The concept of health system resilience has gained popularity in the global health discourse, featuring in UN policies, academic articles and conferences. While substantial effort has gone into the conceptualization of health system resilience, there has been no review of how the concept has been operationalized in empirical studies. We conducted an empirical review in three databases using systematic methods. Findings were synthesized using descriptive quantitative analysis and by mapping aims, findings, underlying concepts and measurement approaches according to the resilience definition by Blanchet et al. We identified 71 empirical studies on health system resilience from 2008 to 2019, with an increase in literature in recent years (62% of studies published since 2017). Most studies addressed a specific crisis or challenge (82%), most notably infectious disease outbreaks (20%), natural disasters (15%) and climate change (11%). A large proportion of studies focused on service delivery (48%), while other health system building blocks were side-lined. The studies differed in terms of their disciplinary tradition and conceptual background, which was reflected in the variety of concepts and measurement approaches used. Despite extensive theoretical work on the domains which constitute health system resilience, we found that most of the empirical literature only addressed particular aspects related to absorptive and adaptive capacities, with legitimacy of institutions and transformative resilience seldom addressed. Qualitative and mixed methods research captured a broader range of resilience domains than quantitative research. The review shows that the way in which resilience is currently applied in the empirical literature does not match its theoretical foundations. In order to do justice to the complexities of the resilience concept, knowledge from both quantitative and qualitative research traditions should be integrated in a comprehensive assessment framework. Only then will the theoretical ‘resilience idea’ be able to prove its usefulness for the research community.

Access to health care for asylum-seekers and refugees (AS&R) in Germany is initially restricted before regular access is granted, allegedly leading to delayed care and increasing costs of care. We analyse the effects of (a) restricted access; and (b) two major policy reforms (1997, 2007) on incident health expenditures for AS&R in 1994-2013. We used annual, nation-wide, aggregate data of the German Federal Statistics Office (1994-2013) to compare incident health expenditures among AS&R with restricted access (exposed) to AS&R with regular access (unexposed). We calculated incidence rate differences (∆IR_t) and rate ratios (IRR_t), as well as attributable fractions among the exposed (AFe) and the total population (AFp). The effects of between-group differences in need, and of policy reforms, on differences in per capita expenditures were assessed in (segmented) linear regression models. The exposed and unexposed groups comprised 4.16 and 1.53 million person-years. Per capita expenditures (1994–2013) were higher in the group with restricted access in absolute (∆IR_t = 375.80 Euros [375.77; 375.89]) and relative terms (IRR = 1.39). The AFe was 28.07% and the AFp 22.21%. Between-group differences in mean age and in the type of accommodation were the main independent predictors of between-group expenditure differences. Need variables explained 50-75% of the variation in between-group differences over time. The 1997 policy reform significantly increased ∆IR_t adjusted for secular trends and between-group differences in age (by 600.0 Euros [212.6; 986.2]) and sex (by 867.0 Euros [390.9; 1342.5]). The 2007 policy reform had no such effect. The cost of excluding AS&R from health care appears ultimately higher than granting regular access to care. Excess expenditures attributable to the restriction were substantial and could not be completely explained by differences in need. An evidence-informed discourse on access to health care for AS&R in Germany is needed; it urgently requires high-quality, individual-level data.

Aufgrund fehlender Routinestatistiken des Gesundheitsstatus und der medizinischen Versorgung von Asylsuchenden kommt empirischen Studien eine besondere Rolle bei der Abbildung dieser Aspekte zu. Ziel dieses Reviews ist es, die Forschungslandschaft in diesem Bereich umfassend abzubilden, empirische Erkenntnisse zu synthetisieren und prioritären Forschungsbedarf abzuleiten. Eine dreigliedrige Suchstrategie umfasste die Suche nach empirischen Studien in nationalen/internationalen Datenbanken und im Internet, das Durchsuchen von Referenzlisten sowie Anfragen an Experten. Alle Studien, die vorab festgelegte Einschlusskriterien erfüllten, wurden in einer Evidenz-Map thematisch strukturiert und in einer narrativen Synthese beschrieben. Die Suche ergab 1190 Treffer. Davon erfüllten 52 Artikel alle Einschlusskriterien. Es lagen 41 quantitative Studien (78,9 %), 10 qualitative (19,2 %) und ein Review (1,9 %) vor. Insgesamt 30 Primärstudien (58,9 %) untersuchten Aspekte der psychischen Gesundheit, gefolgt von Infektionskrankheiten (n = 12, 23,5 %). Die qualitativen Studien, meist Ethnografien und Fallstudien, thematisierten psychische Erkrankungen und soziale Determinanten der Gesundheit und belegen einen Einfluss der Lebensumstände auf Gesundheit und Versorgung. Wenige Studien untersuchten chronische Erkrankungen (n = 3) oder Erkrankungen bei Kindern (n = 6), keine Studie die Bedarfe/Versorgung von Frauen während Schwangerschaft und Geburt. In 62,7 % aller Primärstudien wurden Asylsuchende an einem einzigen Standort rekrutiert. Bei 2 quantitativen Studien lag eine überregionale externe Validität vor. Forschungsbedarf liegt vor allem im Bereich chronischer Erkrankungen, Kinder- und Müttergesundheit vor. Die Divergenz und Heterogenität der Studien erschweren einen übergreifenden und vergleichbaren Erkenntnisgewinn und betonen die Notwendigkeit kollektiver Forschungsanstrengungen, um die in diesem Bereich bestehenden Wissenslücken zu schließen.

