Background: Health challenges like coronavirus disease 2019 (COVID-19) are becoming increasingly complex, transnational, and unpredictable. Studying health system responses to the COVID-19 pandemic is an opportunity to enhance our understanding of health system resilience and establish a clearer link between theoretical concepts and practical ideas on how to build resilience.Methods: This narrative literature review aims to address four questions using a health system resilience framework: (i) What do we understand about the dimensions of resilience? (ii) What aspects of the resilience dimensions remain uncertain? (iii) What aspects of the resilience dimensions are missing from the COVID-19 discussions? and (iv) What has COVID-19 taught us about resilience that is missing from the framework? A scientific literature database search was conducted in December 2020 and in April 2022 to identify publications that discussed health system resilience in relation to COVID-19, excluding articles on psychological and other types of resilience. A total of 63 publications were included.Results: There is good understanding around information sharing, flexibility and good leadership, learning, maintaining essential services, and the need for legitimate, interdependent systems. Decision-making, localized trust, influences on interdependence, and transformation remain uncertain. Vertical interdependence, monitoring risks beyond the health system, and consequences of changes on the system were not discussed. Teamwork, actor legitimacy, values, inclusivity, trans-sectoral resilience, and the role of the private sector are identified as lessons from COVID-19 that should be further explored for health system resilience.Conclusion: Knowledge of health system resilience has continued to cohere following the pandemic. The eventual consequences of system changes and the resilience of subsystems are underexplored. Through governance, the concept of health system resilience can be linked to wider issues raised by the pandemic, like inclusivity. Our findings show the utility of resilience theory for strengthening health systems for crises and the benefit of continuing to refine existing resilience theory. It acknowledges the system’s context and interactions between the system’s components and actors, not just the building blocks.3 As health challenges become increasingly transnational and unpredictable, health systems will need to become more resilient. The global health community has recognized the need for a systemic approach to global health challenges, and the importance of strengthening health systems along with addressing the social and economic determinants of health. Universal health coverage and drives for higher quality systems have reimagined the role of health systems in addressing the broader contextual and systemic determinants of health.5 These capacities for change are governed by the rules, norms, and power structures that influence the interactions, relationships, and decisions among health system actors.6 Examining resilience can help build stronger health systems but will require investigating all these aspects of health systems if one wants to assess the capacities of health systems. Resilient health systems have the capacity to absorb shocks using existing resources while maintaining the same essential functions as before, adapt to them by adjusting their functions and use of resources, or fundamentally transform their functions to reduce risks in response to the shock.5 Coronavirus disease 2019 (COVID-19) is defined as a complex shock, being multi-factor and multi-scale in its cause and effects. Studying health system responses to the pandemic — a shock on a global scale — provides an opportunity to refine our current understanding of health system resilience. The objective of this paper is to re-evaluate what is known about health system resilience, by evaluating the overlap in resilience concepts that are discussed in the recent literature on resilience and COVID-19 and concepts in an existing health systems resilience framework.5 is used as a structure for the analysis of the literature on health systems resilience and COVID-19. The framework has four dimensions that create the capacity to absorb, adapt, or transform.5 Systems must be able to integrate, process, and make decisions using knowledge about their resources, risks, and health needs by interacting with different actors and groups inside and beyond the health system. They are able to anticipate and cope with uncertainty through the actions and decisions of individuals, groups, and networks in response to the shock. They must also be able to manage interactions with other systems beyond the health system (interdependence) and recognize the impact of contextual and external factors on the system’s behavior, capacities, and resources. Finally, systems must create a legitimate system that is trusted to provide socially acceptable and contextually appropriate care. The dimensions are not mutually exclusive. The widely cited Dimensions of Resilience Governance frameworki) What do we understand about the framework’s dimensions of resilience? (ii) What aspects of the resilience dimensions remain uncertain? (iii) What aspects of the resilience dimensions are missing from the COVID-19 discussions? and (iv) What has COVID-19 taught us about resilience that is missing from the framework? This review addresses four questions:  that explicitly discussed health system resilience in relation to COVID-19, published in English in scientific journals. We excluded articles on personal and psychological resilience at the individual level. We also excluded articles on individual or community resilience and resilience in other types of systems , if they were not directly linked to a discussion on health systems. The first author screened articles by title, abstract, and full text against the eligibility criteria; articles where eligibility was unclear were checked with the remaining authors. The first search identified 184 articles. After screening titles and abstracts, 104 full texts were read and 19 articles were included for analysis . The sec Any findings or discussion points on health system resilience and COVID-19 from each study were extracted onto a data form. The data were subsequently grouped by the framework’s four dimensions by the first author and reviewed with the remaining authors to confirm that the data were relevant to the dimensions it was placed under. The data were then re-assessed by the first author to determine whether there was agreement in the data about the concepts in a dimension (what was understood about the dimension) or whether there was disagreement in the data (what remains uncertain about the dimension). The authors discussed the agreements and disagreements until consensus was found. Concepts from the dimensions in the framework that were not observed in the data were noted as not discussed. Any discussion points and findings from the articles that were not described in the framework were identified and summarized. Six new thematic areas were identified during analysis that reflected these new discussion points: teamwork, health system actor legitimacy, the influence of values, equity, linking health system resilience to societal resilience, and governance of the private sector. Two analyses were conducted separately: one on the first search and another one on the second search. The results of the two analyses were compared and merged into a single analysis in June 2022.Learning: The selected manuscripts emphasize the adaptive nature of health systems and their potential to learn  outbreak how to mitigate widespread, system-level challenges.38 The emphasis on learning is on individual country systems learning from previous successes or shocks to create a successful response to COVID-1944 The influence of context on learning was relatively overlooked,45 with a few exceptions: one study describing how the 2003 SARS outbreak changed community values and the political environment for public health in Singapore and how this redefined the health system’s context prior to COVID-19,10 and one study describing how the pandemic has influenced the political climate for developing new frameworks on noncommunicable diseases in the European Commission.42 Several articles stated iterative and cyclical learning as a key takeaway, to continuously assess how policies and strategies performed during the pandemic over time, and to use these learnings in future policies.43 Looking forward to future shocks was also recognized as an important learning process following COVID-19, to strengthen public health systems for global health emergencies.Knowledge sharing: Communicating, integrating, and using information from a variety of sources was regarded as important to control COVID-19, distribute resources, plan health services, and coordinate a response.49 The importance of knowledge to support decision-making is not surprising, as health communication, surveillance, and information gathering are the fundamentals of public health and outbreak response.15 Integrating knowledge from other sectors and systems into the health system can support innovation and evidence use during response, and could improve risk assessment and decision-making.49 However, only a few systems appeared to have integrated information from other sources, like transport and immigration data, which suggests need for improvement for future shocks. Similarly, decision-making was facilitated when standard sources of population and individual-level information, like health management and information systems, were integrated with new sources inside and outside the health system, like contact tracing apps, travel databases, and research data.50 Earlier