Pathways to health resilience: A cross-country analysis of health system response to re-emerging infectious diseases in Sub-Saharan Africa

Sub-Saharan Africa (SSA) faces recurrent threats from re-emerging infectious diseases, including Ebola virus disease, cholera, measles, Lassa fever, and Marburg virus disease. This study assessed the resilience of health systems in 25 SSA countries from 2000 to 2023 using a multidimensional resilience index and a first-order Markov state-transition framework. Country-year observations were classified as Low Resilience, Moderate Resilience, or High Resilience based on epidemiological performance, health financing, surveillance, response capacity, and recovery indicators. Resilience was heterogeneous and path-dependent. Low-Resilience observations had an 82.4% probability of remaining in that state in the subsequent year and only a 3.1% probability of moving directly to High Resilience. Moderate-Resilience observations had a 19.1% probability of transitioning to High Resilience and an 18.2% probability of declining to Low Resilience. High-Resilience observations had a 63.6% probability of remaining High Resilience, but a combined 36.4% probability of regression. Multinomial logistic regression showed that health expenditure per capita, domestic health-financing share, and GDP per capita were positively associated with High Resilience, whereas internal armed conflict was negatively associated with High Resilience. Southern and Eastern Africa showed stronger resilience profiles than Western and Central Africa, while Central Africa had the greatest concentration of Low-Resilience countries. These findings indicate that resilience is dynamic, unevenly distributed, and strongly shaped by sustained financing, economic capacity, and political stability. Policy priorities include strengthening domestic health financing, targeting Moderate-Resilience countries for accelerated improvement, supporting conflict-affected systems, and harmonising regional surveillance and emergency-response mechanisms.