1. Introduction
Health systems’ institutional choices are inherently political – they reflect contested interests, values, and power dynamics rather than neutral or purely technical decisions (Toth, Reference Toth2021). The same holds true for the pathways toward Health System Resilience (HSR), which unfold within specific health system contexts. Although HSR has become a key objective in health policy reform and research, it is frequently conceptualised as a technical or managerial issue, detached from the political environments in which health systems operate.
This paper examines HSR from a political science perspective, arguing for the adoption of a ‘systemic approach to resilience’ (Capano and Woo, Reference Capano and Woo2017, 8) that is closely linked to governance arrangements and policy processes. It argues that the capacity of health systems to become resilient depends largely on political factors, namely the interplay between institutions, actors, and interests that shape and constrain these systems. This aligns with an often overlooked insight in the resilience literature: that ’demands for resilience without the collective and infrastructural powers and resources to realise resilience are disingenuous’ (Rose and Lentzos, Reference Lentzos, Rose, Trnka and Trundle2017, 45). While HSR has received increasing scholarly attention in recent years, its systematic integration with political theories of health remains underdeveloped. To address this gap, the paper draws on a scoping review to explore how political dynamics – including governance structures, stakeholder agency, power relations, and ideational frames (Agartan and Béland, Reference Agartan, Béland, Powell, Agartan and Béland2024) – are addressed in the current literature on HSR. In doing so, it contributes to the emerging debate on how a political science of health (de Leeuw et al., Reference de Leeuw, Fafard, Cassola, Fafard, Cassola and de Leeuw2022; Fafard et al., Reference Fafard, Cassola, Weldon, Fafard, Cassola and de Leeuw2022) can support more politically informed and effective resilience strategies. Addressing audiences in public and global health, political science, and interdisciplinary health research, this paper aims to bridge disciplinary perspectives and promote a more nuanced understanding of HSR.
The remainder of this paper is structured as follows: Section 2 outlines the theoretical background on HSR and introduces a basic framework of political theories of health for analysing HSR. Section 3 provides an overview of the methodology used in the scoping review. Section 4 explores the current focal areas of HSR research from a governance and politics perspective. Building on these insights, Section 5 discusses findings from the scoping review in light of the political theories of health framework. Finally, Section 6 summarises the paper’s key takeaways and outlines implications for future research.
2. Theoretical background
2.1. Health system resilience: a contested concept
HSR has become a new desideratum of health system research and policy reform. One reason for this is the ‘polysemic’ (Turenne et al., Reference Turenne, Gautier, Degroote, Guillard, Chabrol and Ridde2019, 173) nature of the concept, which makes it difficult to define and operationalise. Originating as a response to the Ebola crisis in West Africa in 2014, the concept gained prominence during the COVID-19 pandemic. HSR is typically defined by a health system’s ability to prepare for, manage (absorb, adapt, and transform), and learn from shocks (Thomas et al., Reference Thomas, Sagan, Larkin, Cylus, Figueras and Karanikolos2020), as well as to ‘bounce back’ and ‘continue to function’ in the face of crises (Turenne et al., Reference Turenne, Gautier, Degroote, Guillard, Chabrol and Ridde2019). This framing draws conceptually on systems thinking and complexity theory (Blanchet et al., Reference Blanchet, Nam, Ramalingam and Pozo-Martin2017; Therrien et al., Reference Therrien, Normandin and Denis2017), which view health systems as dynamic and adaptive entities rather than static infrastructures.
At the same time, scholars have emphasised the necessity of ‘everyday resilience’ (Gilson et al., Reference Gilson, Barasa, Nxumalo, Cleary, Goudge, Molyneux, Tsofa and Lehmann2017) to respond to persistent system-level challenges. As such, HSR places a strong emphasis on inherent coping mechanisms and management capabilities (Blanchet et al., Reference Blanchet, Nam, Ramalingam and Pozo-Martin2017), often assuming that ‘building back better’ is achievable through effective policy reform. However, critics have pointed out that HSR frameworks frequently neglect structural conditions and power asymmetries, framing resilience as an apolitical outcome (Topp, Reference Topp2020, Reference Topp, Thomas and Fleming2024). Moreover, the role of public health within HSR remains contested. While some approaches limit HSR to the healthcare sector, others conceptualise it as a ‘boundary object’ (Marchal et al., Reference Marchal, Michielsen, Simon, Verdonck, Accoe, Tonga, Polman, Tawaytibhongs, Cornu, Dens, Sy, Nieto-Sanchez and Van Belle2023), situated at the interface between public health, healthcare, and adjacent policy fields. Some stakeholders frame resilient systems as those that avoid increased public spending, promoting health literacy and behaviour change over structural reform (Chopra and Kasper, Reference Chopra and Kasper2021; Topp, Reference Topp2020).
2.2. Political theories of health: bridging public health and political science
In health sciences, the Political Determinants of Health (PDoH) framework has become a dominant way in which researchers approach politics (Dawes et al., Reference Dawes, Amador and Dunlap2022; Kickbusch, Reference Kickbusch2015). They include, but are not limited to, governance arrangements, political leadership, institutional path dependencies, stakeholder agency, and ideological orientations towards health (e.g., whether it is predominantly perceived as an individual or a collective good). While initially shaped by concerns over health equity, the PDoH framework is increasingly seen as a functional tool to interrogate the political underpinnings of health system design, reform trajectories, and governance arrangements. As such, the PDoH framework represents a significant attempt by public health scholars to integrate political science perspectives into health research (Lynch, Reference Lynch2023). At best, the concept can contribute to the evolving field of ‘health political science’ (Fafard et al., Reference Fafard, Cassola, Weldon, Fafard, Cassola and de Leeuw2022; Harris, Reference Harris2022) and support a more realistic understanding of health policy processes (Mackenbach, Reference Mackenbach2014). The PDoH framework also provides an entry point to examine global health governance (Kickbusch and Reddy, Reference Kickbusch and Reddy2015; Struckmann, Reference Struckmann, Deciancio, Nemiña and Tussie2022), where transnational actors such as WHO, the World Bank, and philanthropic foundations shape resilience discourses – often without democratic accountability or sensitivity to national political contexts. However, questions remain as to whether current uses of the PDoH in health research amount to ‘political science in public health’ or rather ‘political science with public health’ (Fafard et al., Reference Fafard, Cassola, Weldon, Fafard, Cassola and de Leeuw2022, 20). In other words, political science knowledge is largely employed instrumentally to support functionalist perspectives that emphasise predefined public health goals (e.g. system performance and coordination) or structuralist approaches focusing on power asymmetries and political-economic constraints within health systems. By contrast, institutionalist perspectives, which analyse how formal rules, norms, and path dependencies shape governance capacities and resilience outcomes, are rarely substantively integrated into genuinely interdisciplinary research approaches.