outbreaks, like Ebola, have seen similar findings.5152 These included integrating routine administrative data to monitor health system performance,53 setting up informal networks among local facilities to monitor resource levels,26 and creating real-time algorithms for transmission risk and health service performance.52 A challenge to using information for decisions was identified when actors lacked shock-specific, service-specific, or level-specific response guidelines and information.56 In such situations, health system actors reported difficulty in responding without clear guidelines and protocols that were tailored to their situation. In some health systems, stakeholders changed the way that risks to the system were identified, by evolving existing information mechanisms or integrating new data sources from within and beyond the health sector.56 For instance, when the public reacted negatively towards a tool developed to categorized the level of COVID-19 transmission risk at a subnational level in Italy, the National Public Health Institute held weekly presentations and question and answer sessions that were open to the public.52 The authors perceived the open and transparent sharing of information as a useful method to help quell public criticism of the tool. Top-down information sharing might combat misinformation about COVID-19 if it comes from a trusted authority, although how to prevent and reduce misinformation in the first place was an unresolved challenge.54 Consistent, clear, concise, and transparent communication from the health system and the government to the population – tailored to cultural norms and to health literacy levels – was essential to persuading people to adhere to COVID-19 regulations.23 Individuals and communities are important sources of knowledge for COVID-19-related activities, like contact tracing, providing expertise, and sharing information on local resources.28 However, neglecting to involve civil society in decision-making can lead to disempowerment and distrust in the health system and government.57 The capacity to manage resilience may be lower in health systems that do not gather knowledge from civil society. Many governments adopted a top-down, dominant approach in the early stages of the pandemic, leaving few mechanisms to involve civil society.58 For resilience, it will be important to delineate which community engagement processes were successfully used during COVID-19 and which effects these processes had on the effectiveness and appropriateness of the response. Communities should be seen as integral knowledge sources in the health system, not just as beneficiaries.59 For instance, a lack of information on existing supplies, health system infrastructure, and availability of resources across organizations has created challenges in distributing resources.15 In a study of care homes, hospice knowledge brokers, like hospice workers, were identified as a valuable resource to connect smaller facilities and less prominent actors to each other, to other local facilities, and to information on resources and guidelines.26 Such social networks supported actors, for example, in creating local guidelines. However, not all communication mechanisms were able to successfully integrate their target groups, who were then required to find their own ways to access information to support their decisions. An incident management system designed to streamline communication to a single point of contact was found to have excluded lower level networks and actors, reinforced top-down information sharing in the system, and duplicated work in the lower levels.55 Within the health system, open and clear communication between services, groups, and levels helped actors make timely decisions while the system adapted.Leadership: The role of strong and transparent leadership in managing uncertainty has been acknowledged before,62 and remains relevant for the COVID-19 pandemic. Fast, flexible, and transparent leadership for coordination and clear roles and responsibilities for individuals and groups across the system characterized effective health system responses to COVID-19.63 Good leadership supported and structured decision-making while the situation changed. For example, it improved communication around mistakes and was able to align similar processes between different ministries. Good leaders were also perceived as having a clear and transparent vision that let others understand their decisions. For instance, in situations with considerable unknowns, making a somewhat faulty decision quickly and swiftly was perceived by the public as a better approach than any repercussions that might have come by waiting to make a decision with more information.4866 The presumed result is a system that is less flexible and less able to mobilise surge capacity.64 Although large amounts of financial resources have been allocated to public health and health systems for COVID-19, it has often been in the context of previous periods of austerity, underfunding, and streamlining to create more efficient medical systems. In Spain and the United Kingdom, prior reductions in spending hampered the system’s ability to scale up testing and contact tracing, and isolation and led to an undersupply of intensive care beds and ventilators.64 Chronic underinvestment in public health and primary care created a weak base leading into the pandemic,67 such as in India, where resource shortages were already an issue prior to COVID-19.66 Health systems with a robust and diversely skilled workforce,66 stable and protected funding,65 and reserve capacities for physical resources66 were perceived to have fewer service interruptions and to be more resilient. To respond to the pandemic, resources and infrastructure needed to be readily available for distribution and use. Sustained, long-term investment in public health systems, particularly infrastructure and human resources, is noted as widely lacking in many systems.33 Reducing uncertainty around the availability, capability, and well-being of the health workforce meant health systems had to adapt policies to meet changing demands for services and to protect the workforce from infection and poor mental health outcomes.68 Adaptations varied in scale, from changing the working hour limits to changing national recruitment regulations. For example, in Trinidad and Tobago, intensive care nurses were recruited from Cuba, and in Spain, and it was allowed to hire final year medical and nursing students.64 Adapting also required organizational culture changes, such as allowing healthcare workers to work in new ways that would not have been acceptable prior to the pandemic, like exceeding maximum work hours.26 However, this also meant that healthcare worker occupational protections had to be simultaneously strengthened . To counteract uncertainty around resource availability, systems needed to find flexible and innovative ways to generate and use resources. For funding, this included changing funding and financing rules and processes as needed , creating standardized processes to distribute funds, trying to negotiate better procurement deals, and reducing reliance on external resources.69 This was also perceived to reduce the burden on higher levels of a centralized response and to account for contextual differences in the response.56 While the pandemic hit all health systems, it did not hit every level of every health system in the same way. As such, blanket policies proved to be ineffective, leading to maladaptive implementation at different levels. Using a “bottom up” and more democratic approach to include actors from different levels and sectors in the decision-making process was thought to reduce uncertainty by ensuring that decisions about the response were appropriate for differing levels of the health system.Interdependence: Countries have had to conduct long-term, national level responses to COVID-19. Measures to prevent and contain COVID-19 have impacted multiple sectors. There is agreement that the breadth of COVID-19 requires better integration and awareness of interdependence during the response.69 First, health systems should be collaborating, coordinating, sharing information, and making decisions with civil society, academic, the private sector, and other government sectors , which required good communication skills and adept leadership at the national level. Doing so might help health systems absorb or adapt, assist in decision-making, and overcome diverse objectives across sectors.5439 Interdependence was also raised in the context of solidarity among actors to avoid competition over resources and keep the response cohesive.63 Working in a multisectoral way towards a common goal was seen as a learning process that required clear, aligned roles at all system levels, training on interdisciplinary and interprofessional values, developing cross-sectoral plans, and allowing new ways of working together to develop.48 Second, health systems should be strengthening internal links, such as those between healthcare facilities or between public health and clinical medicine, and links with international bodies and other health systems.46 With COVID-19, well-established health systems in high-income countries are now experiencing different and novel problems. For instance, the United Nations International Children’s Emergency Fund initiated its first-ever emergency response in the United Kingdom to feed vulnerable children.71 Low-income countries may no longer have access to technical and financial assistance from high-income countries, who are responding to the shock themselves.20 Supply chains globally became unpredictable, highlighting the dominance of the international supply chain and the infeasibility of many countries to produce resources