Background: Health monitoring in Germany falls short on generating timely, reliable and representative data among migrants, especially transient and marginalized groups such as asylum seekers and refugees (ASR). We aim to advance current health monitoring approaches and obtain reliable estimates on health status and access to essential healthcare services among ASR in Germany’s third largest federal state, Baden-Württemberg. Methods: We conducted a state-wide, cross-sectional, population-based health monitoring survey in nine languages among ASR and their children in collective accommodation centres in 44 districts. Questionnaire items capturing health status, access to care, and sociodemographic variables were taken from established surveys and translated using a team approach. Random sampling on the level of 1938 accommodation centres with 70,634 ASR was employed to draw a balanced sample of 65 centres with a net sample of 1% of the state’s ASR population. Multilingual field teams recruited eligible participants using a “door-to-door” approach. Parents completed an additional questionnaire on behalf of their children. Results: The final sample comprised 58 centres with 1843 ASR. Of the total sample expected eligible (N = 987), 41.7% (n = 412) participated in the survey. Overall, 157 households had children and received a children’s questionnaire; 61% (n = 95) of these were returned. Age, sex, and nationality of the included sample were comparable to the total population of asylum applicants in Germany. Adults reported longstanding limitations (16%), bad/very bad general health (19%), pain (25%), chronic illness (40%), depression (46%), and anxiety (45%). 52% utilised primary and 37% specialist care services in the previous 12 months, while reporting unmet needs for primary (31%) and specialist care (32%). Younger and male participants had above-average health status and below-average utilisation compared to older and female ASR. Conclusions: Our health monitoring survey yielded reliable estimates on health status and health care access among ASR, revealing relevant morbidities and patterns of care. Applying rigorous epidemiological methods in linguistically diverse, transient and marginalized populations is challenging, but feasible. Integration of this approach into state- and nation-wide health monitoring strategies is needed in order to sustain this approach as a health planning tool.

Zusammenfassung Hintergrund Daten zur gesundheitlichen Versorgungssituation von Asylsuchenden sind bislang nur regional verfügbar, eine bundesweite Bestandsaufnahme ist jedoch aufgrund hoher Flüchtlingszahlen von zunehmender Bedeutung für Entscheidungsträger. Ziel der Arbeit (Fragestellung) Abbildung der Strukturen, Prozesse sowie prioritärer Bedarfe bei der gesundheitlichen Versorgung von Asylsuchenden von der Erstaufnahmeeinrichtung bis hin zur dauerhaften Unterbringung in Landkreisen aus Sicht von Gesundheitsämtern. Material und Methoden Wir führten eine bundesweite, gemischt quantitativ-qualitative („Mixed-Methods“-)Analyse der Versorgungssituation von Asylsuchenden durch. Alle Gesundheitsämter (N = 389) in Deutschland wurden angeschrieben und zur Teilnahme an einer schriftlichen Befragung eingeladen. Erhoben wurden Angaben zu: (1) ärztlichen Maßnahmen und Screening; (2) Prävention und Gesundheitsförderung; (3) Kommunikation; (4) Dokumentation und Information; (5) Koordination; (6) strukturellen Ressourcen und Bedarfen. Begleitend führten wir semistrukturierte, qualitative Interviews mit ausgewählten Gesundheitsämtern. Ergebnisse An der schriftlichen Befragung nahmen 123 Ämter (Rücklauf: 31,6 %), an der telefonischen 29 Ämter aus allen Bundesländern teil. Verbesserungen der Versorgung sind vor allem in den Bereichen Koordination und Standardisierung des Vorgehens, zügige Durchführung von Impfungen, standardisierte Erhebung und datenschutzkonforme Übermittlung gesundheitsbezogener Informationen sowie Konzentration auf wenige, bevölkerungsmedizinisch wichtige Infektionskrankheiten bei der Erstuntersuchung (nach § 62 AsylVfG) nötig. Schlussfolgerung Die verwendeten Befragungsinstrumente erwiesen sich für bundesweite Untersuchungen zur gesundheitlichen Versorgung von Asylsuchenden als geeignet. Erneute Befragungen zu einzelnen Schwerpunkten könnten zukünftig dazu dienen, in regelmäßigen Abständen ein noch detaillierteres Abbild der Versorgungssituation zu generieren.