In this paper, it is argued that the PDoH framework is not suitable to analyse the political constitution of health systems and their capacity for resilience. The PDoH framework is only partially connected to contemporary political science theories, particularly scholarship on the impact of ideational frames (Agartan and Béland, Reference Agartan, Béland, Powell, Agartan and Béland2024) and institutions (Powell and Béland, Reference Powell, Béland, Powell, Agartan and Béland2024) towards health policy processes. Resilience can be considered an ideational frame par excellence that, however, evolves in interaction with institutional dynamics within domestic and global health policy. To strengthen the analytical grounding of the relation between institutional path dependencies and resilience, this paper also draws on core strands of institutional theory in political science (Peters and Pierre, Reference Peters, Pierre, Powell, Agartan and Béland2020). Historical institutionalism highlights how path dependencies, critical junctures, and institutional layering shape governance capacities and constrain reform options over time. Sociological institutionalism emphasises the stabilising role of norms, professional cultures, and taken-for-granted rules, while discursive institutionalism focuses on how ideas, narratives, and frames enable or limit institutional change through policy discourse (Schmidt, Reference Schmidt2008).
Building on these traditions, political theories of health conceptualise governance as the institutionalised distribution of authority and decision-making power, leadership as a situated exercise of agency within these structures, and power as embedded in formal rules, norms, and resource asymmetries. From this perspective, the interplay between institutional structures and stakeholder agency shaped by path dependencies, veto points, and institutional layering conditions whether and how health systems develop governance capacities that enable resilience (Lee and Crosbie, Reference Lee and Crosbie2020; Toth, Reference Toth2021). These structure-agency relations matter for resilience because they determine which actors can mobilise resources, define policy priorities, and exercise leadership when health systems face shocks.
Moreover, this institutional sensitivity helps explain why governance opportunities for HSR differ markedly across health system types. For example, in National Health Service (NHS) systems, particularly those with a strong primary care orientation (e.g. Sweden), institutional arrangements provide governance capacities that differ fundamentally from those in Statutory Health Insurance (SHI) systems, where hospital care is traditionally dominant and public health authorities are comparatively marginalised (e.g. Germany) (Ewert et al., Reference Ewert, Wallenburg, Winblad and Bal2023). From the perspective of political theories of health, health politics are therefore not shaped by generic political ‘determinants’ but by institutional designs that produce distinct resilience trajectories, ranging from the reproduction of existing response patterns to incremental adaptation or transformative change in the face of shocks. This system focus is largely absent from the PDoH literature, which frequently refers to stakeholders, power relations, and policy processes without systematically situating these factors within governance architectures of different health systems. A similar limitation applies to parts of the global health literature, where a more sustained engagement with political science – specifically, with analyses that examine network dynamics and the actual roles and influence of actors within global health governance – is widely regarded as essential (Hoffman and Cole, Reference Hoffman and Cole2018) and, indeed, ‘indisputable’ (Stoeva, Reference Stoeva2022, 2082). This gap persists despite a substantial body of political science research that offers detailed insights into how global institutions, funding arrangements, and geopolitical dynamics shape the resilience of global health systems (McInnes et al., Reference McInnes, Lee and Youde2018; Parker & García, Reference Parker and García2018), yet remains only selectively integrated into HSR scholarship.
Taken together, understanding HSR through political theories of health requires unpacking the institutional configurations and power dynamics that define who is able to shape resilience strategies in a certain health system and whose interests are served by them. This perspective invites normative questions about voice, representation, and equity that are often absent in technical resilience assessments. In short, identifying country-and context-specific institutional underpinnings of health is a prerequisite for understanding and supporting systematic analysis of HSR.
3. Methodology
This paper draws on a scoping review to examine literature that addresses the political nature of HSR – a concept discussed across health policy, public health, global health, and healthcare management. Scoping reviews are particularly suited for mapping key concepts and identifying gaps in complex, interdisciplinary research fields (Arksey and O’Malley, Reference Arksey and O’Malley2005). Given the heterogeneity of approaches to politics in HSR and the varying degrees of explicitness with which political aspects are addressed, a narrowly defined research question would be too restrictive.
Instead, this review applies an inclusive logic to explore the breadth of ways in which political determinants intersect with the HSR discourse. The guiding research question is:
What can be learned from the existing literature about the political nature of Health System Resilience (HSR)?
To identify relevant literature, peer-reviewed articles were retrieved from three widely used databases – PubMed, Web of Science, and Scopus – which cover both health – and policy-oriented publications. The following Boolean search combinations were applied:
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• ‘health system* resilience’ AND ‘poli*’
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• ‘health system* resilience’ AND ‘govern*’
These terms were selected after pre-tests demonstrated they offered the most appropriate balance between breadth and specificity. A fourth database (JSTOR) was considered but excluded due to a low yield of relevant results (fewer than five). While omitting search terms beyond ‘poli*’ and ‘govern*’ may exclude some literature that discusses politics implicitly, it was judged that such sources would rarely focus on political determinants in a meaningful way.
