Evaluation of Health System Resilience in 60 Countries Based on Their Responses to COVID-19

Introduction: In 2020, the COVID-19 epidemic swept the world, and many national health systems faced serious challenges. To improve future public health responses, it's necessary to evaluate the performance of each country's health system.

Methods: We developed a resilience evaluation system for national health systems based on their responses to COVID-19 using four resilience dimensions: government governance and prevention, health financing, health service provision, and health workers. We determined the weight of each index by combining the three-scale and entropy-weight methods. Then, based on data from 2020, we used the Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) method to rank the health system resilience of 60 countries, and then used hierarchical clustering to classify countries into groups based on their resilience level. Finally, we analyzed the causes of differences among countries in their resilience based on the four resilience dimensions.

Results: Switzerland, Japan, Germany, Australia, South Korea, Canada, New Zealand, Finland, the United States, and the United Kingdom had the highest health system resilience in 2020. Eritrea, Nigeria, Libya, Tanzania, Burundi, Mozambique, Republic of the Niger, Benin, Côte d'Ivoire, and Guinea had the lowest resilience.

Discussion: Government governance and prevention of COVID-19 will greatly affect a country's success in fighting future epidemics, which will depend on a government's emergency preparedness, stringency (a measure of the number and rigor of the measures taken), and testing capability. Given the lack of vaccines or specific drug treatments during the early stages of the 2020 epidemic, social distancing and wearing masks were the main defenses against COVID-19. Cuts in health financing had direct and difficult to reverse effects on health systems. In terms of health service provision, the number of hospitals and intensive care unit beds played a key role in COVID-19 clinical care. Resilient health systems were able to cope more effectively with the impact of COVID-19, provide stronger protection for citizens, and mitigate the impacts of COVID-19. Our evaluation based on data from 60 countries around the world showed that increasing health system resilience will improve responses to future public health emergencies.