[Health Policy] Building a health system resilience framework: national, state, regional, and local perspectives

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.