The inclusion was limited to English-language, peer-reviewed journal articles published from 2014 onward (i.e., until April 2025), covering the decade following the 2014–2016 Ebola outbreak, which marked the emergence of the HSR concept, and including the COVID-19 period, which significantly advanced its development.
3.1. Screening and inclusion process
The search across the three databases yielded 1,577 articles (Scopus = 1,184; PubMed = 176; Web of Science = 217), which were imported into Rayyan software to facilitate the removal of duplicate records (n = 295). This resulted in a dataset of 1,282 articles subjected to a three-step screening and inclusion process (see Figure 1).
Flow diagram of the conducted scoping literature review.
In the first step, titles and abstracts were screened according to basic eligibility criteria: studies had to address HSR in a substantial way and engage – explicitly or implicitly – with its political dimensions. This led to the selection of 61 articles for full-text review.
The second step applied more refined criteria to assess the conceptual and analytical depth of the studies. To be included, articles needed to introduce at least a minimal HSR concept, offer a theoretical framework, or engage in substantive discussion of resilience. Moreover, studies had to examine relevant policy processes, governance mechanisms, or political decision-making. Following this full-text assessment, 47 articles were retained.
In a third and final step, four additional studies were added based on expert judgement, reflecting the authors’ familiarity with the field and awareness of key literature not captured through the initial database search.
The final sample comprised 51 articles, all of which were reviewed in-depth with regard to how they addressed political aspects of HSR, including governance arrangements, institutional path dependencies, stakeholder agency, power relations, and ideational frames. A detailed overview of all included studies – summarising their geographical focus, study design, research focus, and the political determinants covered – is provided as supplementary material (see annex).
3.2. Limitations
While the selected databases and search terms provided a broad overview of relevant literature, certain limitations of the review process must be acknowledged. First, articles published in Frontiers journals were excluded due to ongoing concerns regarding the consistency and transparency of their peer-review processes (Owens, Reference Owens2024). While this decision was supported by expert consensus during the ECPR workshop ‘Towards a Political Science of Health and Healthcare’ (2025), it may have led to the omission of potentially relevant perspectives, particularly from interdisciplinary contributions. Second, the use of relatively narrow search terms such as ‘poli*’ and ‘govern*’ was necessary to maintain a clear focus on core political dimensions of HSR and to delineate the research process a priori. However, this approach might have introduced selection bias by underrepresenting studies addressing political determinants through concepts such as power, discourse, or ideology. Future reviews should apply broader sensitivity analyses to capture these perspectives more systematically. Together, these limitations highlight the need for reflexivity in the selection and interpretation of sources when conducting scoping reviews at the intersection of political science and public health.
4. Results from the scoping review
4.1. Development of publications
A clear majority of the included sources (n = 46) were published from 2020 onwards, marking the onset of the COVID-19 pandemic as a catalyst for intensified scholarly attention to HSR. The publication output reached its peak in 2024 (n = 11), following similarly high levels in 2023 (n = 10) and 2022 (n = 10). Numbers from 2025 (n = 6; January to April only) reflect continued academic engagement with the topic.
4.2. Distribution across disciplines, research fields, type of article, and world regions
Given the applied search terms, it was expected that the majority of included sources – based on the journals in which they were published – would fall within the fields of health and social sciences rather than the natural sciences. This assumption proved to be correct, with a distribution of 48 to 3 sources, respectively. Within the health sciences, the slight predominance of publications from global health (14) and (public) health policy and management (13) is noteworthy. The distribution of scoped sources across journals has been fairly balanced, with Health Policy and Planning (6), BMJ Global Health (4), Journal of Health Policy and Management (4), and BMC Health Services Research (3) leading in terms of the number of included articles. In addition, several articles represent joint efforts by scholars from both domains. A prime example is the most frequently cited source (more than 1430 times), i.e., Haldane et al. (Reference Haldane, De Foo, Abdalla, Jung, Tan, Wu, Chua, Verma, Shrestha, Singh, Perez, Tan, Bartos, Mabuchi, Bonk, McNab, Werner, Panjabi, Nordström and Legido-Quigley2021), which was authored by an interdisciplinary team and published in a distinguished medical journal (i.e., Nature Medicine). Notably, the minority of sources were published in journals with a strong focus on determinants of health policymaking processes, such as Health Policy or Health Economics, Policy and Law. Single-country analyses are most often article type among the scoped sources (20), followed by comparative studies (12), literature reviews (10) and commentaries, viewpoints or editorials (7). While most sources focus on HSR in Western, industrialised countries – or conduct comparative research dominated by these contexts – a number of studies (12) centred on the Global South (e.g., Chamla et al., Reference Chamla, Iwu-Jaja, Jaca, Ndlambe, Buwa, Idemili-Aronu, Okeibunor, Wiysonge and Gueye2024; Narwal and Jain, Reference Narwal and Jain2021; Regmi et al., Reference Regmi, Bertone, Shrestha, Sapkota, Arjyal, Martineau, Raven, Witter and Baral2024; Truppa et al., Reference Truppa, Yaacoub, Valente, Celentano, Ragazzoni and Saulnier2024) are also included in the sample.