internally,46 with exceptions: interindustry technology transfers were seen in countries like Vietnam, who were able to begin manufacturing ventilators in-country.28 The pandemic provides an opportunity to understand interdependence at the international level and the value of effective global health governance in a world where we saw the reemergence of borders and national preference. COVID-19 has forced an interdependent response at a global level. An emerging issue has been understanding how interdependence works at the international level when usual patterns of interaction have changed with the closure of borders and competition to have access to masks, oxygen, and vaccines.Legitimacy: Linked to the ideas on interdependence and communication, legitimacy was enhanced by having a supportive political environment that is accepted by the population as a legitimate, responsible actor in the COVID-19 response.64 Because of the scope of COVID-19, the government has been the only institution with enough legitimacy and capability to take on responsibility for coordinating and managing the response.72 This has created challenges for health system actors, as health systems cannot fully separate themselves from governmental legitimacy.43 Examples include political and social unrest, which influenced public trust in government information about the pandemic; opposition to new governmental decrees on lockdown measures; and exacerbations of prior tension between federal and regional governments.64 However, this is not new; for example, deep political mistrust has contributed to persistent transmission of Ebola in the Democratic Republic of Congo and Sierra Leone.74 With the COVID-19 pandemic, there are concerns that governments and leaders with low legitimacy will reduce the population’s acceptance of control measures , which would ultimately undermine the effectiveness of the health system response.4610 In Quebec, it was observed that getting rid of a contact tracing mobile app appeared to increase public trust in the government’s response.16 However, social and political contexts can mediate the acceptability of control strategies; governments with top-down approaches to complying with COVID-19 regulations have been able to introduce universal, app-based technologies that curtail individuals’ movement based on contact with COVID-19 cases. The uptake of similar apps has been low in contexts that place a high value on privacy and civil liberties.75 Misinformation can also fuel mistrust in the health system,15 impeding the system’s ability to accurately predict and respond to changes in COVID-19 transmission and healthcare demand. Health systems that do not adequately address concerns about data sharing and misinformation may have long-term consequences on the population’s trust in the system. In conjunction with the issue of legitimate governments, individual privacy during a population-wide response appears to influence the system’s capacity to respond. For instance, contact tracing apps have been implemented in many settings, but their effectiveness depends on whether the population trusts how the data would be collected, used, and stored.48 At the healthcare delivery level, local facilities and actors that were able to incorporate requests from communities  were thought to have better connections to communities and were better able to overcome policy obstacles.76 However, the long duration of the pandemic has required some governments to prolong unpopular and unusual interventions, like those that curtail freedom of movement, which has led to protests in multiple countries.77 Government responses worldwide have been publicly critiqued and politicized, in some cases reducing transparency.78 One recommendation includes creating permanent mechanisms for involving communities that extend beyond the shock, as long-term confidence in the government may depend on reciprocal actions by communities to adhere to health system requests and by health systems to support ownership.79 Trust is also linked to populations’ power to take ownership in the health system and influence its response. Spaces are recommended where communities and health system professionals can communicate and interact.30 and pushing to implement health system reforms during the pandemic.25 One reason for the focus on adaptation and absorption may be the tendency of the manuscripts to define resilience as the ability to prepare for and respond to shocks while maintain core functions and responding to health needs,80 or as the ability to withstand and adapt to a specific shock,81 which de-emphasize the capacity for profound change. The tendency to equate resilience with maintaining essential health services or with emergency preparedness may also draw attention away from possible structural and functional changes and towards short-term change in particular sub-systems or areas. This focus on performance overlooks the underlying capacities that allow a health system to fundamentally change. The absorptive and adaptive focus might also be explained by the time horizon of the articles, as about one-third of the manuscripts reviewed were written early in the pandemic. Across discussions on health system changes during COVID-19, transformative capacity has received the least attention, compared to absorptive and adaptive capacity. Examples of transformation have been described, like creating parallel systems for COVID-19 care69 Instead of following “the temptation to deescalate healthcare reform”25 during COVID-19, the pandemic was a chance to move away from the status quo. For instance, the pandemic changed the perceptions of recent public management approaches in Quebec and created new possibilities to change health system management structures.16 Reconciling the predominant focus on absorption and adaptation and the view of crises as a chance for transformation will require recognizing that endless absorptive and adaptive capacity are unsustainable since health systems are embedded in an unpredictable, constantly changing context.82 However, the pandemic was also reframed from a crisis to a clear opportunity to initiate reforms that could support transformation.48 For instance, investing in local research capacity to generate localized knowledge, such as local vaccine production, may reduce a system’s reliance on the international community during future shocks.34 Although the necessity to integrate and use multiple forms and sources of information is clear, it is still unclear which sources and forms are most influential on the system’s ability to respond and its capacity for resilience. While connecting knowledge from sources like communities and other sectors to the response has clearly been described as beneficial, knowledge goes beyond linking sources together. If the process of producing, collecting, integrating, and interpreting knowledge can be strengthened, it may prove to be protective to the health system’s response to future shocks.28 For example, care home healthcare workers improved their confidence in their leadership skills when the unique skills that they developed during the pandemic, such as learning how to negotiate with local suppliers, were recognized and repeatedly used.50 Supporting the capacity of health system actors to make and act on decisions may be useful for their ability to adapt to change in the future. An emerging idea from COVID-19 is the need to build the capacity of the healthcare workforce and other health system actors to make decisions in response to a shock. This moves beyond what decisions can be made and by whom, to how to build individual and group capacities to act.83 Policy makers have been under pressure to quickly assess a changing situation, react to new information, and provide expertise on a novel virus.84 Several authors argue that clarifying the process would have reduced the uncertainty among health system actors that the decisions were correct and could be trusted.52 Governments were criticized for not openly discussing the uncertainty of the decisions they were making and that decisions could change in future circumstances.23 However, distrust in decisions may relate more to a described lack of inclusion in the decision-making process for groups of health system actors.56 An exclusive decision-making process may have led to inefficiency in health system responses. Without access to a centralized incident management system that made decisions about care, primary healthcare actors had to spend additional time advocating for their needs and decided to duplicate decision-making streams.55 To understand the dimension of uncertainty, future analyses will need to address how the process of decision-making influences the system’s ability to act, including the effect of social relationships. A second emerging area is the need to make the decision-making process transparent, including stating a clear rationale for decisions. The different decision-making processes for COVID-19 responses has been relatively overlooked; this may be because many national-level response decisions were considered to be political decisions that went beyond a public health purpose.44 In theory, trust might be stronger in rural areas and with the primary care sector, where there are closer links between service providers and communities.36 Future discussions on resilience will need to explore the implications of implementing top-down interventions on legitimacy. Many COVID-19 public health interventions have relied on individuals and local communities to change their behavior and comply with regulations. The willingness of the general public to comply is closely tied to trust in the government, the health system, and the acceptability of the interventions. There is still uncertainty on how to understand