Analysis of the Conceptualization, Frameworks, and Operationalization of Health System Resilience in Empirical Research

AIM: Health system resilience (HSR) has gained prominence in response to acute shocks and chronic stressors, particularly following the COVID-19 pandemic. This study aimed to analyze the conceptualization, frameworks, and operationalization of HSR in empirical research. METHODS: We searched PubMed, Web of Science, and Global Health databases from inception to January 26, 2024 to identify empirical HSR studies. We screened studies independently, and systematically extracted data. Analyzed were conducted across study characteristics, shocks/stressors types, conceptualizations/definitions, framework traditions, and methodological approaches. RESULTS: A total of 125 empirical studies were included, with a marked increase from 2020 onward. Most studies examined acute shocks (84%), with the largest share in the Europe (23.3%) and Africa (16.8%). HSR was predominantly conceptualized as a system capacity to absorb and adapt to shocks, while learning and transformation were less frequently operationalized. Health system-specific frameworks (e.g., Kruk; Blanchet) were most commonly used, primarily as analytical lenses rather than measurement tools. Qualitative methods predominated, although mixed-methods approaches are emerging. Evidence on continuity of essential functions and everyday resilience remained limited. CONCLUSIONS: Despite growing conceptual sophistication, empirical HSR research remains constrained by fragmented frameworks use and limited operationalization. Advancing the field requires clearer conceptual boundaries, improved methodological integration, and greater attention to how resilience is enacted in routine system functioning.