3. Building a health system resilience framework: national, state, regional, and local perspectives

Antonio, M., Paschoalotto, C., Lazzari, E. A., Rocha, R., Massuda, A., & Castro, M. C. (2025). Building a health system resilience framework: national, state, regional, and local perspectives. www.thelancet.comThis study proposes a Health System Resilience (HSR) framework specifically designed for the decentralized context of Brazil’s Unified Health System (SUS). Resilience is defined as the system’s ability to absorb, adapt, and transform its essential functions in order to preserve equity under acute shocks and chronic stressors. The framework was developed and validated through a three-phase qualitative process involving 48 national and international experts, resulting in nine dimensions, 18 subdimensions, and 65 indicators applicable at federal, state, regional, and municipal levels. A key contribution is the clear distinction between routine system performance and resilience capacity, emphasizing dynamic capabilities such as workforce adaptability, real-time monitoring, emergency regulation, and multilevel governance. The model is designed as a practical management tool, proposing a six-step implementation cycle that includes scoping, mapping, scoring, prioritization, planning, and continuous monitoring. Although tailored to the SUS, the framework’s logic is transferable to other decentralized health systems worldwide.