4.3. Political underpinnings of HSR concepts
Political underpinnings refer to the foundational ideas, governance structures, and ideological beliefs that shape and influence health policy approaches (Dawes and Gonzalez, Reference Dawes and Gonzalez2023; Lynch, Reference Lynch2023). As outlined in the background section, political theories of health investigate system-specific institutional arrangements through which authority, power, and agency are organised in ways that enable or constrain resilient action. To what extent are they referred to in the included sources? Only four articles place political considerations at the core of HSR concepts, emphasising that resilience is the result of political action. Critiquing the ambiguous nature of the HSR concept, Topp (Reference Topp2020, 3) argues that ‘the ability of a health system to be resilient must be assessed in light of the interests and intentions of health system actors’. Central to this dynamic and process-oriented understanding is the question of ‘who or what benefits’ (ibid.) from HSR policies and whether these have been debated or imposed in a top-down manner. In a similar vein, Witter et al. (Reference Witter, Thomas, Topp, Barasa, Chopra, Cobos, Blanchet, Teddy, Atun and Ager2023) recommend investigating the link between resilience and broader economic and political systems that are marked by ‘power imbalances’, which hide ‘system-level structures and institutions’ (ibid., e1457) that caused crises and have hindered transformative change. Without explicitly referring to health-related political science literature, these authors call for power-sensitive analyses of resilience policies to examining actor relationships and resource control in order to unveil ‘the ‘political game’ that determines healthcare decisions’ (Toth, Reference Toth2021, 210). Blanchet et al. (Reference Blanchet, Nam, Ramalingam and Pozo-Martin2017) propose a conceptual ‘framework on governance of resilience’, emphasising knowledge, uncertainties, interdependencies, and legitimacy as key governance dimensions to absorb, adapt, and transform in response to shocks – dimensions that guide context-specific, evidence-based resilience strategies. Barasa et al. (Reference Barasa, Cloete and Gilson2017) reject the simplified ‘bouncing back’ rhetoric of – some – HSR concepts which do conceive health systems are complex adaptive systems. For them, resilience is a negotiated good or worse result shaped by dynamic interactions among system actors. Moreover, they stress that HSR relies not just on infrastructure and resources (hardware), but even more on management capacities, values, relationships, and power dynamics (software). Recognition, however, that capacities for software and hardware governance directly result from specific institutions understood as a crucial type of explanation in health policy research (Powell and Béland, Reference Powell, Béland, Powell, Agartan and Béland2024) is missing. A similar gap exists where Barasa et al. (Reference Barasa, Cloete and Gilson2017, 4) emphasise ‘adaptive and transformative approaches’ towards resilience’ require ‘to address the wider political economy influences that shape both the goals and dynamics of health systems’ without systematically theorising the institutional mechanisms through which these influences operate.
4.4. Global health versus health system frame
From a politics-and policy-oriented perspective, the scoped articles distinguish between a global health frame and a health system frame. The former examines how HSR is interpreted and acted upon within global health governance, shaping power, responsibility, and policy responses (e.g. through the WHO), while the latter links HSR-related action or inaction to specific health systems, focusing on institutional settings, sectors, and stakeholders. References to global policy are clearly evident in several of the scoped sources; however, they are insufficiently interconnected with global health and multilevel governance theory emanating from political science (de Leeuw et al., Reference de Leeuw, Townsend, Martin, Jones, Clavier, de Leeuw and Clavier2013; McInnes et al., Reference McInnes, Lee and Youde2018). For example, van de Pas (Reference van de Pas, Ashour, Kapilashrami and Fustukian2017) argues that addressing current global health threats requires moving beyond a narrow notion of resilience toward a vision grounded in solidarity, recognising shared risks and collective responsibility for building sustainable and equitable health systems. Similarly, Marchal et al. (Reference Marchal, Michielsen, Simon, Verdonck, Accoe, Tonga, Polman, Tawaytibhongs, Cornu, Dens, Sy, Nieto-Sanchez and Van Belle2023, 2–3) call for a ‘multiscale perspective’ on HSR that considers ‘the messiness of power, politics and governance in a turbulent world’. Often, such articles emphasise the need for social equity through global partnerships and a ‘unified agenda for global collaboration’ (Dsouza et al., Reference Dsouza, Katyal, Kalaskar, Kabeer, Rewaria, Satyanarayana, Nallamalla and Chokshi2024, 1), or they highlight the role of HSR in advancing ‘global health security’ (Okyere et al., Reference Okyere, Lomazzi, Peri and Moore2024, 18). Put pointedly, these sources question whether HSR can be meaningfully pursued without engagement at the global level, yet pay little attention to the complexities of global health governance, particularly the contested interplay of public, private, and supranational actors in a world increasingly hostile to multilateralism. On the other hand, the majority of sources pursuing a health system frame, either by single case or comparative studies, explore government responses within health systems and partially derive learning for other countries. For instance, Burke et al. (Reference Burke, Parker, Fleming, Barry and Thomas2021, 7) showcases how the Irish government enhanced the functioning of a health system by utilising ‘the shock of COVID-19 to progress significantly its flagship health reform programme’. Moreover, Regmi et al. (Reference Regmi, Bertone, Shrestha, Sapkota, Arjyal, Martineau, Raven, Witter and Baral2024) illustrates how strong, adaptable governance and enhanced subnational government capacity are key to managing public health, drawing on Nepal’s experience to identify pathways that support HSR. These and other studies do not situate their findings within the broader debate on comparative health policy (Toth, Reference Toth2021), as they do not systematically contrast country-specific institutional arrangements that result in different resilience trajectories.
