Open Access Highly Accessed Research article

A framework for assessing health system resilience in an economic crisis: Ireland as a test case

Steve Thomas1*, Conor Keegan1, Sarah Barry1, Richard Layte2, Matt Jowett3 and Charles Normand1

Author Affiliations

1 Centre for Health Policy and Management, Trinity College Dublin, 3-4 Foster Place, College Green, Dublin 2, Ireland

2 Economic and Social Research Institute, Whitaker Square, Sir John Rogerson’s Quay, Dublin, Ireland

3 WHO Barcelona Office for Health Systems Strengthening, Marc Aureli 22-36, E-08006, Barcelona, Spain

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BMC Health Services Research 2013, 13:450  doi:10.1186/1472-6963-13-450

Published: 30 October 2013



The financial crisis that hit the global economy in 2007 was unprecedented in the post war era. In general the crisis has created a difficult environment for health systems globally. The purpose of this paper is to develop a framework for assessing the resilience of health systems in terms of how they have adjusted to economic crisis. Resilience can be understood as the capacity of a system to absorb change but continue to retain essentially the same identity and function. The Irish health system is used as a case study to assess the usefulness of this framework.


The authors identify three forms of resilience: financial, adaptive and transformatory. Indicators of performance are presented to allow for testing of the framework and measurement of system performance. Both quantitative and qualitative methods were used to yield data for the Irish case study. Quantitative data were collected from government documents and sources to understand the depth of the recession and the different dimensions of the response. Semi-structured interviews were conducted with key decision makers to understand the reasons for decisions made.


In the Irish case there is mixed evidence on resilience. Health funding was initially protected but was then followed by deep cuts as the crisis deepened. There is strong evidence for adaptive resilience, with the health system showing efficiency gains from the recession. Nevertheless, easy efficiencies have been made and continued austerity will mean cuts in entitlements and services. The prospects for building and maintaining transformatory resilience are unsure. While the direction of reform is clear, and has been preserved to date, it is not certain whether it will remain manageable given continued austerity, some loss of sovereignty and capacity limitations.


The three aspects of resilience proved a useful categorisation of performance measurement though there is overlap between them. Transformatory resilience may be more difficult to assess precisely. It would be useful to test out the framework against other country experiences and refine the measures and indicators. Further research on both the comparative resilience of different health systems and building resilience in preparation for crises is encouraged.

Resilience; Health systems; Sustainability; Economic crisis; Ireland