGOs and survivor networks (social media, radio, national broadcast, etc.), and were reinforced by collaboration with NGOs, the use of survivor stories, and the formation of RCCE working groups [61, 65, 85, 92, 93, 100]. These initiatives strengthened public awareness, countered misinformation, and improved community compliance with public health measures. Community-led initiatives, including localised surveillance and reintegration programmes, further strengthened system adaptability and self-regulation [13, 95, 100, 138].

However, risk communication was sometimes weakened by overly centralised communication structures, poor coordination, digital divides, and persistent misinformation [13, 95, 101–104, 112, 138]. As Kruk et al. [9] note, adaptability requires the ability to adjust strategies in response to real-time learning and local context. Top-down communication approaches that fail to incorporate community knowledge therefore risk undermining resilience. Evidence from Ebola responses in Liberia and the Democratic Republic of Congo illustrates how community resistance often stemmed from mistrust and exclusion from decision-making processes rather than ignorance or irrational behaviour [104]. Saulnier et al. [139], similarly caution that top-down, one-way communication limits community agency and risks undermining resilience. Strengthening trust through community participation, culturally appropriate messaging, and engagement of trusted local leaders is therefore critical for improving response effectiveness and adherence to public health measures [13, 70, 93] (Rugarabamu et al., 2020; Adebisi et al., 2021). In response, the revised framework emphasises community-led engagement, culturally sensitive communication, trusted local influencers, and structured infodemic management as key strategies for strengthening system legitimacy and adaptive learning.

Health workforce resilience was also significantly strained during both crises. Shortages of personnel, inadequate protective equipment, unsafe working conditions, fear of infection, and high levels of mental and occupational stress placed considerable pressure on frontline health workers [41, 73, 77, 90, 91, 102]. Nevertheless, many countries demonstrated adaptability through rapid recruitment of additional personnel, redeployment of community health workers, and targeted training in areas such as infection prevention, surveillance, and mental health support [11, 42, 43, 92, 128]. Ghana, for instance, expanded its public HWF by 35% during the COVID-19 crisis [128].

However, many of these measures were short-term responses rather than sustained investments in human resource development. In some contexts, incentive schemes were unevenly implemented, generating dissatisfaction among excluded health workers [60]. Community health workers also often operated under precarious conditions with limited institutional support. Other studies echo this concern, revealing that while CHWs were essential to COVID-19 response efforts, their work came at a high personal cost, bearing heavy emotional, mental, physical, and financial burdens [26, 140]. These challenges highlight the need for comprehensive human resource reforms. The revised framework, therefore, emphasises workforce sustainability through psychosocial support, occupational safety, incentives, and continuous capacity-building to enhance workforce preparedness, diversity, stability, and adaptability.

Operational and logistical challenges exposed significant weaknesses in system preparedness during the early phases of both Ebola and COVID-19 responses. These included shortages of essential medicines and PPE, limited ICU and oxygen capacity, weak supply chains, inadequate infrastructure, poor WASH facilities, over-reliance on imports, and limited local manufacturing capacity [85]. Over time, however, these constraints stimulated innovation and adaptive responses. Investments in treatment centres, oxygen production, and digital logistics platforms improved coordination, supply chain visibility, and service delivery [43, 117, 136].

The reviewed studies further indicate that technological innovations were central to mitigating supply-side disruptions and sustaining essential services. Examples include drone delivery of medical supplies in Ghana, Rwanda, and Kenya; digital partnerships to expand access to health products; and the local production of PPE, solar-powered oxygen systems, and contact-free WASH devices [121]. These responses reflect a shift from initial unpreparedness to more coordinated, context-responsive strategies, demonstrating how crisis-induced learning can enhance system adaptability in resource-limited settings. Building on these insights, the revised framework highlights the importance of strengthening supply chains, ensuring transparent emergency procurement, and improving facility readiness to enhance system self-regulation and operational resilience.

Across all domains, equity, inclusivity, and coherence emerged as foundational principles for resilient health systems. Yet equity considerations were often overlooked. Gender-blind policies and poorly targeted interventions disproportionately affected women and informal sector workers during lockdowns [59, 63, 75, 86, 90, 91]. Marginalised communities also faced limited access to health services, digital technologies, and social protection measures [60, 73, 74]. As Saulnier and Topp [26] warn, resilience efforts that ignore equity risk creating “bad resilience,” where systems function but impose disproportionate burdens on vulnerable populations. Resilience strategies that overlook broader socio-economic and political contexts risk overburdening vulnerable populations and falling short of achieving a truly adaptive and inclusive system. Sustained political commitment to equity is therefore essential for achieving genuinely resilient health [141].

The review also highlights a misalignment between service delivery and policy, with many initiatives remaining externally driven and insufficiently institutionalised. Fragmented, vertical programming often weakens coordination and system resilience, particularly when donor priorities diverge from national strategies, as observed in South Sudan [71], or where limited regional coordination constrains cross-border response efforts [65]. The revised framework therefore promotes stronger coherence across national, regional (e.g., Africa Centres for Disease Control and Prevention), and global health agendas, alongside institutionalised community engagement and multisectoral collaboration to strengthen coordination, resource mobilisation, and system adaptability in line with the resilience vision proposed by Kruk et al.’s [9].

Digital health and data systems emerged as critical cross-cutting enablers of resilience. Technologies such as mHealth platforms, DHIMS2, SORMAS, and electronic logistics systems significantly improved surveillance, communication, and resource tracking during health emergencies [85, 108, 130, 136] However, fragmented data systems, limited interoperability and weak digital infrastructure, particularly in rural areas, continued to constrain situational awareness and system self-regulation [65, 85, 130].

