Images: © European Union ECHO Mallika Panorat, Flickr (left) & Ashim Shrestha, 2019 (right)

The challenge we face and how we are addressing it

ReBUILD for Resilience examines health system resilience in fragile settings experiencing violence, conflict, pandemics and other shocks.

• Contexts experiencing high and extreme fragility are home to 2.1 billion, or 25% of the world’s population, but 72% of the world’s extreme poor. By 2040, 92% of the world’s extreme poor could be living in contexts with high or extreme fragility.
• Young people (aged 15-24) account for 20% of people experiencing high or extreme fragility.
• Of the 61 contexts with high and extreme fragility in 2025, 24 were experiencing armed conflict and 8 were in a state of war.
• Eight of the ten contexts with the widest gender gaps are highly and extremely fragile.
• Such contexts host most of the world’s forcibly displaced. Over 100 million refugees and internally-displaced persons originate in highly and extremely fragile contexts, representing almost four fifths of all forcibly-displaced persons worldwide.

(Figures from OECD, State of Fragility 2025 [opens new tab])

Fragile contexts are susceptible to shocks and stressors. These include political unrest, conflict and violence, economic and social crises, natural disasters and climate change.

Health systems in these contexts face severe resource constraints and, as this animation from 2020 demonstrates, shocks and stressors compound their problems. Some health systems will collapse under the pressure, while others will make maladaptive or short-term changes. Others will make positive or resilient responses.

The ReBUILD for Resilience primary research question is therefore:

‘How do we develop resilience capacities to ensure responsive, effective, inclusive, gender-equitable and sustainable health systems in fragile and shock-prone settings?’

What is ‘fragility’?

In its ‘States of Fragility 2025’ report the OECD characterises fragility as:

“…the combination of exposure to risk and the insufficient resilience of a state, system and/or community to manage, absorb or mitigate those risks. The OECD multidimensional fragility framework assesses fragility based on 56 indicators of risk and resilience across six dimensions: economic, environmental, political, security, societal and human. ”

The framework identifies 61 countries and territories as having ‘high and extreme fragility’.

Following the shocks of recent years, including COVID-19 pandemic, global fragility remains at a near-record high level. There is a diversity of fragility profiles across all contexts, eg Sudan, Yemen, Afghanistan and Somalia have ‘extreme fragility’ but each presents unique combinations of risk and resilience. This is also true within the medium to low fragility classification, where otherwise resilient contexts have concentrated subnational pockets of fragility, often characterised by acute poverty, environmental fragility and localised violence.

How ReBUILD for Resilience is meeting this challenge

There is a shortage of innovative, timely, relevant evidence that demonstrates how we can develop stronger, more resilient health systems – especially evidence generated in partnership with key stakeholders.

ReBUILD for Resilience seeks to meet that need. The consortium is providing high-quality, practical, multidisciplinary, operationally-relevant and scalable health system research, which can be utilised by policymakers and other stakeholders to improve the health and lives of many millions of people.

Within this central focus are a number of key research questions which are explored in the research section. Here we also discuss our theory of change and resilience framework.