Resilience of health systems in Africa to infectious disease shocks: A systematic review

Stronger health systems are better equipped to withstand shocks and continue providing quality services as response measures are implemented. We conducted a systematic review to synthesize the understanding of the concept of health system resilience from various stakeholders in Africa, focusing on definitions and attributes of a resilient health system. We conducted a search for peer-reviewed articles and grey literature, filtered for Africa, from 1980 to 2023, using the SPIDER framework. We searched four databases: PubMed, the Bielefeld Academic Search Engine, the Cumulative Index to Nursing and Allied Health Literature, and Scopus, and reviewed the websites of the World Health Organization, Africa CDC, and Ministries of Health of African countries. Articles were selected based on set inclusion and exclusion criteria. Qualitative articles were appraised using the Critical Appraisal Skills Programme, and mixed-methods articles using the Mixed Methods Appraisal Tool. We mapped the distribution of included articles by country studied; categorized the articles based on reported shock, health system building block described; and identified the definition of health system resilience, and its attributes in each article. The search yielded 4,306 relevant records, fifty-five of which were included in the study. Studies were found from 48 of the 54 African countries. Up to 75% of the articles focused on COVID-19; others were on Ebola Virus Disease, cholera, and meningitis. Service delivery and health workforce were the most frequently studied health system building blocks. In defining or describing health system resilience, the adaptive capacity (39, 65%) was most frequently mentioned, followed by absorptive capacity (17, 28%), preparedness (3, 5%), and recovery (1, 2%). Identified attributes of a resilient health system were: community engagement and involvement; leadership and governance; collaborations and partnerships; human resources for health; health education and promotion; health information systems; health service delivery; decentralization and local governance; health infrastructure and logistics; preparedness; learning and adaptation; and innovation and financing. Our review reports four core capacities that define a resilient health system: preparedness, absorptive capacity, adaptive capacity, and recovery. Essential attributes encompass community engagement, health education and promotion, leadership and governance, surveillance and laboratory capacity, innovation, service delivery, and adaptability.