localized trust and how to harness it to improve compliance to national policies requiring rapid collective behavior change. Trust in public health messaging and the effectiveness of local responses might be improved by involving and soliciting feedback from community members and local influencers.67 For example, maximizing vaccination uptake and coverage is essential to preventing transmission but is highly dependent on the population’s trust in vaccinations and the health system. In some contexts, it may be possible to implement policies that mandate vaccination, like previous COVID-19 policies that have emphasized personal responsibility.10 In others, this may be legally or contextually impossible. How should health systems adjust if they are unable to meet vaccination targets? Some given strategies to adjust include reorienting health system actions to the population’s wants, rather than the system’s preferences  and incorporating quality of care domains into all aspects of emergency preparedness and response.49 It is likely that in future crises, health systems will need to rethink their response strategies to create socially acceptable solutions in light of the population’s level of trust. Health systems may need to adjust to low levels of trust while responding to COVID-19 and other crises, although the most effective and appropriate ways to do so remain unclear.55 For instance, one individual primary care stakeholder was able to access information and decision-making processes and then informally link them to other primary care stakeholders.55 Such individuals may be the key to integrating health system groups and services during shocks, which can support their response to shocks.85 However, in some contexts, political tensions between groups and organizations appear to be a threat to the ability of groups to interact and the health system to respond. The political independence of pandemic agencies has been called for in the United States, to protect them from political threats,46 and growing sectarianism amid political turmoil in Lebanon was thought to have weakened the health system’s mechanisms to collaborate and coordinate.17 The types of individuals and groups that are effective at engaging with others will likely differ by context and health system structure, but identifying the underlying factors to their success could be worthwhile exercise with practical implications for future responses.86 The ability to lead a robust national response to COVID-19 requires governments to work across sectors and systems. There remains relatively little describing which individuals and groups are involved in effectively engaging with each other, both inside and outside the health system. Making use of the individuals and groups who are able to efficiently interact with others is likely to be supportive of the health system’s capacity to change and respond to a shock.20 A challenge with the pandemic has been the need to act quickly to a rapidly changing situation, making outcomes difficult to predict and little time to assess possible consequences. One consequence of rapid action was observed in a study of care homes, where the homes were forced into a new, dependent relationship with government supply chains, following a government decision to reorganize the supply chain to prioritize hospitals; the consequence was a slower, more expensive, and inefficient supply chain for the care homes.26 Health systems have needed to react quickly and constantly to COVID-19. Certain short-term consequences from the changes are predicted, like a backlog of unmet health needs that will have to be addressed following the cancellation of routine health services. The longer-term consequences on the system and the context have been harder to observe. For example, changes in service utilization patterns have impacted the income of providers who use volume-based payment plans.5 The pandemic has created a number of risks to the health system besides the virus itself, through the response to the pandemic and its impact on societal systems. COVID-19 has been a prime example of these risks. The pandemic’s impact on economic and food systems led to growing malnutrition, with estimates that an additional 6.7 million children under five years old would become wasted and an additional 128 000 child deaths from malnutrition would occur in 2020.87 At the same time, essential nutritional services like community screening and vitamin supplementation have been disrupted or are no longer accessible in vulnerable countries.88 The pandemic has also threatened health system resources, such as reduced financing because of economic recession.20 Although these risks were acknowledged in the articles, there was little discussion on how they could be monitored or identified. Health systems need to be able to monitor risks as they develop beyond the health system. The necessity of cross-sectoral and national and international-level interdependence for resilience is well-described in relation to the pandemic; the vertical interdependence of the health system is not. Health systems are interdependent across scales and subsystems as well as with other systems, which is fundamentally reflected in our results on knowledge sharing and uncertainty. The link between effective teamwork and health system actor legitimacy and vertical interdependence is also acknowledged (further discussed in the section “What is missing from the framework?”). Yet the causes of failures at different health system scales or subsystems or ways to strengthen vertical interactions have not been explored. We identified six main areas omitted in the resilience framework that were essential elements during the pandemic: teamwork, actor legitimacy, influence of values, explicit consideration of equity and fairness, linking health system resilience to societal resilience, and governance of the private sector.Teamwork: The pandemic shows that information flows, decision-making, and interactions between the systems levels are impacted by the quality of teamwork among health system actors and groups.76 The ability for actors and healthcare workers to successfully work together as colleagues and in teams relies on trust, power dynamics, and perceived inclusion in groups and in processes. Multi-country evidence shows that the resilience of the health workforce requires more than funding, governance, and good organization of services24: since teams constitute a sub-system of the health systems, resilience is not possible without resilient teams with supportive team dynamics.65 Power imbalances among groups and team members and lack of trust-building mechanisms like whistle-blowing or feedback tools led to uneven levels of trust between healthcare providers themselves and with other actors.16 The lack of such mechanisms was especially felt with top-down approaches, which appeared to decrease the workforce’s collective belief in the capacity of local and national governments.76 ‘Low power’ actors in the health workforce, like primary care and care home staff, may regularly experience isolation from operations and decision making, not only during shocks. The lack of access to information and support created an environment of isolation and little solidarity among actors.55 An expected consequence to low trust and solidarity among teams is an unwillingness for various actors to cooperate, share information, and work together.69 Training in collaborative practice and interprofessional teamwork, including evidence-based dissemination of information and enforcement, addressing data ownership and confidentiality, may be key to address the issue.65Health system actor legitimacy: In addition to community legitimacy, actors in the system must also perceive the system as legitimate. Their perceptions of the governance mechanisms of the health system will influence their behavior in carrying out and committing to health system actions .76 Legitimacy extends to both the governmental services as well as the non-governmental sectors and actors, such as professional unions who protect healthcare worker rights, non-governmental organizations, and the private sector. Groups that were often excluded from decision-making or information flows, like community healthcare workers, nursing home personnel, primary care providers, and the public health workforce, had to adapt on their own. This led to resentment, decreased trust, and decreased willingness to cooperate with local governments and commit to centralized strategies, particularly in the groups that lacked mechanisms to disagree with more powerful actors.76 Other existing issues, like hostile work environments for healthcare workers, existed before the pandemic but exacerbated the workforce’s mistrust in local and central governments and their frustration during the crisis.69 Not only is remuneration for the health workforce important, but also respect that is embedded in operations, communication, and practices.41Values: Individual, institutional, and societal values have shaped many of the decisions that were made in responding in COVID-19 and the objectives of the response and recovery.89 With the pandemic presenting a situation of great uncertainty, decisions often had unknown outcomes and consequences when they were made, leading to ethical dilemmas among decision makers.79 For example, guidelines and ethical frameworks could be lacking or conflict with the context, the available resources, or community, group or individual values – all of which constituted a major barrier to providing services and implementing new decisions.79 The act of prioritizing services for different groups can be a value-based judgement, as well as a technical decision. Priority setting both in evidence generation and resource allocation were