Table 3.

Overview of aims, methods, concepts used and dimensions of resilience addressed by qualitative research papers (n = 16)

Author	Year	Country	Research objective	Key findings	Study design and data source	Conceptual framework used	Management capacity dimensions	Resilience outcome dimensions
Assessing national-level health system resilience in context of a specific crisis
Ager et al.	2015	Nigeria	To identify key pathways of threat to provision, response and adaption for health service resilience in Nigeria in context of Boko Haram	Transport restrictions, health worker migration and suspension of external programmes identified as threat to provision. Political will, indigenous staff commitment and policy changes supported health system recovery/function.	Structured Interviews, systems dynamics analysis with group model building approach	UK Government Humanitarian Policy (DfID 2011)	N/A	Absorption Adaptation Transformation
Alameddine et al.	2019	Lebanon; Jordan	To assess the ‘validity and utility of a capacity-oriented resilience framework […] in Lebanon and Jordan in the context of the Syrian crisis’.	‘We find that UNRWA systems in Lebanon and Jordan were broadly resilient, deploying diverse strategies to address health challenges and friction between host and refugee populations’.	Semi-structured interviews with health professionals in primary care and management functions	‘capacities’ framework (Blanchet et al. 2017)	Uncertainties Interdependence Legitimacy	Absorption Adaptation Transformation
Ling et al.	2017	Liberia	‘To understand how a health system adapts to crisis and how the priorities of different heath system actors influence this response’.	Although the Ebola epidemic stimulated some positive adaptations in Liberia's health system, building a resilient health system will require longer-term investments and sustained attention	Thematic analysis of semi-structured interviews and focus group discussions	‘resilience index’ framework (Kruk et al. 2015)	Knowledge Uncertainties Interdependence Legitimacy	Absorption Adaptation Transformation
Assessing health service delivery in context of a specific crisis
Landeg et al.	2019	United Kingdom	‘To assess the health care system impacts associated with the December 2013 east coast flooding in Boston, Lincolnshire, in order to gain an insight into the capacity of the health care sector to respond to high-impact weather’.	‘The health care sector appears to have limited capacity to respond to weather-related impacts and is therefore unprepared for the risks associated with a future changing climate’.	Semi-structured interviews with key decision-makers;Document analysis	N/A	Knowledge Uncertainties Interdependence	Absorption Adaptation
Ridde et al.	2016	Burkina Faso	To describe the management of the Ouagadougou Terrorist attack in January 2016 from the standpoint of health system resilience.	Identified strengths were an emergency response plan which had been put in place and available blood bank and psychological services. Challenges included the development, application and coordination of framework documents for financial, material and human resources.	Observations and expert interviews structured as anecdotal event report	‘Resilience index’ framework (Kruk et al. 2015)	Knowledge Uncertainties Interdependence Legitimacy	Absorption Adaptation
Back et al.	2017	United Kingdom	‘To examine escalation policy in theory and practice, using resilient health care principles to identify opportunities for improving the way escalation is planned and managed’.	Under pressure it may be difficult to dynamically reconfigure resources, such as staff and equipment and lead to informal management of processes not specified in the policies.	Policy analysis Observation	Concepts for Applying Resilience Engineering (CARE) model of resilient healthcare (Anderson et al. 2016)	Uncertainties	Adaptation
Errett et al.	2018	Canada	‘To identify maritime transportation disruption impacts on available health care supplies and workers necessary to deliver hospital-based acute health care in geographically isolated communities post-disaster’	Critical vulnerabilities to care delivery include ‘lack of information about the existing supply chain, lack of formal plans and agreements, and limited local supply storage and workforce capacity’.	Semi-structured key informant interviews	N/A	Knowledge Uncertainties	N/A
Taking a community resilience perspective
Alonge et al.	2019	Liberia	‘To understand key factors that constitute community resilience and their role in responding to the EVD outbreak in Liberia’.	‘Efforts to systematically build responsible leadership and social capital at community level, including those that strengthen bonds in communities and trust across key actors in the health systems, are needed to address health shocks like EVD outbreaks’.	Key informant interviews and a national stakeholder meeting	N/A	Legitimacy	Absorption Adaptation Transformation
Health workforce issues
Gilson et al.	2017	Kenya; South Africa	To compare experiences from district health systems in Kenya and South Africa order to reveal patterns and insights for everyday resilience	Stable governance structures and adequate resources influence everyday resilience, however empowerment of leaders, mindful staff engagement and social networks also appear important.	Case study methodology: synthesis of document reviews, interviews, group discussions and observations	Vulnerability reduction framework (Béné et al. 2012) Everyday resilience (Barasa et al. 2017)	Knowledge Uncertainties Interdependence	Absorption Adaptation Transformation
Raven et al.	2018	Nepal; Sierra Leone	To assess how health workers cope in times of crisis and how they can best be enabled to continue their work.	‘In both contexts, health workers demonstrated considerable resilience in continuing to provide services despite limited support’.	In-depth interviews with health workers (Sierra Leone); Observation, semi-structured interviews with health workers & management (Nepal)	N/A	Knowledge Uncertainties Legitimacy	Absorption Adaptation
Russo et al.	2016	Portugal	To ‘explore physicians’ perceptions of the changes brought on by the [economic] crisis and associated austerity measures to the market for medical services, as well as to their working routines, remuneration and intention to leave the sector’.	The economic crisis brought considerable changes for the health system, however insights to existence of resilience merged	Semi-structured interviews with physicians	N/A	N/A	Absorption Adaptation Transformation
Thude et al.	2019	Denmark	‘To understand how the staff at the two wards with challenged leader teams coped with everyday work and whether the way in which the staff handled the challenges was resilient’.	‘The staff at both wards were handling the everyday work in a resilient way. […] To increase the resilience in an organisation, leaders should acknowledge the need to establish strong emotional ties among staff and at the same time ensure role structures that make sense in the everyday work’.	Semi-structured interviews with healthcare staff	N/A	N/A	Absorption
Development of preparedness checklists and assessment tools
Toner et al.	2017	USA	To use experiences from communities affected by Hurricane Sandy 2012 for developing a checklist outlining action steps for assessing and strengthening communities' health sector resilience	Description of a conceptual map of health sector resilience, with key findings organized in eight themes. Identification of recommended actions for improvement of health sector resilience at local level	key informant interviews; focus groups; literature review	N/A	Uncertainties Interdependence	Absorption Adaptation
O'Sullivan et al.	2013	Canada	To explore the complexity of disasters at the micro level and to determine levers for action to facilitate collaborative action and promote health among high risk population	‘Promoting population health in disaster context requires shifting from risk management to resilience, […] from command and control models to collaboration’.	Community-based participatory research design with focus groups	Resilient communities framework (Norris et al. 2008)Functional needs framework (Kailes and Enders 2007)	Knowledge Uncertainties Interdependence Legitimacy	N/A
Khan et al.	2018	Canada	‘To describe the essential elements of a resilient public health system and how the elements interact as a complex adaptive system’.	Eleven essential elements for public health emergency preparedness were identified, and a conceptual framework developed with ethics and values at its core.	Focus groups using Structured Interview Matrix facilitation technique	N/A	Knowledge Uncertainties Interdependence Legitimacy	N/A
Meyer et al.	2018	USA	To identify and integrate lessons from response to the EVB epidemic into an actionable checklist.	‘Health care facilities shouldered much of the response, and even those facilities with designated treatment units had to adapt in real time’. Experiences can help inform future response.	Semi-structures key informant interviews	N/A	Knowledge Uncertainties Interdependence Legitimacy	Absorption Adaptation