The COVID‑19 pandemic proved to be the greatest health crisis in a century. It highlighted how health systems are not resilient to shocks, with consequent impact on the global economy and global community. Even the most advanced health systems in the world were not resilient enough.

The COVID‑19 pandemic is a tragedy. Over 6.8 million deaths due to COVID‑19 were reported worldwide in January 2023. Analysis of excess mortality suggests that as many as 18 million people may have died worldwide because of the pandemic by the end of 2021. Life expectancy decreased in many OECD countries in 2020 and 2021. There was widespread disruption to society and education. GDP dropped by 4.7% in 2020 across OECD economies.

Not being sufficiently prepared for a shock like the COVID-19 pandemic results in major loss of life and well-being, and requires costly interventions that have repercussions for years to come. Health systems must also be resilient to shocks beyond pandemics. This report uses the lens of the COVID-19 pandemic and the latest evidence to analyse how ready health systems were to prepare for, absorb and recover from a crisis, and how they can be adapted to be more resilient to future challenges. This report offers recommendations in six policy areas to improve health system resilience. These policy areas relate to the health system and to its interactions with broader society. Implementing these recommendations will produce health systems that deliver high-quality care before, during and after crises.

Although relatively new to health systems, the resilience methodology has decades of application in other fields. This chapter outlines the common features of resilience across various sectors. It discusses how resilience has been applied in infrastructure, finance, the environment, cybersecurity, disaster response, and medicine and public health. Common features and lessons for health systems, and common methods of testing for resilience are identified. Improving health system resilience should use the lessons learnt from its application in other sectors, with a focus on systems adapting to shocks and an emphasis on a multi-systems view.

The impact of COVID‑19 has been substantially different across OECD countries. This chapter offers an exploratory assessment of the impact of health system capacity and government strategies on COVID‑19 outcomes until December 2021. The aim is to provide insights into why certain OECD countries had better outcomes over the first two years of the COVID‑19 pandemic (2020‑21) and how policy makers can shift their health systems to be better prepared for future challenges. After controlling for core demographic and economic factors, indicators of increased health system capacity and access to high-quality care were associated with better COVID‑19 outcomes. Higher COVID‑19 vaccination rates were also associated with lower excess mortality, as were certain measures of trust. Health risk factors and social risk factors also influenced outcomes. Beyond national aggregates, the chapter highlights how older people, socially disadvantaged populations, and ethnic minority groups suffered more from the pandemic than others. The main indirect effects of the pandemic are also analysed.

Containment and mitigation strategies are the only viable measures to counter a pandemic before effective pharmaceutical interventions are available. These measures require a variety of societal capacities and resources, delivered in a harmonised manner, to achieve the best outcomes and minimise unintended consequences. This chapter reviews the core capacities traditionally emphasised in preparedness for public health emergencies, and summarises actions taken by OECD countries to combat the COVID‑19 pandemic. Based on global experiences and national lessons learnt from the crisis response, this chapter investigates gaps between preparedness and actual response. Drawing on these findings, it outlines what capacities need to be strengthened, and how these efforts can be supported, to better prepare for the next pandemic and, more broadly, to improve resilience in national health systems.

The COVID-19 pandemic placed enormous strain on critical care resources. After introducing a framework for critical care surges, this chapter analyses the prepare and absorb stages of the response to the COVID-19 pandemic by OECD countries, identifying strengths and weaknesses. Capacity was increased with the introduction of more resources. Alternative uses of critical care resources were reduced, increasing their availability for patients with COVID-19. Organisational changes improved the efficient use of these resources. The use of modelling was valuable and widespread, but required data about resources and information to be developed. Increasing investment in critical care should be planned carefully to balance resilience and sustainability. Improving resilience in the future, including for threats beyond COVID-19, will need to build on the gains made during the pandemic response.

The impact of the COVID‑19 pandemic was particularly felt among those who live with chronic diseases. This chapter outlines the impact on, and response of, non-COVID‑19 services in the pandemic context. It also describes the impact on primary care services and the changes that took place in the mix of providers and service delivery models. Roles in the delivery of primary health care services changed. The use of telehealth was widespread. Adaptations to improve continuity of care and limit the harm of future shocks include improving preventive care; supporting a workforce capable of adapting to shocks; and ensuring that governance models, information systems and financial incentives support integrated care.

This chapter describes the impact of the COVID‑19 pandemic and the corresponding policy responses on the long-term care sector. It also presents policy avenues to make long-term care more resilient in the future. The chapter focuses on avoiding fragmentation of long-term care, financing and funding of the sector, preventive and rehabilitation services, and the critical role of long-term care workers and informal carers.