4.5. Governance and leadership
Governance – albeit in different nuances – emerges as the ‘most important building block for creating health system resilience’ (Fridell et al., Reference Fridell, Edwin, von Schreeb and Saulnier2020, 6). However, there is an imbalance between the nominal presence of the term – the vast majority of the sources refer to governance as a HSR dimension (see supplementary material) – and its analytical depth. Governance is thereby understood as a basic capability or technique (Saulnier et al., Reference Saulnier, Duchenko, Ottilie-Kovelman, Tediosi and Blanchet2022) that shapes resilience by influencing how system actors behave, make decisions, and respond to shocks (Saulnier et al., Reference Saulnier, Blanchet, Canila, Cobos Muñoz, Dal Zennaro, de Savigny, Durski, Garcia, Grimm, Kwamie, Maceira, Marten, Peytremann-Bridevaux, Poroes, Ridde, Seematter, Stern, Suarez, Teddy, Wernli, Wyss and Tediosi2021). In this view, governance differs from management by structuring authority and decision-making, while power, see section below, is shaping whose interests, knowledge, and resources prevail in moments of crisis. Blanchet et al. (Reference Blanchet, Nam, Ramalingam and Pozo-Martin2017) identify need for a dedicated resilience governance framework that involves integrating diverse knowledge, anticipating and managing uncertainties, handling interdependent dynamics, and developing legitimate institutions. Although governance is essential for effective shock response, it is often neglected, uncoordinated or overly top-down (Hanefeld et al., Reference Hanefeld, Mayhew, Legido-Quigley, Martineau, Karanikolos, Blanchet, Liverani, Yei Mokuwa, McKay and Balabanova2018). There is consensus that strong resilience requires coordinated, inclusive governance across all levels and sectors of the health system, supported by calls to strengthen good governance (Forsgren et al., Reference Forsgren, Tediosi, Blanchet and Saulnier2022), promote adaptive government actions (Smaggus et al., Reference Smaggus, Long, Ellis, Clay-Williams and Braithwaite2022), ensure accountability (Witter et al., 2023), and foster multistakeholder and multisectoral collaboration (Gooding et al., Reference Gooding, Bertone, Loffreda and Witter2022; Neill et al., Reference Neill, Neel, Cardona, Bishai, Gupta, Mohan, Jain, Basu and Closser2023) to achieve pandemic preparedness. Furthermore, authors draw a strong connection between governance and (individual, organisational or governmental) leadership, viewing ‘top-down policy action’ (Nakrošis and Bortkevičiûtėas, Reference Nakrošis and Bortkevičiūtė2022, 295) a major leverage toward resilience (Barasa et al., Reference Barasa, Cloete and Gilson2017; Chamla et al., Reference Chamla, Iwu-Jaja, Jaca, Ndlambe, Buwa, Idemili-Aronu, Okeibunor, Wiysonge and Gueye2024; Dsouza et al., Reference Dsouza, Katyal, Kalaskar, Kabeer, Rewaria, Satyanarayana, Nallamalla and Chokshi2024; Fridell et al., Reference Fridell, Edwin, von Schreeb and Saulnier2020; Reiss et al., Reference Reiss, Kraus, Riedel and Czypionka2024; Weishaar et al., Reference Weishaar, Evans, Chemali, Maray, Böttcher, Umlauf, Abunijela, Muller, Buchberger, Geurts, Fischer and El Bcheraoui2025). Conceptually, leadership is thus best understood not as distinct from governance but as one of its constitutive elements, mediating how formal rules and coordination mechanisms are enacted in practice. Several scholars highlight the role of leadership in the management of COVID-19. For example, Gooding et al. (Reference Gooding, Bertone, Loffreda and Witter2022) revealed that countries in sub-Saharan Africa and South Asia relied on strong political leadership and coordination across sectors and levels, while weak leadership and poor data transparency often hindered efforts. Similarly, Chua et al. (Reference Chua, Tan, Verma, Han, Hsu, Cook, Teo, Lee and Legido-Quigley2020, 2) underscore the coordination work of Singapore’s ‘multiministry government task-force’ throughout the pandemic. In particular, consistent communication from heads of state has seen as key to public compliance and trust. Importantly, however, ‘strong’ leadership is normatively ambiguous, as centralised and authoritative leadership may enhance decisiveness while simultaneously undermining participation, expertise, and accountability. In some cases, centralised decision-making sidelined scientific experts, weakening legitimacy and sustainability of governmental leadership (Neill et al., Reference Neill, Neel, Cardona, Bishai, Gupta, Mohan, Jain, Basu and Closser2023). With a view on the health systems in Kenya and South Africa, Gilson et al. (Reference Gilson, Barasa, Nxumalo, Cleary, Goudge, Molyneux, Tsofa and Lehmann2017) concluded that everyday resilience emerges from leadership that empowers frontline actors, promotes learning, and leverages relationships to manage routine challenges. Strengthening HSR thus requires focusing on the ‘software’ of health systems – such as agency, governance, and organisational capacities – rather than relying solely on structures or technologies. Critical engagement with the interplay between resilience and governance issues plays only a minor role in the scoped literature. For example, it is stated that the resilience narrative tends to bypass democratic processes by asserting an exceptional policy space in public health (van de Pas et al., Reference van de Pas, Ashour, Kapilashrami and Fustukian2017). The result is then top-down decision-making in the sake of resilience without considering other policy pathways (ibid.). In addition, authors point to the general risk of ‘fragmented governance’ (Witter et al., Reference Witter, Thomas, Topp, Barasa, Chopra, Cobos, Blanchet, Teddy, Atun and Ager2023, e1454) across political levels, and fragmented accountability across political stakeholders (Witter et al., 2022) due to incoherent and inconsistent HSR policy programmes.
Across the included studies, governance is predominantly conceptualised as a functional capacity or steering mechanism that shapes actor behaviour, coordination, and decision-making under conditions of uncertainty, rather than as a system-specific institutional arrangement. Structure-agency dynamics are implicitly addressed through an emphasis on leadership and coordination, yet rarely theorised, leaving unclear how institutional constraints and opportunities condition the capacity of actors to enact resilient responses.