Finally, our findings suggest that health system resilience is not determined solely by formal governance and service delivery structures but is also shaped by broader contextual factors, including workforce flexibility, public and institutional trust, community legitimacy, local production capacity, domestic financing, and innovation. Workforce flexibility, such as remote work arrangements, adjustable schedules, and leave provisions, can enhance job control, engagement, and well-being among health workers. Trust and community legitimacy emerged as critical factors influencing compliance, health-seeking behaviour, and community mobilisation during health emergencies [85, 103]. Where top-down responses excluded meaningful community engagement, trust and legitimacy eroded, contributing to misinformation, resistance, and weakened response efforts [13]. Overreliance on external actors can similarly undermine sustainable system development. This underlines the importance of strengthening domestic financing and locally driven solutions. Local innovations, including solar-powered handwashing stations, domestic PPE production [43] and the adaptation of diagnostic platforms such as GeneXpert for COVID-19 testing [59] demonstrate how local capacity and investment can enhance adaptability and strengthen the broader resilience of health systems.

Strengths and limitations of the study

This study provides a comprehensive synthesis of evidence on health system responses to the COVID-19 pandemic and EVD outbreaks across Africa and develops an empirically grounded conceptual framework for strengthening health system resilience to epidemic shocks. A major strength of this review lies in the breadth of evidence considered, drawing on diverse study designs, policy documents, and reports from multiple African countries. This wide scope enabled the identification of common response patterns, governance approaches, and operational challenges across different health system contexts. Again, integrating insights from both the academic literature and policy experience provides a more holistic understanding of how health systems across the continent responded to large-scale public health emergencies. The inclusion of country-specific examples further enriches the analysis by illustrating how resilience strategies were implemented in practice across settings. In addition, the study moves beyond descriptive synthesis by developing a conceptual framework that integrates these empirical insights into a structured model for strengthening health system resilience in future emergencies.

Despite these contributions, several limitations should be acknowledged. First, the analysis focused specifically on EVD and COVID-19, which may limit the inclusion of lessons from other public health emergencies, such as cholera outbreaks, malaria, or humanitarian crises. However, these two epidemics represent the most widespread and disruptive health shocks experienced in Africa in recent decades, and thus, provide a valuable basis for examining system-level responses and resilience mechanisms. Second, consistent with the methodological approach of scoping reviews, the study did not conduct a formal quality appraisal of the included sources. While this approach allowed for the inclusion of a broader range of evidence, including policy reports and operational documents, it limits the ability to assess the relative methodological strength of individual studies. Third, the review relied primarily on publicly available literature and official reports, which may have excluded relevant unpublished experiences or locally documented practices that were not captured in the searchable databases or grey literature sources. Finally, the findings should be interpreted with caution, as health system responses are inherently shaped by political, institutional, and socio-economic contexts. Consequently, strategies that proved effective in one setting may not be directly transferable to other contexts without appropriate adaptation.

Notwithstanding these limitations, the study offers important insights for strengthening health system resilience in Africa and other regions facing similar structural and resource constraints. The conceptual framework developed in this review provides a useful foundation for policymakers, health system planners, and researchers seeking to design more integrated and context-sensitive epidemic preparedness and response strategies. Future research should further examine the long-term institutional changes that have emerged from recent epidemic responses and assess how these reforms influence health system resilience over time. In particular, there is a need for more empirical studies evaluating the sustainability of digital health innovations, local pharmaceutical and medical supply production initiatives, and financing reforms introduced during the COVID-19 pandemic. Additional research should also explore the role of community health systems, multisectoral governance arrangements, and regional cooperation mechanisms in strengthening epidemic preparedness and response. Comparative cross-country studies may provide further insights into how variations in governance structures and health system organisation influence resilience during future public health emergencies.

Conclusion

This review emphasises the need for equitable, inclusive, and coherent strategies to strengthen resilient health systems in Africa. It calls for a shift from reactive, fragmented approaches to a long-term, system-wide transformation grounded in inclusive governance, equitable social protection, robust digital health systems, a sustainable workforce, integrated and trusted community engagement, and adaptive physical infrastructure. Importantly, the review affirms that addressing deep-seated political, structural, and social inequities is crucial to ensuring resilience does not become an empty concept. The framework developed from this review provides a roadmap for policymakers to embed resilience as a core, institutional principle of long-term health system transformation, rather than a temporary emergency measure.

Electronic supplementary material

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Abbreviations

CDC

Centre For Disease Control

CHWs

Community health workers

CHN

Community health nurse

CSOs

Civil society organizations

DHIS

District health information systems

ECOWAS

Economic community of west african states

EOC

Emergency operations centre

eELMIS

Information system

EVD

Ebola virus disease

EXPH

Expert panel on effective ways of investing in health

HRH

Human resources for health

HIS

Health information systems

HWF

Health workforce

ICU

Intensive care unit

IEC

Information, education and communication

IDSR

Integrated disease surveillance and response system

IMS

Incident management system

IPC

Infection prevention control

IT

Information technology

NCDs

Non-communicable diseases

NGOs

Non-governmental organizations

PCR

Polymerase chain reaction

PoE

Port of entry

PPE

Personal protective equipment

RCCE

Risk communication and community engagement

SORMAS

Surveillance outbreak response management and analysis systems

SPL

Supplementary list

UN

United nations

WASH

Water, sanitation, and hygiene

WHO

World health organisation

Author contributions

GAN and MA conceptualized the study with input from all authors. MA, GAN, GAO, LY and AAAB conducted the searches and analyzed the extracted data. The first draft of the manuscript was produced by MA, GAN and GAO and reviewed by the remaining authors to improve the manuscript. Final editing was done by GAN and LY, and all authors have approved the final version for submission.

Funding

The research was funded by a small grant from University of Ghana Business School with Grant Number UGBS/RCC/2023-24/011.

Data availability

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

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.