This chapter focuses on the impact of shocks and systemic disruptions on people’s mental health, with a focus on the COVID‑19 pandemic. It presents information about the prevalence of anxiety and depression in OECD countries, and about the disruption to mental health services. In response to the pandemic, the chapter reviews measures taken by OECD countries to protect and promote mental health, and improve mental health support. It concludes by offering recommendations to strengthen mental health and mental health support at individual and societal levels to build resilience and readiness to face future challenges.

This chapter reviews the impact of the COVID‑19 pandemic on access to elective (non-urgent) care and waiting times. In many OECD countries, waiting times for elective care were already on the rise before the pandemic, indicating that supply was not keeping-up with demand. The pandemic exacerbated the backlog for elective procedures as most OECD countries suspended non-urgent care to divert efforts towards COVID‑19 patients and avoid other patients being infected. Recovery of these “missing” volumes and the impact on waiting times differed across OECD countries, reflecting differences in the effectiveness of containment measures, the speed at which elective care resumed, the pre‑existing capacity of health workers and equipment, and the ability to mobilise additional resources to increase activity. Addressing the backlog in elective procedures calls for activity-based financing, boosting the supply of health workers, and better management and monitoring of waiting lists. The chapter concludes with policy recommendations to tackle waiting times for elective care.

The COVID‑19 pandemic has exacerbated pre‑existing health workforce issues in OECD countries, including shortages of doctors and nurses, insufficient investment in education and training, and retention challenges. These shortages have increased workloads and pressures. Many health workers have emerged from the pandemic exhausted and intending to leave their positions. This chapter reviews the health workforce capacity of OECD countries going into the pandemic and strategies used to mobilise additional health workers (surge capacity) to respond to peaks in demand during the absorb stage of the pandemic. It also reviews new strategies implemented by countries to increase health workforce capacity and flexibility in the recovery stage of the pandemic, to avoid future shortages and increase preparedness for future shocks. Addressing health workforce shortages calls for greater investment in education and training, increased staff recruitment to reduce the workload and pressure on existing staff, and increased retention rates by improving working conditions and pay rates for categories of workers that have traditionally been undervalued. At least half of all new investments needed to make health systems more resilient should be directed towards workforce training, recruitment, and retention.

The effective functioning of health systems relies on an adequate and reliable supply of equipment and therapeutics, including essential medicines and medical devices. While shortages of both types of products occurred prior to the COVID‑19 pandemic, it highlighted some key vulnerabilities in their respective supply chains. This chapter outlines the nature of medicine and medical device supply chains, and presents several case studies – both pre‑ and post-pandemic. Finally, it identifies policy options for improving the responsiveness and reliability of supply of medicines and medical devices, to support the resilience of OECD countries’ health systems and, by extension, their economies.

This chapter discusses the digital and data context in which OECD countries entered the COVID‑19 pandemic and their responses, common challenges and lessons learnt. The pandemic accelerated the digitisation of health systems. Improvements in data, data governance, analytics, and digital foundations were required to manage health systems effectively in response to the pandemic. OECD countries improved data reporting and almost all enhanced data timeliness. The chapter outlines how increasing the availability of integrated digital information, underpinned by appropriate governance frameworks, would strengthen health system resilience. Beyond building resilience to address future shocks, improving the use of health data and its governance would aid the functioning of health systems between crises.

The COVID-19 pandemic revealed that access to global public goods and other essential technologies was far from adequate. Global public goods are those that are of benefit to all, but have traditionally been underproduced, giving rise to a global policy challenge. This chapter discusses current and proposed models for incentivising the research, development, manufacture and distribution of essential health technologies to enable them to approximate global public goods. The policies outlined also aim to ensure the affordable and equitable global dissemination of these technologies.

This chapter identifies a set of priority investment areas needed to strengthen resilience, reinforcing the foundations of countries’ health systems and their ability to respond to evolving pandemics and other emerging shocks. It then produces order-of-magnitude estimates of the expected costs of such investments, drawing extensively from existing OECD data and analytical studies. These priority investments represent an estimated 1.4% of GDP, on average across OECD countries (ranging from 0.6% to 2.5%), compared with pre‑pandemic expenditure of 8.8%. A combination of targeted spending and measures to reduce wasteful spending could mitigate the overall increases in health spending in the medium to long term.

The OECD Resilience of Health Systems Questionnaire 2022 was sent to OECD countries on 3 December 2021, and responses were accepted until April 2022.