important not only during the shock: subsystems and areas that were neglected pre-shock appeared as weak links in the response, creating a risk for next crisis.79 It is likely that individual, institutional, and societal values have impacted health system responses in other ways, since values will shape the way that the dimensions of the framework manifest in a health system.Equity: Fostering an equitable, inclusive response to COVID-19 at local, national, and international levels has been crucial to containing the pandemic , improving access to and quality of services for vulnerable groups, and reducing the health impacts on populations.91 Focusing on vulnerable groups, like migrant workers living in densely populated housing, can help prevent transmission.10 The pandemic has shown system weaknesses and existing disparities in accessing and receiving care along social and economic lines, in contradiction to the principles of universal health coverage.94 At the local and national level, disadvantaged and vulnerable groups, such as the homeless, people living with chronic illness(es), and those unable to afford healthcare, have been disproportionately affected by COVID-19 and the indirect effects of COVID-19-related interventions like lockdowns.94 Lockdowns and other restrictions have disrupted, sometimes purposely, access to and provision of reproductive and sexual health services, including support for gender-based violence, contraceptives for teenagers, and abortions.58 Uptake of adaptive measures is also greatly influenced by social inequalities. For example, Colombia introduced telemedicine services but struggled to reach the one-third of the population that did not have access to broadband.69 Internationally, existing resource inequalities between higher and lower-income countries are likely to be worsened by COVID-19,95 and lower-income health systems may have greater difficulty providing health services and accessing and distributing resources like vaccines.96 To address inequities, resilient health systems should be able to identify vulnerable groups in the population, detect processes and services that sustain inequity in the system, and adjust in response. They must also recognize that health systems can also generate more inequity through their own actions, such as not being proactive at targeting minorities or ignoring the intersectionality between areas such as gender inequality and climate, and find ways to address the root causes of inequality that affect health outcomes and the system’s performance.9097 trust is affected by the ability of individuals and groups to access, pay for, and receive quality care when systems are primarily focused on COVID-19 care58; knowledge sharing can help to identify vulnerable groups,15 and so on. COVID-19 has drawn attention to how health systems may only be able to manage resilience at one level and for particular groups, perpetuating equity gaps. Health systems may be capable of managing resilience in urban areas, for example, but unable to absorb, adapt, or transform in rural areas that can be under-resourced and serving a more disadvantaged population.12 This raises questions around the comparative value of the dimensions and interactions within them at different levels, and if they are weighted equally in their contribution to resilience capacity. Equity is linked to all the dimensions in the resilience framework. Similar to earlier outbreaks,Transsectoral: The COVID-19 pandemic has been called a syndemic, an interaction between the biological threat of COVID-19 and social, economic, and environmental factors that results in adverse outcomes.98 Factors like poverty and social and gender inequality have created the inequity and disporportionate impact of COVID-19 on vulnerable and disadvantaged groups. While universal health coverage is key to ensuring that all people are able to obtain good quality health services without experiencing financial hardship as a result, the responsibility for social care and protection are outside the remit of the health system. Yet these factors are a large contributor to the outcomes that the health system is responsible for.100Private sector: For the public and private sector to respond in a complementary manner, strong governance of the private sector is required.64 During the COVID-19 pandemic, private sectors played a major role in the ability of multiple health systems to coordinate a response and to maintain routine health. They also affected the amount of financial resources available to the public sector and the speed with which the public health system was able to react to the pandemic.64 However, it is the public sector that runs the COVID-19 response in most countries.29 Some public sectors have been weakened by reduced investment in state-funded, government-run systems, leading to poorly integrated services, less trust in the health system as a whole, and poorer coordination between sectors during the response.58 For example, in India, the private sector was able to fill gaps in lab testing and COVID-19 care when the public sector was unable to accommodate additional patients. The need to use private providers resulted in disproportionate economic effects on lower socioeconomic classes, with knock-on consequences to health outcomes and trust in the system.58 In some cases, robust oversight of the private sector, like introducing centralized purchasing, helped to reduce competition over system resources, reduce profiteering, and strengthen collaboration between the private and public sectors. Interactions can be structured to promote resource sharing and collaboration but it requires governments to have the necessary regulatory capacity to ensure that public-private approaches are cost-effective, accountable and transparent.64 How should the private sector be governed and regulated to promote resilience? In general, the role and position of the private health sector in the system’s overall capacity to respond to current and future shocks has not been well-studied. The resilience framework makes no distinction between governance of the private and public sector, under the assumption that the four dimensions are relevant to resilience capacity for the whole system. However, like with equity, resilience capacities may vary greatly between the public and private sectors, particularly in systems with highly unregulated private sectors. In turn, this likely influences the four dimensions and the system’s capacity to manage resilience. Differentiating between the governance of health system levels and sectors could help further explain resilience capacity. Table shows summary of 63 articles included in the review. Our narrative review of health systems resilience and COVID-19 shows a moderate level of agreement and understanding on the concepts of health system resilience from the Dimensions of Resilience Governance framework. We have identified lessons from the discussions on COVID-19 that show the limits of the framework and point to a wider role for resilient health systems in protecting health and in society. However, there are several concepts from the framework that do not appear in the COVID-19 literature.101 Changes that were made to prepare for, respond to, and control COVID-19 now should pay off for future shocks and create more sustainable, inclusive and responsive health systems in the future.14 They are also likely to have long-term implications that could change the system’s context. A challenge with the pandemic has been the need to act quickly to a rapidly changing situation, making outcomes difficult to predict and leaving little time to assess possible consequences.26 In addition, some of the proposed health system strategies and reforms for COVID, like scaling up telehealth, require long-term management changes and redesign of functions and structures12; consequences may not become apparent until later. The challenge will be to continue monitoring the system to observe consequences across all system elements, and to understand which absorptive, adaptive, and transformative changes have had a net positive effect. As complex systems, the changes made during COVID-19 will have intended and unintended consequences for the health system.102 One Health approaches to managing risk during pandemics and other shocks present an opportunity to learn how to incorporate risk awareness beyond the health system into resilience work, thanks to their inherently intersectoral model for integrating and sharing knowledge.103 Despite keen awareness of the risks that COVID-19 posed to all of society, our understanding of how to monitor risks from other sectors is limited. Resilient systems should be proactively aware of risks as they develop and understand their potential impacts on the system, including risks that develop after the initial onset of a shock or that occur because of the shock. It is likely that more effective coordination and collaboration across sectors to monitor risks will be required. Analyzing information flows would be one way to identify information silos and describe bottlenecks in information-sharing interactions between sectors. The results suggest that knowledge on health system resilience are often projected onto the whole health system, without considering of the resilience of different subsystems. What impact would the failure of the regional level of the health system have? What are the implications if the public health services subsystem has less capacity for resilience than the healthcare services? Future research on health system resilience will need to understand how the scales and subsystems support the resilience of the others.40 The importance of equity and fairness in the way that health systems react to crises has been a key lesson from the