Resilience dimensions in health system performance assessments, European Union.

Objective: To explore the definition and operationalization of resilience in health system performance assessments in European Union countries. Methods: We conducted multiple empirical case study analyses. We identified relevant cases through a literature review from 2014 to 2023 using Google Scholar and through a snowball technique to retrieve additional information. We included only documents that explicitly mentioned resilience in health system performance assessments. We performed a content analysis to identify common patterns in defining resilience. Findings: The final sample consisted of six countries: Belgium, Croatia, Czechia, Estonia, Ireland and Italy. Each country adopted a distinct approach to conceptualizing resilience, with countries prioritizing specific aspects based on lessons learnt from the coronavirus disease 2019 (COVID-19) pandemic. Some countries focused on maintaining essential health-care services and protecting vulnerable groups. Other countries prioritized management capacity, staff preparedness, digital health utilization and strengthening of primary health care. Content analysis revealed six resilience definitions derived from the key performance indicators: addressing unmet needs and maintaining outcomes; protecting vulnerable groups; acquiring and using resources; having trained and prepared staff in place; using digital health; and strengthening primary health care. Conclusion: Integration of resilience into the health profiles of European Union countries preceded its inclusion in national health system performance assessments, the latter of which became more prominent after the COVID-19 pandemic. Variations in interpretations within health system performance assessments reflect differences in indicators and policy responses.