Measuring what matters: key indicators for performance and resilience in fragile, low-income contexts. A scoping...

Measuring and monitoring health system performance and resilience is key for planning and managing resilience-building activities. Recurrent simultaneous shocks, particularly in fragile contexts which are home to nearly one quarter of the world's population, underscore the need for resilient health systems able to provide the needed health care. This scoping review aims to examine how the performance and resilience of the health system have been assessed and measured in fragile, low-income contexts, identify gaps and provide recommendations to improve resilience measurement.

A scoping review of peer-reviewed literature on health systems' performance or resilience indicators was conducted following PRISMA guidelines. Only studies that were set in countries classified by the OECD as fragile and low-income and that took a whole-of-system approach were included. Of 2175 articles identified 18 met the inclusion criteria. Indicators were classified against the WHO's building blocks and four resilience dimensions, then assessed for comparability, feasibility and relevance to resilience.

The studies covered 23 of the 24 countries classified as fragile and low-income by the OECD. A total of 466 indicators were identified. Among the four dimensions of resilience, 39% of the indicators assessed the system's capacity to manage multiple- and cross-scale dynamics and feedback (interdependence), and only 5% of the indicators assessed the capacity to anticipate and cope with shocks (uncertainty). Less than half of the indicators (n = 230) rely on data from routine health information systems or global datasets, those were classified as feasible. In total, 58% of indicators enable comparison across countries and subnational entities (comparable). Of the 218 indicators classified as both feasible to measure and comparable, 61 indicators were identified as relevant for assessing health system resilience and hence categorized as core indicators.

Significant gaps remain in measuring health system resilience. Qualitative indicators lacked standardization, quantitative indicators did not track health system's status over time, and few assessed the capacity to anticipate shocks. Improving resilience measurement in fragile low-income contexts requires a whole-of-system approach, using indicators that assess the health system's capacity to respond to shocks, track performance over time, and provide feedback to guide policy decisions.