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

## TL;DR

This paper presents a framework for building health system resilience in Brazil, focusing on decentralized governance and practical implementation steps.

## Contribution

The novel contribution is a Brazil-specific health system resilience framework with nine dimensions and 65 indicators for multi-level governance.

## Key findings

- The framework distinguishes steady-state performance from resilience-specific capacities.
- It includes nine dimensions, 18 subdimensions, and 65 indicators for governance and emergency response.
- The framework is adaptable to other decentralized health systems with appropriate modifications.

## Abstract

Health system resilience (HSR) is essential to sustaining equitable essential functions under acute and chronic stressors in decentralized systems. We developed and validated a Brazil-tailored HSR framework that distinguishes steady-state performance from resilience-specific capacities and assigns responsibilities across federal, state, regional, and municipal levels. Using a three-phase qualitative deductive–inductive approach with 48 international and national experts, we identified nine dimensions, 18 subdimensions, and 65 indicators that prioritise governance coherence, surge workforce strategies, emergency regulation, real-time monitoring, and access to critical technologies. The framework clarifies boundaries between general health system performance and adaptive, absorptive, and transformative functions, and specifies how managers can apply it in practice through structured scoping, mapping, scoring, prioritisation, planning, and monitoring steps. Although designed for Brazil's Unified Health System (SUS), the development logic generalises to other decentralised contexts with appropriate re-allocation of responsibilities and calibration to national financing rules. This policy-facing tool supports actionable resilience strengthening in complex, multi-level systems.