<p>Countries represented in the included articles.</p>

Strong and resilient health systems are those equipped to withstand shocks and continue providing quality services as response measures are implemented. We conducted a qualitative evidence synthesis of stakeholders’ understanding of health system resilience in Africa, focusing on definitions and attributes. We searched for peer-reviewed articles and grey literature, filtered for Africa, from 1980 to November 2025, using the SPIDER framework. The search was conducted in four databases: PubMed, the Bielefeld Academic Search Engine, the Cumulative Index to Nursing and Allied Health Literature, and Scopus; we also reviewed the websites of the World Health Organization (WHO), Africa Centers for Disease Control and Prevention (Africa CDC), and Ministries of Health of African countries. Articles were selected based on predefined inclusion and exclusion criteria. Qualitative articles were appraised using the Critical Appraisal Skills Programme, and mixed-methods articles using the Mixed Methods Appraisal Tool. We mapped the distribution of included articles by the country studied, the infectious disease responsible for the shock, and the health system building block described. For each article, we identified the definition of health system resilience and its attributes. The search yielded 5,448 relevant articles, eighty-three of which were included in the synthesis. Articles were from 48 of the 54 African countries. Up to 74.5% of the articles focused on COVID-19; others were on Ebola Virus Disease, cholera, and meningitis. Service delivery, leadership and governance and health workforce were the most frequently cited health system building blocks. Adaptive capacity of health systems resilience was most frequently cited, followed by absorptive capacity, preparedness, and recovery. Identified attributes of a resilient health system were community engagement and involvement; leadership and governance; collaborations and partnerships; human resources for health; health education and promotion; health information systems; health service delivery; decentralization and local governance; health infrastructure and logistics; preparedness; learning and adaptation; and innovation and financing.