pandemic, particularly in regards to the social and economic consequences. This goes beyond the equitable and fair performance of the health system during a shock and links to our findings on the relationship between health system resilience and societal resilience. If health systems are expected to enact and sustain universal health coverage, then we should consider how to connect societal resilience to health system resilience. For instance, defining a successful COVID-19 response by metrics beyond the number of cases and deaths might help elucidate health system reforms that can improve societal resilience to future shocks. Expanding social protection schemes for health, like paid sick leave, and investing in social development and gender equality while still prioritizing health might create stronger, more equitable health systems that are better prepared for future shocks.5 the concepts in Kruk and colleagues’ Resilient Health System framework104 support the relevance of our findings. The Blanchet and Kruk frameworks both draw on ideas from systems thinking and complexity, seen in the capacities of the Dimensions framework and in the characteristics of awareness, self-regulation, integration, and adaptation in the Resilient Health System framework. In Kruk’s framework, rapid and open knowledge sharing among decision-makers and with communities creates system awareness; regional and global actors can be used to build capacity and improve self-regulation; collaborating and engaging with non-health sectors and the community builds trust and leads to integration; and adaptation is derived from resource flexibility, local and rapid decision making, and learning from experience. In the context of the two frameworks, the resilience aspects that were missing from the COVID-19 literature become more pressing. For instance, both frameworks support strong vertical integration inside the health system, yet the idea was relatively overlooked in the COVID-19 literature. It is unlikely that the idea is irrelevant to the shock caused by the COVID-19 pandemic. Does the absence of vertical integration in the literature indicate that it is relatively less important than other aspects of resilience, or that vertical integration is not being practiced during COVID-19? COVID-19 should serve as an impulse to reevaluate the relevance of resilience frameworks and promote the aspects that remain underexplored and underreported. Although the COVID-19 literature was viewed through a single framework, Blanchet et al’s, We have identified lessons from the discussions on COVID-19 that show the limits of the framework and point to a wider role for resilient health systems in protecting health and in society. The Dimensions of Resilience Governance framework has clear utility in examining aspects of resilience, as seen by the variety of ideas in the COVID-19 discussions that are present in the framework. The coherence of the findings suggests that health system resilience is beneficial for understanding how to strengthen health systems for shocks. Our analysis presents a review of resilience through one lens. It would be worthwhile to conduct further analyses using other frameworks, to ascertain areas of overlap between concepts and to generate a more comprehensive assessment of where the concept of health system resilience currently stands. Not applicable. Authors declare that they have no competing interests. DDS, FT, and KB conceptualized the study. DDS conducted the searches, data extraction and analysis. AD and SOK contributed to screening, data extraction, and analysis of the second search. All authors contributed to the final analysis. DDS drafted the first manuscript and all authors critically revised the manuscript. The work was supported by the initiative “Foster Inter-University Initiatives and Collaborations” from the Swiss School of Public Health.Supplementary file 1. Scientific Database Search Strategy for COVID-19 and Health System Resilience Literature.Click here for additional data file.


The changes in demographic and family structures have weakened the traditional norms of filial piety and intergenerational relationships dramatically. This study aims to examine the dynamic association between financial support of adult children to their parents and informal care provision in China and its differences in household registration, residence arrangement and community-based care services.Data was derived from the 2008–2018 Chinese Longitudinal Healthy Longevity Survey (CLHLS), which is a longitudinal survey of a nationally representative sample of individuals aged 60 and over. Random effects model was used to assess the association between financial support and informal care provision of adult children to their parents.It was found that financial support showed an upward trend while informal care provision showed a download trend from 2008 to 2018. The result indicated a significant and negative association between financial support and informal care provision of adult children to their parents  = -0.761 to -0.239). And the association was significant among elderly people who were from urban areas , co-resided with adult children , and had community-based services .Financial support was negatively associated with informal care provision of adult children to their parents in China, and the association has differences in household registration, residence arrangement and community-based care services. It is suggested that policymakers should prioritize planning interventions for elderly care services and establish a family caregiver support system. China is undergoing a rapid population aging process. By the end of 2021, the number of Chinese elderly people over 60 had reached 267 million, accounting for 18.9% of the total population , 4. At tIn the transformation from a traditional society to a modern one, China is experiencing a decline in fertility rate, a shrinking in family size, a separation in intergenerational residence arrangement, and the reversal of intergenerational family status. According to statistics, the fertility rate in China dropped from 5.81 in the 1970s to approximately 1.15 in 2021 . During Studies in some developed countries have demonstrated that there are substitutions between informal and formal care. In Germany, long-term care policies provide cash benefits, which made family caregivers reduce the time of home care, increase labor supply, and pay more formal care for older people . Long-teFinancial support and informal care provision are two core contents of adult children’s support to their parents, and they are also indispensable resources to ensure the happiness of elderly individuals. In the decision making within the family, the association between financial support and informal care provision is changing and its ultimate goal is to maximize the benefits of the family . HoweverAlthough previous studies found that there is a negative association between financial support and informal care provision, they are mostly based on cross-sectional data or data in some regions, and some studies mainly focus on a particular group, such as elderly people with a disability or dementia or living in cities , 36. It The data was derived from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), which was a nationally representative survey performed jointly by the Center for Healthy Aging and Development Studies at Peking University and Duke University. A baseline survey was conducted in 1998 and was followed by seven waves of surveys in 2000, 2002, 2005, 2008, 2011, 2014 and 2018, which was from 22 sample areas in 31 provincial administrative units. The population of the surveyed region accounts for 85.3% of the total population in China, which could be regarded as a nationally representative sample . All resThis study employed the longitudinal sample from 2008 to 2018, which contained rich information on financial support, informal care provision, health status and lifestyle, family resources, adult children’s information, community-based care services, as well as characteristics of the respondents. After excluding cases with missing information on key variables and considering that there is insufficient information to confirm the age reported by extremely elderly people, we also excluded elderly people aged 120 and over. The final sample  did you get from your children and their spouses no matter living with you or not last year?”