4.6. Institutional path dependencies
Institutional path dependencies shape health system responses to shocks, as inherited structures, norms, and decision-making layers influence governance capacities and resilience as emphasised in several studies (de Graaff et al., Reference de Graaff, Huizenga and Bal2025; Ewert et al., Reference Ewert, Wallenburg, Winblad and Bal2023, Juarez-Ramirez et al., Reference Juárez-Ramírez, Reyes-Morales, Gutiérrez-Alba, Reartes-Peñafiel, Flores-Hernández, Escalante-Castañón, Muños-Hernández and Malo2022; Regmi et al., Reference Regmi, Bertone, Shrestha, Sapkota, Arjyal, Martineau, Raven, Witter and Baral2024; van den Bovenkamp et al., Reference van de Bovenkamp, de Graaff, Kalthoff and Bal2024). As Nunes (Reference Nunes2024, 117) notes regarding effective heatwave public health planning, the core challenge lies in transforming institutional roles to foster environments that support resilience, that means, in political science vocabulary: transforming institutional roles and leveraging existing path dependencies. However, the role of institutions is often insufficiently detailed or remains implicit in the literature even though institutional design structures the trajectories along which resilience can develop or erode over time. For example, resilience is frequently framed in vague terms – such as health care being described as a ‘complex, socio-technical system’ (Smaggus et al., Reference Smaggus, Long, Ellis, Clay-Williams and Braithwaite2022, 1683) or calls for ‘context-specific approaches’ (de Claro, Reference de Claro2023, 1) – without unpacking the institutional underpinnings. This vagueness overlooks how historical, sociological, and discursive institutional dynamics (Peters and Pierre, Reference Peters, Pierre, Powell, Agartan and Béland2020; Schmidt, Reference Schmidt2008) shape resilience-oriented governance capacities of health systems over time. Applying an institutional theory lens, Burau et al. (Reference Burau, Falkenbach, Neri, Peckham, Wallenburg and Kuhlmann2022; Reference Burau, Mejsner, Falkenbach, Fehsenfeld, Kotherová, Neri, Wallenburg and Kuhlmann2024) link health workforce contributions to resilience with country-specific institutional arrangements, such as modes of healthcare financing, service provision, and governance. Similarly, Ewert et al. (Reference Ewert, Wallenburg, Winblad and Bal2023) identify bottlenecks rooted in institutional configurations that hinder resilience-building efforts by referring to institutional theory emanating from political science and introducing concepts such as country-specific veto players, institutional layering ands stakeholder constellations. Although a few studies examine the actions of governments and key stakeholders within specific institutional settings (Burke et al., Reference Burke, Parker, Fleming, Barry and Thomas2021; Farsaci et al., Reference Farsaci, Fleming, Almirall-Sanchez, O’Donoghue and Thomas2024; Narwal and Jain, Reference Narwal and Jain2021; Regmi et al., Reference Regmi, Bertone, Shrestha, Sapkota, Arjyal, Martineau, Raven, Witter and Baral2024; Weishaar et al., Reference Weishaar, Evans, Chemali, Maray, Böttcher, Umlauf, Abunijela, Muller, Buchberger, Geurts, Fischer and El Bcheraoui2025), most stop short of closely analysing how existing structures enable or constrain distinct resilience or rather result in different policies for HSR.
4.7. Power and politics
Several sources explicitly address the impact of power imbalances and political dynamics, moving beyond a narrow interpretation of political determinants as merely governance-related issues. From the perspective of political theories of health, the crucial question is the extent to which power asymmetries are understood as dependent variables emerging from historically developed institutional settings, stakeholder constellations, and resource distributions across health systems. As expected, studies that identify ‘power and politics’ as relevant factors tend to rely on non-systemic explanations to capture their impact on HSR. Chopra and Kasper (Reference Chopra and Kasper2021) introduce the notion of critical displacements to describe how dominant approaches to HSR often sideline deeper structural issues such as political economy, power relations, and historical injustices in favour of technocratic, expert-led solutions. This tendency risks obscuring inequalities and hindering transformative change. Relatedly, other studies highlight that resilience also depends on whether a health system is sustainably resourced – financially, in terms of workforce and materials – and whether there is sustained political will to strengthen its capacities beyond immediate crises (Farsaci et al., Reference Farsaci, Fleming, Almirall-Sanchez, O’Donoghue and Thomas2024; Neill et al., Reference Neill, Neel, Cardona, Bishai, Gupta, Mohan, Jain, Basu and Closser2023). Topp (Reference Topp2020) views resilience as a product of the power relations within health systems that either support or disadvantage stakeholders’ interests. She proposes an adapted resilience framework that explicitly integrates actor power and differentiates between system capacities, strategic decisions made under pressure, and the ethical implications of resulting outcomes (ibid.). Moreover, Topp (Reference Topp2020) underscores that acknowledging power dynamics is crucial for developing both a robust theoretical understanding and more equitable practices of HSR. Similarly, Ewert et al. (Reference Ewert, Wallenburg, Winblad and Bal2023, 68) emphasise the ‘historically evolved balance of power among institutions and stakeholders’, while Burau et al. (Reference Burau, Mejsner, Falkenbach, Fehsenfeld, Kotherová, Neri, Wallenburg and Kuhlmann2024, 8) conclude that ‘resilience is complex, embedded, and subject to power dynamics’. Witter et al. (Reference Witter, Thomas, Topp, Barasa, Chopra, Cobos, Blanchet, Teddy, Atun and Ager2023, e1456) ask ‘how, why, when, and for whom resilience capabilities are developed’, recommending the integration of power and equity considerations into HSR analyses. Barasa et al. (Reference Barasa, Cloete and Gilson2017, 4) conceptualise power dynamics, values, and norms as part of the health system’s intangible ‘software’, which interfaces with and conditions the effectiveness of governance ‘hardware’ such as formal structures, resources, and infrastructure in shaping resilience, without theorising how these governance dynamics are embedded in specific health system institutional arrangements. Saulnier et al. (Reference Saulnier, Blanchet, Canila, Cobos Muñoz, Dal Zennaro, de Savigny, Durski, Garcia, Grimm, Kwamie, Maceira, Marten, Peytremann-Bridevaux, Poroes, Ridde, Seematter, Stern, Suarez, Teddy, Wernli, Wyss and Tediosi2021) highlight that the legitimacy of HSR depends on the power of the stakeholders who promote and implement related policies. Notably, these studies view power configurations – particularly those that hinder transformative changes toward HSR – as a persistently overlooked factor explaining why resilience strategies may fail in practice. In contrast, Rawat et al. (Reference Rawat, Karlstrom, Ameha, Oulare, Omer, Desta, Bahuguna, Hsu, Miller, Bati and Rasanathan2022, 10) highlight the enabling role of power by recommending that health systems harness ‘the power of communities as reservoirs of resilience’ through the deliberate strengthening of the community health workforce. Similarly, Gilson et al. (Reference Gilson, Barasa, Nxumalo, Cleary, Goudge, Molyneux, Tsofa and Lehmann2017) conclude that ‘everyday resilience’ in health systems can be achieved by empowering frontline managers and staff.
