IN A NUTSHELL
Author's note
A commentary here on developing a national framework to assess health system resilience to communicable disease outbreaks in Iran.
This article reflects on our experience, while working together with a multidisciplinary team at Iran’s Ministry of Health, of translating the concept of health system resilience into measurable indicators, and considering how resilience can be assessed across different levels of the health system
By Dr. Narges Roohi
PhD. Health in Disasters & Emergencies
Teheran, Iran
Developing a National Framework to Measure Health System Resilience to Communicable Disease Outbreaks
Early Lessons from Iran
Introduction
Health system resilience was discussed in the scientific literature before COVID-19 and gained prominence following the Ebola epidemic. COVID-19 further strengthened its place in health policy, management and research. The pandemic demonstrated that effective preparedness and response require coordination across the health system, continuity of essential services and adaptation to changing conditions, alongside disease control and clinical care. Experiences across countries during COVID-19 highlighted the importance of governance, financing, the health workforce, health information systems, service delivery, access to medical products and technologies, and public health functions in absorbing the effects of a shock, adapting and responding effectively.
In Iran, studies conducted during COVID-19 examined challenges in the health-system response, including managerial and organizational issues, and the resilience of healthcare facilities. The involvement of health policy-makers, managers and staff in some of these studies helped clarify implementation challenges. Findings emphasized coordination, resource management, workforce preparedness, health information systems and management capacity, underscoring the need for a health-system-wide approach to pandemic response.
A central question was how to translate the broad concept of health system resilience into components and indicators that could be measured and monitored. This challenge was not unique to Iran. In its 2020 report, Strengthening Health Systems Resilience: Key Concepts and Strategies, the European Observatory on Health Systems and Policies emphasized that resilience assessment should reflect the type of shock and the health-system context, and draw on a range of quantitative and qualitative measures.
In its 2021 position paper on health systems resilience, WHO emphasized linking health-system strengthening, health security, universal health coverage, primary health care and essential public health functions. COVID-19 had shown that addressing these areas separately could limit the capacity to respond to major crises.
In 2024, WHO’s Building Health System Resilience to Public Health Challenges: Guidance for Implementation in Countries provided a clearer pathway for putting this approach into practice. The guidance emphasizes adapting actions to country contexts and the roles of national and subnational actors, helping countries translate resilience into practical health-system interventions.
From global guidance to framework development in Iran
In Iran, this work began with the challenge of translating resilience into capacities that could be identified, assessed and strengthened in practice. In 2025, the Center for Communicable Disease Control at the Ministry of Health and Medical Education initiated the development of a framework adapted to the country’s health-system structure to assess capacities for preventing and responding to communicable disease outbreaks. The aim was to identify priorities for improvement and informed decision-making, with particular attention to the relationship between national policies and their implementation at subnational and service-delivery levels.
Framework development combined a review of international documents, including WHO’s health system resilience indicator package, with expert-led adaptation to the country’s structure and priorities. Preliminary meetings and the establishment of a steering committee enabled participation by specialists and operational managers in communicable diseases, primary health care, health-system management, disaster and emergency health, and biostatistics. Group discussions, documented comments and additional feedback supported iterative indicator refinement and expert consensus.
The framework covered six domains: governance, the health workforce, service delivery, health information systems, access to essential medicines and technologies, and health financing. The assessment level and evidence requirements were considered for each indicator. Pilot implementation in the Fardis County Health Network, involving local experts and Alborz University of Medical Sciences, enabled the framework’s application to be examined in practice. Policy and programme documents, administrative records and service-delivery records provided the evidence, which was reviewed collaboratively.
This commentary examines framework development and lessons from pilot implementation. As the project remains ongoing, detailed results, scores and quantitative comparisons are not reported here. The initial assessment was operational and exploratory and was conducted in one local setting. It therefore does not establish national health system resilience or the validity and reliability of the assessment tool.
Early lessons for assessment design and interpretation
First, each indicator requires a clearly defined assessment level and implementation responsibility. Some capacities concern national policy-making, others depend on coordination at provincial and district levels, and others are assessed at service-delivery units. Reviewing national documents within a local pilot does not, by itself, support conclusions about national performance. Comparisons across levels must also account for differences in the sets of applicable indicators.
Second, structural non-applicability must be distinguished from missing data and an unmet capacity. A blank assessment cell does not necessarily indicate poor performance: the indicator may not apply at that level under the framework’s design. Defining this distinction is essential for selecting appropriate denominators and interpreting results correctly, and should be addressed during framework development.
Third, the existence of an approved policy or plan does not, by itself, demonstrate effective implementation. Joint review of documentation can clarify the relationship between formal commitments, organizational responsibilities and local implementation. However, documentation alone cannot establish that essential services will be maintained during an actual shock. Subsequent assessments should complement evidence on capacities with evidence on health-system performance during crises, service continuity and learning after events.
Fourth, relying solely on an overall score may obscure important implementation gaps. An assessment has greater policy value when each priority for improvement is linked to a specific corrective action, a responsible actor, required resources and a follow-up timetable. Assessment findings should therefore inform implementation priorities and the monitoring of corrective actions.
Project continuity amid armed conflict
The project was implemented amid escalating regional armed conflict. Direct conflict between Iran and Israel in April 2024 formed part of the security context preceding the project. The 12-day war began on 13 June 2025, with direct US military involvement on 22 June, followed by joint US and Israeli attacks on Iran on 28 February 2026. According to the implementation team’s experience, hostilities during the project period substantially delayed its progress. This commentary does not quantify the delays or assess the pathways through which the conflict affected implementation.
This experience demonstrates the need to plan for continuity of resilience assessment and strengthening activities during crises. Flexible timelines, systematic documentation of decisions, preservation of records and arrangements for phased implementation could inform future planning. The project delay is reported as an implementation experience; it does not, by itself, provide a basis for assessing the resilience of the entire health system.
Policy implications and next steps
Before wider implementation, the framework requires evaluation of content validity, inter-rater reliability, test–retest reliability, completion time, implementation burden and acceptability across different settings. Completing an assessment in one local setting demonstrates that initial application was possible, but does not establish feasibility at scale or the generalizability of findings. Scoring thresholds should be presented as operational programme benchmarks and, until validated, should not be used to classify a health system definitively as resilient or non-resilient.
Further framework development should incorporate health equity through explicit assessment questions: are essential services maintained for vulnerable groups during crises? Are geographic and financial barriers to access reduced? Does resource allocation reflect the differing needs of population groups? These questions are proposed priorities for future framework development, rather than reported project findings. WHO’s position paper on resilience, universal health coverage and health security provides the conceptual basis for this direction.
Iran’s early experience suggests that developing a national resilience measurement framework requires clearly assigned implementation responsibilities, transparent rules for interpreting evidence and a defined pathway from assessment findings to decision-making, alongside indicator selection. As the project continues, the framework’s practical value should be evaluated in terms of its contribution to corrective action, continuity of essential services and reduced health inequities during crises.
