Intended for healthcare professionals


Building resilient health systems: a proposal for a resilience index

BMJ 2017; 357 doi: (Published 23 May 2017) Cite this as: BMJ 2017;357:j2323
  1. Margaret E Kruk, associate professor of global health1,
  2. Emilia J Ling, researcher1,
  3. Asaf Bitton, assistant professor of healthcare policy2,
  4. Melani Cammett, professsor of government3,
  5. Karen Cavanaugh, director4,
  6. Mickey Chopra, global solutions lead for service delivery5,
  7. Fadi el-Jardali, professor of health policy and systems6,
  8. Rose Jallah Macauley, country representative7,
  9. Mwihaki Kimura Muraguri, independent consultant,
  10. Shiro Konuma, minister8,
  11. Robert Marten, health systems strengthening coordinatior9,
  12. Frederick Martineau, research fellow10,
  13. Michael Myers, managing director11,
  14. Kumanan Rasanathan, senior health specialist12,
  15. Enrique Ruelas, senior fellow13,
  16. Agnès Soucat, director of health systems14,
  17. Anung Sugihantono, director-general of public health15,
  18. Heiko Warnken, head of the development for health, social security, and population policy16
  1. 1Harvard TH Chan School of Public Health, Boston, US
  2. 2Harvard Medical School, Boston, USA
  3. 3Harvard University, Cambridge, USA
  4. 4Office of Health Systems, US Agency for International Development, Washington, DC, USA
  5. 5World Bank, Washington, DC, USA
  6. 6American University of Beirut, Beirut, Lebanon
  7. 7John Snow Inc., Monrovia, Liberia
  8. 8Mission of Japan to the European Union, Brussels, Belgium
  9. 9World Health Organization, Freetown, Sierra Leone
  10. 10London School of Hygiene and Tropical Medicine, London, UK
  11. 11The Rockerfeller Foundation, New York, USA
  12. 12UNICEF, New York, USA
  13. 13Institute for Healthcare Improvement, Cambridge, USA
  14. 14World Health Organization, Geneva, Switzerland
  15. 15Ministry of Health, Jakarta, Indonesia
  16. 16Ministry of Economic Cooperation and Development, Bonn, Germany
  17. Correspondence to: M E Kruk

Health system resilience begins with measurement of critical capacities ahead of crisis say Margaret E Kruk and colleagues

The 2014 west African Ebola epidemic shone a harsh light on the health systems of Guinea, Liberia, and Sierra Leone. While decades of domestic and international investment had contributed to substantial progress on the Millennium Development Goals,1 2 national health systems remained weak and were unable to cope with the epidemic. Routine care of the population also deteriorated during the outbreak.1 2 3 4 Surveillance systems did not function effectively, allowing Ebola to spread within and between the countries. Global institutions were slow to respond to the crisis, squandering an opportunity to stem its course.5 6 7

Since then, diverse panels of experts have pointed to political and technical deficiencies in multilateral organisations in tackling health crises.8 9 10 11 These reports have noted that the first line of defence against future pandemics is an effective national health system. They have also called for better measurement of public health capacity, and investment to build resilient health systems—systems that can withstand health shocks while maintaining routine functions.10 The issue of how global bodies can support countries in withstanding future health shocks is playing out now in the election of the new director general of WHO, with several candidates making health system resilience part of their election planks.

Based on recent literature, this paper defines health system resilience as “the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learnt during the crisis, reorganise if conditions require it.”12 Health system resilience is relevant in all countries facing health shocks—whether sudden (Ebola, earthquakes, terror attacks, refugees), slower moving (new pathogens such as …

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