From emergency preparedness to organisational maturity: a systematic review of health systems resilience

Objective To examine how health system resilience (HSR) in routine and emergency operations aligns with organisational maturity, using the Capability Maturity Model Integration (CMMI) as an analytical framework. Methods We conducted a systematic literature review of peer‑reviewed studies published between 2019 and 2024, following a protocol registered in PROSPERO and reported in accordance with PRISMA‑P guidelines. Searches were performed in PubMed, the Virtual Health Library, Scopus and Web of Science. Twenty eligible studies were synthesised narratively and analysed using the CMMI maturity model. Findings HSR is consistently described as a multidimensional capacity encompassing absorption of shocks, adaptation of processes and transformation through learning. Most health systems operate at low maturity levels, characterised by reactive responses and basic planning that becomes unreliable under stress. Higher maturity levels—defined processes, quantitative management and continuous optimisation—remain uncommon but are strongly associated with sustained system performance during crises. Conclusion Applying a maturity‑based lens highlights why many health systems struggle to reconcile efficiency in routine operations with flexibility in emergencies. The CMMI framework offers a practical pathway for policymakers to structure incremental investments in governance, measurement and learning, supporting more resilient health systems globally.