5. Discussion: analysing HSR through a political theories of health lens
Although unevenly addressed, findings from the scoping review broadly suggest that HSR result from dynamic interactions among power structures, institutional configurations, policy processes, interest group influence, and dominant ideological orientations. The latter touch upon the question of whether resilience serves to responsibilise stakeholders or to equip them with ‘the power and resources required to make resilience a reality’ (Rose and Lentzos, Reference Lentzos, Rose, Trnka and Trundle2017, 46). However, instead of addressing political determinants in a comprehensive and coherent manner, most sources focus on isolated aspects of the politics underlying HSR or merely identify and list them as decisive factors (see supplementary material) without referencing political science frameworks and theories. Or they underscore the importance of single factors that facilitate HSR – such as community engagement (Haldane et al., Reference Haldane, De Foo, Abdalla, Jung, Tan, Wu, Chua, Verma, Shrestha, Singh, Perez, Tan, Bartos, Mabuchi, Bonk, McNab, Werner, Panjabi, Nordström and Legido-Quigley2021) – without reflecting on the institutional settings and political conditions under which these factors may play a role at all. Hence, only very few sources explicitly engage with ‘ideas, interests, and institutions’ (Powell and Béland, Reference Powell, Béland, Powell, Agartan and Béland2024, 131) or systematically ask which competing notions of HSR are advanced by which stakeholders within which concrete health system arrangements, coming close to the ideal of ‘political science with public health’ (Fafard et al., Reference Fafard, Cassola, Weldon, Fafard, Cassola and de Leeuw2022, 20). For example, Topp (Reference Topp2020, 3) comes to the unequivocal conclusion that ‘[w]hat promotes the ability of a health system to be resilient must be assessed in the context of the interests and intentions of health system actors and the ways in which they mobilise and channel their power’. Accordingly, developing a framework on governance of resilience (Blanchet et al., Reference Blanchet, Nam, Ramalingam and Pozo-Martin2017) and ‘recognising ‘[HSR] embeddedness in power relationships’ (Witter et al., Reference Witter, Thomas, Topp, Barasa, Chopra, Cobos, Blanchet, Teddy, Atun and Ager2023, e1457) are essential for investigating structural imbalances that hinder or prevent HSR. Thus, it is a rather trivial insight that governance matters for achieving resilience, yet different components of governance such as federalism (Greer and Singer, Reference Greer, Singer, Powell, Agartan and Béland2024) may give rise to fundamentally different versions of HSR. However, such critical recommendations for further research are, if it all, voiced in commentaries (Barasa et al., Reference Barasa, Cloete and Gilson2017; de Claro, Reference de Claro2023; Marchal et al., Reference Marchal, Michielsen, Simon, Verdonck, Accoe, Tonga, Polman, Tawaytibhongs, Cornu, Dens, Sy, Nieto-Sanchez and Van Belle2023), rather than actually serving as a foundation for further inquiry or becoming the focus of HSR studies. In addition, they are not accompanied with substantial analytical frameworks on ‘how and why power manifests in the world and what impact it has on health’ (Lynch, Reference Lynch2023, 400) – an area of expertise that originates from, and must be provided by, political science.
The majority of the scoped sources incorporate selected political determinants into HSR analysis, generally stating that specific institutions, governance styles or political leadership facilitate or hinder the process of HSR. In no case have scholars systematically mapped and investigated the political and institutional underpinning of HSR driving their implementation processes. Even sources that acknowledge that strengthening resilience is mostly about improving governance (Forsgren et al., Reference Forsgren, Tediosi, Blanchet and Saulnier2022) or policy coordination (Haldane et al., Reference Haldane, De Foo, Abdalla, Jung, Tan, Wu, Chua, Verma, Shrestha, Singh, Perez, Tan, Bartos, Mabuchi, Bonk, McNab, Werner, Panjabi, Nordström and Legido-Quigley2021) do not investigate the specific interrelated circumstances of governance dynamics, such as interactions driven by institutional configuration and power relations within health systems. Characteristically, these sources, originating from disciplines other than political science, demonstrate an in-depth interest in HSR as a subject (i.e., its policy dimension) while, at best, only briefly mentioning the relevant polities (i.e., political frameworks) and politics (i.e., political processes) that promote or hinder the implementation of these policies.
Accordingly, the political processes – or politics – underpinning HSR policies remain largely unexamined in such publications as well as theoretically informed suggestions on how to address those political determinants. Likewise, studies adopting a global health frame on resilience conclude that health systems in ‘fragile, dysfunctional settings (…) might require global support’ (Witter et al., Reference Witter, Thomas, Topp, Barasa, Chopra, Cobos, Blanchet, Teddy, Atun and Ager2023, e1455) without further specifying the underlying power imbalances and global governance dynamics. Recent global political shifts, including U.S. domestic polarisation caused by the second Trump administration, intensifying great-power competition, and the erosion of multilateralism, have weakened the authority, financing stability, and coordinating capacity of global health institutions such as the WHO, thereby constraining collective action for resilience (Gostin, Reference Gostin2025). These dynamics increase global health fragility by fragmenting funding pathways, politicising knowledge and norm diffusion, and limiting the adaptability of health systems that rely on global support in times of crisis.
