A Conceptual Framework for Health System Collapse: Linking External Stressors, Internal Vulnerabilities, and Cascading Risks

Abstract

Health-system collapse is rarely attributable to a single shock or isolated system failure. Evidence generated across a sequential research program indicated that systemic deterioration emerges through the interaction of external pressures, internal vulnerabilities, cross-domain propagation, and declining system capacity. This study aimed to integrate these findings into a comprehensive conceptual and diagnostic framework for assessing the risk of health-system collapse.

An integrative conceptual framework-development approach was applied through cross-study synthesis of findings from ten preceding empirical and conceptual studies. The synthesis integrated evidence on external stressors, internal vulnerability domains, early-warning signals, vulnerability interactions, and functional deterioration. Findings were further interpreted in relation to the SEA dimensions of Stability, Efficiency, and Adaptability.

The synthesis identified eight categories of external stressors and six internal vulnerability domains and resulted in the WAVE Model, comprising four interconnected components: Wider Environmental Stressors (W), Activated Internal Vulnerabilities (A), Vulnerability Interactions and Cascades (V), and Escalating Systemic Risk (E). A structured WAVE Diagnostic Assessment Tool was subsequently developed to operationalize these components through domain-specific diagnostic items scored on a 10-point scale and hierarchically standardized to four 0–100 component scores. These scores can be retained as a diagnostic risk profile and provisionally integrated into an overall 0–100 collapse-risk score.

WAVE conceptualizes health-system collapse as a progressive systemic risk process rather than the consequence of a single failure. The framework provides a structured basis for detecting how external pressures activate vulnerabilities, how vulnerabilities interact and cascade, and when deterioration begins to threaten system-wide functioning. Empirical validation is required to establish item performance, differential weighting, risk thresholds, and predictive validity.