. After eliminating the extreme values, we subjected logarithmic processing of financial support. We had adjusted financial support for inflation during processing the data.All analyses included a series of covariates associated with the care recipient according to the previous studies , 45, 46.We first used descriptive analysis to describe the general characteristics of the participants and examined the trends in financial support and informal care provision of adult children to their parents from 2008 to 2018. Then, we assessed the association between financial support and informal care provision of adult children to their parents by random effects models. Finally, considering that there are differences in household registration, residence arrangement and the availability of community-based care services among elderly people, we explored the association between financial support and informal care provision in different groups. All analysis was conducted using the statistical software Stata15 .Table There are differences in the family economic status of Chinese elderly people. We divided the family income of elderly people into ten equal parts, and considered the top 10 percent as the high-income group and the bottom 10 percent as the low-income group , 48. TheTable Table Based on the national representative sample with longitudinal data, this study attempted to focus on all Chinese elderly people, exploring the association between financial support and informal care provision of adult children to their parents, and analyzing this association based on the differences in household registration, residence arrangement, and community-based care services. The results indicated that financial support showed an upward trend while informal care provision showed a download trend on the whole. It was found that financial support was negatively and significantly associated with informal care provision of adult children to their parents. And the association was significant among elderly people who were from urban areas, co-resided with adult children, and had community-based care services.It was found that financial support was negatively associated with informal care provision of adult children to their parents, and financial support is increasing with the downward trend of informal care provision for low-income and high-income groups of elderly people. The results were consistent with previous studies , which iIt was found that there was difference of household registration in the association between financial support and informal care provision of adult children to their parents. For elderly people in urban areas, financial support was negatively and significantly associated with informal care provision of their adult children, while the association is not significant for those in rural areas. That could be explained by the differences in concepts of filial piety, pensions and the availability of formal care services caused by the dual structure of urban and rural areas in China. In rural areas, filial piety emphasizes the importance of informal care provision of adult children to their parents while filial piety is gradually declining in cities with a higher level of modernization . In urbaThe results showed that there was difference of residence arrangement in the association between financial support and informal care provision of adult children to their parents. The association of financial support and informal care provision was significantly negative among elderly people co-resided with adult children, but the association was not significant among those who lived alone. This suggests that adult children are more likely to replace informal care provision with financial support, even if they co-reside with their parents, which could be explained in two ways. On the one hand, elderly people who co-reside with adult children have more intergenerational communication, and get more filial piety from adult children . It is oThere was difference of community-based care services in the association between financial support and informal care provision of adult children to their parents. For elderly people who had community-based care services, financial support was negatively and significantly associated with informal care provision while the association was not significant for those who had no community-based care services. The welfare triangle theory showed that the public care services provided by the government will have a crowding out effect on informal care provision , 55. TheEvaluating the association between financial support and informal care provision of adult children to their parents is beneficial for constructing a perfect care system aimed at providing and improving elderly care services (public care services and market-based care services) outside the family. Numerous elderly people in China, especially in rural areas, are confronting the dilemma of being left at home with nobody to take care of them. In consideration of the association between financial support and informal care provision varies in terms of the household registration, residence arrangement, and community-based care services, the Chinese government should pay more attention to the planning of the elderly care service system, expand the coverage of community-based care services and establish a support system for family caregivers. First, Chinese government needs to mobilize social resources to establish long-term care programs. Policymakers should leverage available policy instruments such as tax exemptions and subsidies, to explicitly encourage the construction of long-term care facilities, especially those in rural areas . Second,Nevertheless, the research findings from this article should be interpreted cautiously due to some limitations. First, the indicator of informal care provision was self-reported by the elderly people. The elderly people who co-resided with adult children may overstate the length of time about informal care provision, which would cause measurement inaccuracy of informal care provision. Second, some characteristics of adult children, such as occupation and working status, are important factors affecting the association between financial support and informal care provision. Unfortunately, these factors are not included in the CLHLS and we cannot select these variables in analysis. Last, due to the lack of detailed data on the financial support and informal care provision provided by each adult child, the distribution of financial support and informal care among each adult child was not fully considered in this study. Despite these limitations, this study discovered that the association between financial support and informal care provision of adult children to their parents was negative and significant, which provide evidence from Chinese families.This study demonstrated that financial support was negatively and significantly associated with informal care provision from the dynamic perspective, which fills the gap in literature on the association between financial support and informal care of adult children to their parents in China. It was found that the association of financial support of adult children to their parents and informal care provision was significant among elderly people who are from urban areas, co-resided with adult children and had community-based care services. But the association was not significant among elderly people who are from rural areas, lived alone and had no community-based care services. Considering the trends of decreasing informal care provision with increasing financial support of adult children to their parents, the social policies and social services should be initiated to support families. Policymakers should prioritize planning interventions for elderly care services and establish a family caregiver support system.


Triticum  and Secale . Triticale has several final destinations; herbages and grains are mainly used for livestock feeding, the grains can be used for niche food and the whole plant can be used as energy crop. In 2020, more than 13 million tons were harvested in Europe. Italy contributes to European production with a minority share that is equal to approximately 0.5% of the entire production. An overview of the varietal landscape, major uses and perspectives for triticale cultivation in Italy is presented.Triticale is a human-created cereal, originally bred with the aim of combining the useful traits of Triticale is currently grown throughout the world with a wider diffusion in Europe, with Poland, Belarus, Germany, France and Spain as major producers. Although triticale occupies a very small fraction of the Italian cultivated land , a continuous interest for this crop and its possible uses explains the work and progress made by breeding activities in different periods. The aim of this review is to report some experiences related to the cultivation of triticale in Italy. A general long-term view of the performance of triticale varieties in Italy has been distilled from a large amount of data derived from the pluri-decennial Italian national variety trials network. This activity, historically coordinated by CREA-GB, extends over several decades and examines the agronomic performance, in different Italian environments, of the most widespread and emerging varieties of triticale. Indications on new breeding targets can be deduced from the elaborations in the frame of both climatic change and market demands. Triticum ssp.) and the male parent rye , thereby combining the genomes A and B or A, B and D of wheats with the R of rye. The interest for this human-created cereal was stimulated by the aim to combine the useful traits of Triticum  and Secale  [Triticale is an amphidiploid produced by doubling the number of chromosomes of the sterile intergeneric hybrid between the female parent wheat (ditions) . Triticaditions) ,3,4. Intditions) .Triticale is currently grown throughout the world with a wider diffusion in Europe, with Poland, Belarus, Germany, France and Spain as major producers. In 2020, more than 13 million tons were harvested in Europe . Italy cTriticale, in Europe and in Italy, is mainly used for livestock feeding. As a feed grain, it is already well established and of high economic importance . The graIn some countries, grains have also been employed for food . But theMore recently, triticale has received attention as a potential energy crop, and research is currently being conducted on the use of the crop biomass in bioethanol production. Szempliński et al.  underlinThe breeding effort in triticale started from the hypothesis to combine the favorable traits of wheat and rye, and as expected, this resulted in an ample genetic variability derived from the combination of two species . The oriHere, we present a qualitative review of the literature on the cultivation and use of triticale in Italy, along with publicly available statistical information.The interest in triticale as a crop in Italy dates back to the early 1970s when the first breeding program, developed using CIMMYT  segregating populations, was aimed at breeding cultivars adapted to Italian