Getting unstuck: reframing health systems strengthening and resilience in fragile and conflict-affected settings

The concepts of health systems strengthening and health systems resilience are conceptually different but often used interchangeably in health policy and systems research and practice. Operationalising them can be difficult, but both are particularly relevant in contexts of conflict, violence and institutional fragility. In the current landscape of increasing complexity of humanitarian crises and constrained resources, understanding their meaning can be helpful to reaffirm their significance and value for achieving equitable access to care for the most vulnerable populations.We propose reframing health systems strengthening and resilience across three key dimensions: actors, levels and time. Donors and multilateral and international organisations need to explicitly recognise and engage a broader range of local health systems actors, including community-based, faith-based and non-state actors, alongside national authorities. Actors should work across levels, from individual and communities to district and national domains, minimising gaps and vulnerabilities. It is also crucial to adopt longer time frames in the conception, design, implementation, monitoring and evaluation of interventions to strengthen health systems and increase their resilience in fragile and conflict-affected settings. This timeframe shift can help mitigate potential unintended long-term consequences of short-term interventions, support sustainability, improve learning capabilities and enhance transformation.Such a three-pronged shift demands a deeper engagement with the affected communities and local health actors. It entails transferring decision-making power to them rather than exclusively transferring risks. This can ground health systems strengthening and resilience interventions in the contextual reality and needs rather than in externally defined priorities and frameworks.