Health system shocks and the responses to them always leave behind a legacy.

Governments should act to redress negative legacies for workforce and user access.

Coherent preparedness strategies that integrate prior learnings are essential.

Each crisis brings new opportunities for reform and building constructive legacies.

Shocks, and the responses to them, always leave behind a legacy. In situations of sequential shocks or even permacrisis the legacy can become cumulative. It is therefore vital for decision-makers in a crisis to understand that their decisions will have long-lasting implications for health system performance and resilience.

In this article the authors explore the nature of legacy and a shock cycle approach to health system resilience. We investigate the case study of the Irish health system, which has undergone several shocks in succession, from economic austerity to COVID-19, a cyberattack and the cost-of-living crisis.

We explore quantitative health system performance metrics as well as qualitative interviews with health system experts who have been involved in the health system since the economic crisis in order to illuminate learnings around legacy and resilience. The case study is informed by analysis from the PHSSR programme and the PRESTO report.

The results indicate that key cumulative legacy effects of the shocks in Ireland have been both negative and positive. There have been longer waiting lists, as well as demotivation, turnover and disengagement of staff that has resulted in poorer access to routine care. Yet there have also been successful reform efforts to universalise the health system and expand community-based care. This includes dropping access charges, additional funds to support capacity and democratising decision-making within services.

Taken together, this analysis highlights the compounding nature of shocks to the health system and their enhancement of both the strengths and weaknesses of health systems.

Health policy

Health system resilience

Health systems

Shocks

Crises

Legacies

Covid-19

Ireland

Permacrisis

Polycrisis

Cost-of-living crisis

Austerity

© 2025 The Authors. Published by Elsevier B.V.