The limited uptake of political theories of health in HSR research may also reflect entrenched epistemic hierarchies within public and global health, where technical and measurable approaches are privileged over political and critical ones (Adams, Reference Adams2016). Political science perspectives are often embedded in interpretive or constructivist epistemologies that are less familiar – and sometimes less valued – in the largely positivist cultures of health research (Parkhurst, Reference Parkhurst2017). These epistemological barriers continue to constrain meaningful political analysis in resilience-focused research. Furthermore, the broad spectrum of health sciences often treats ‘policymaking as a technical exercise’ (Cairney et al., Reference Cairney, St Denny and Mitchell2021, 28) or ‘deploy political science theories and concepts instrumentally’ (Fafard and Cassola, Reference Fafard and Cassola2020, 108). If the still developing HSR research aims to avoid those shortcomings – above all, the political naivety – that characterises, for example, much of the Health in All Policies (HiAP) literature (Cairney et al., Reference Cairney, St Denny and Mitchell2021), a more systematically examination of the ‘policymaking context’ (ibid., 26) is indispensable. Applying a political theories of health lens, focusing on the specific institutional arrangements, actors, ideas and power structures (Agartan and Béland, Reference Agartan, Béland, Powell, Agartan and Béland2024; Powell and Béland, Reference Powell, Béland, Powell, Agartan and Béland2024) that shape the adaptability and transformation capacity of health systems ought to be the point of departure for scholars examining HSR. This could be studied using process tracing or mixed-methods approaches from comparative politics to uncover how differing institutional contexts and administrative cultures influenced national responses to the COVID-19 pandemic (Kuhlmann et al., Reference Kuhlmann, Hellström, Ramberg and Reiter2021), as it has done quite rarely in relation to HSR (see Burau et al., Reference Burau, Falkenbach, Neri, Peckham, Wallenburg and Kuhlmann2022 and Reference Burau, Mejsner, Falkenbach, Fehsenfeld, Kotherová, Neri, Wallenburg and Kuhlmann2024; Ewert et al., Reference Ewert, Wallenburg, Winblad and Bal2023).
If pursued, such studies might further reinforce criticism of the HSR concept, as it tends to obscure political conflict and raise false hopes of comprehensive reform, while in practice reinforcing the health system’s status quo (Topp, Reference Topp, Thomas and Fleming2024). Indeed, some scholars have cautioned that the resilience discourse may be co-opted into neoliberal governance frameworks (van de Pas, Reference van de Pas, Ashour, Kapilashrami and Fustukian2017), where responsibility for managing shocks is devolved to frontline actors and communities, rather than being addressed through systemic reform. In this view, ‘resilience’ risks becoming a rhetorical device that masks structural injustices and justifies inaction at higher political levels.
However, at a more general level a key challenge remains: how to encourage scholars to further engage with and advance a political science of health and healthcare without compromising the integrity of their disciplinary foundations. There is much to suggest that it is primarily the responsibility of political scientists to forge cross-disciplinary research partnerships that place the political theories of health at the centre of their work. One can hardly blame health science scholars for insufficiently incorporating health-related political science expertise if it is inaccessible or not tailored for interdisciplinary research. As a starting point, this requires demonstrating greater ‘commitment to the broader public health project’ (Fafard et al., Reference Fafard, Cassola, Weldon, Fafard, Cassola and de Leeuw2022, 24) from political scientists, rather than treating health policy merely as one of many domains for testing and advancing policy theories.
Simply offering isolated political science insights to the diverse community of public health researchers and practitioners is insufficient, as evidenced by the findings of the scoping review on the political nature of HSR. Concrete steps might include embedding political science modules in public health curricula, establishing joint training and interdisciplinary research centres, developing co-authored policy briefs, and creating funding streams that incentivise collaborative publications in both health and political science journals (de Leeuw et al., Reference de Leeuw, Fafard, Cassola, Fafard, Cassola and de Leeuw2022; Fafard and Cassola, Reference Fafard and Cassola2020). While such calls have been made before, the current state of HSR research, once again, underscored its importance.
6. Conclusion
The paper reveals that the political determinants constituting HSR are insufficiently theorised and systematically addressed in the current literature. Instead, selective determinants such as governance, leadership, or power dynamics receive fragmented and often superficial attention, frequently without being embedded in a coherent analytical framework. As a result, HSR risks following the trajectory of other public health concepts (e.g., HiAP), whose normative and problem-solving ambitions have outpaced systematic engagement with the political challenges of implementation. As argued, political science equips HSR research with robust analytical tools to move beyond predominantly managerial and technocratic framings of resilience. Power analysis reveals how asymmetries among stakeholders shape resource allocation and decision-making during shocks, thereby exposing whose interests prevail and whose voices remain marginalised. Institutional analysis elucidates path dependencies, veto points, and processes of institutional layering that constrain or enable adaptive capacities across health systems. Ideational analysis dissects how dominant narratives and policy frames depoliticise resilience or legitimise particular reform trajectories, while multilevel governance theory maps interactions across local, national, and global levels, highlighting coordination failures and accountability gaps.
Together, these approaches foster a politically informed HSR research agenda, enabling more transformative and context-sensitive strategies. By linking HSR more closely to policymaking processes, more reflexive and robust governance approaches (Ansell et al., Reference Ansell, Sørensen, Torfing and Trondal2024) to investigating the politics of resilience can be developed. If health scientists fail to engage more deeply with the political theories of HSR, critics who argue that the concept’s continued popularity rests on its neglect of power relations may be proven right, underscoring the still limited influence of political science within public and global health research.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S1744133126100437
Acknowledgements
The author gratefully acknowledges the feedback received at the ECPR workshop ‘Towards a Political Science of Health and Healthcare’ (20–23 May 2025) and during a research stay at the Dahdaleh Institute for Global Health Research, York University, Toronto, in June 2025.
Financial support
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Competing interests
The author declares no conflicts of interest.
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