environments. The first Italian cultivar, “Mizar”, released in 1980 by ENEA (Roma), featured a spring habit, a medium plant height and good resistance to lodging and showed a high yield potential and good adaptability to less fertile soils . It was From the 1990s to today, new genotypes of high agronomic value with differentiated morpho-physiological traits for a better adaptation to different cultivation environments were introduced. A number of cultivars were made available to growers, mainly with an alternative or winter growth habitus, variable lengths, dimensions and lodging tolerances, with heading dates ranging from a contemporary period to early varieties of barley until dates posterior to the later wheat. The varietal median heading dates in national yield trials range from mid-April to the end of May in Northern Italy and from early April to mid-May in Southern Italy.Among such varieties, a turning point is represented by the introduction of the cultivar, “Oceania” , which wAlthough triticale occupies a very small fraction of the Italian cultivated land  .The interest in varietal innovation had a decisive impact on the volumes of certified seeds that are commercialized. It is noteworthy that, in the past decade, the amount of certified seeds has changed dramatically . In the To support farmers’ decisions for the next sowing, a list of recommended varieties has been annually drawn up, in the past 30 years, by CREA-GB, as a public research and experimentation body at the service of the Italian Ministry of Agriculture. This activity, historically coordinated by CREA-GB in collaboration with several other regional institutions, examines the agronomic performance, in different Italian environments, of the most widespread and emerging varieties of triticale. The final information is structured in three lists of recommended varieties for the three areas of Northern, Central and South Italy and the islands that are made publicly available through the national technical press .The statistical data on the triticale production and yield in Italy are only available for a short period in the late 1980s of the 20th century and then from 2016 onwards. In the intermediate period, lumped figures for triticale and emmer were published. −1 and a substantial ca. 4-fold increase in the area cultivated with triticale.The average annual production in the late 1980s amounted to ca. 14 kt, while it was 68 kt on average in recent years ,18. The In the past three years, the overall Italian triticale production was of 66 kt, with a cultivation area of 14,550 ha . Figure Comparing the production levels and cultivation areas, triticale ranks fifth among small grain cereals cultivated in Italy, after durum wheat, bread wheat, barley and oats. Its production values and cultivation area are much lower than those of wheats, but significantly higher than those of rye. In Italy, triticale is now mainly used as feed; the whole plant used as fresh or silage feed at heading or milky-wax maturity has in fact proven to be viable in terms of both quantity and quality, being comparable in energy value to other winter-sown cereals. Work is in progress to study genetic variability for specific quality traits that are useful for feed, taking into account the frequent events of water scarcity that are affecting more and more regions of Northern Italy. An increased interest in the use of winter-sown triticale as a substitution of maize to produce typical swine and beef high-added-value products has been registered because of the lower fertilization and water demands of triticale relative to maize.An interesting observation regarding this point was made by Cosentino et al.  in milkiNoya et al.  completeGiuberti et al.  showed tBioenergy production is the other main destination of use for triticale in Italy. Triticale grain has been employed with good results for the production of bioenergy (biofuels) and the cultivation system has been studied for optimization with this aim. The unfavorable ratio between grain and straw can promote the use of significant amounts of straw of high quality in the field of bioenergy without encountering ethical problems, not competing with the use as “feed” (limiting) and “food”.In response to this requirement, the Biogasdoneright™ model, based on the double-cropping system along with digestate fertilization and minimum tillage, was proposed. Triticale varieties were evaluated in such a bioenergy production system, and it was found that it is a suitable energy crop for biomethane production .In recent years, the use of the whole plant as a source of renewable energy has attracted high interest. Some results have already been achieved, showing the high yield of biogas that makes triticale a good choice for biomass production ,24,25,26Up to now, the use of triticale for food has been marginal in Italy. The suitability of triticale flour for breadmaking, in comparison with wheat, is limited by the lower gluten quantity and quality, the lower falling number, dough stability and development time. What is more interesting is its use for unleavened baked products, such as biscuits and crackers. Recently, Piazza et al.  formulatDiabrotica in the maize cultivations of the Po Valley and the presence of mycotoxins in corn production have emerged, making triticale an interesting crop alternative. The modern breeding programs take into account these recent needs by focusing on improving the biomass yield and quality and selecting genotypes with a high productivity of the whole plant and resistance to environmental stresses. Detailed knowledge of the factors affecting the biomass quality for animal nutrition on the one hand and for bioenergy production on the other hand is now strategic. Mechanisms involving components that interact with the defense mechanisms protecting the plant from attack by enzymes produced by pathogens and the stability of the plant need to be considered. Useful traits for biomass productions are the maximum production of digestible organic matter (fiber + starch), a high biomass yield, the ability of the plant to stay green at harvest, resistance to fungi and mycotoxin contamination of the plant, and stem properties.In conclusion, at present, there is an increased request in Italy for new genotypes for use as feed and for renewable energy production. New needs for healthy feed production, the spread of Important metabolic changes (such as changes in the levels of cellulose/lignin) must be pursued without limiting the productive potential of the plant, keeping the useful characters selected in the course of time such as the levels of defense against pathogens and the resistance to lodging.For such breeding objectives, several genetic maps have been developed, and quantitative trait loci and candidate genes linked to important triticale traits have been identified, as reviewed by Golebiowska-Paluch and Dyda . ValuablStarting from the observation that feed is the primary destination and that the quality traits of triticale were not recognized by the market quotations, an increased yield capacity is the trait of major interest. Increasing the grain output and biomass for forage (given that the milk forage unit per kg of dry matter is positively correlated to the grain yield) is therefore essential to enhance the triticale acreage in the Italian agricultural reality. However, it is well known that yield is a complex trait, and it is positively correlated with all of its components, such as the number of ears and their length, the number of fertile spikelets, the number of grains and the thousand grain weight, among others. All of these components are influenced by environmental and agronomic factors and are strongly determined by genotypic factors, but also by GXE interactions and the compensation between the yield components .At the beginning of this millennium, the study of the varietal performance in various national environments, including Italian ones, made it possible to identify those traits, which can be enhanced to potentially enable higher yields.However, a warning on this point was raised by Kozak et al. . These a−1 of dry matter in a fertile environment, like the Po Valley in Northern Italy, and can produce 6–7 t ha−1 in typical Mediterranean environments, like Sardinia. At milky-wax maturity, the yield reaches 18–20 t ha−1 and 11–13 t ha−1 of dry matter in the two cases, respectively.Focusing on the triticale biomass production level in Italy, when the whole plants are harvested at heading, Delogu et al.  showed tHowever, it is noteworthy that a wide variability exists among different triticale varieties for a milky-wax maturity yield . A biomaTriticale cultivars are therefore competitive with the major small-grain cereals and produce more biomass than wheat in Mediterranean, dry environments. It has been suggested that such better performance in the biomass increases at anthesis and at maturity is mainly due to the greater RUE (Radiation Use Efficiency) of triticale in comparison with wheat ,32. The Focusing on the grain yield level in Italy, the data obtained with the national varietal trials (publicly available in ) providePrevious studies underlined that a peculiar feature of triticale is the constitutively high number of fertile florets per spike ,33 in co−2) are essential to obtain high grain yields [−2), but also because it affects the source capacity allowing high rates of grain filling in the post-anthesis periodThis highlights the importance of the pre-anthesis period in achieving high yields, even in conditions of increasing drought stress during spring, not only for its effect on the sink formation  and flowering time largely depend on these traits. The frost tolerance, a component of WH, is an essential trait that allows for the high-yielding cultivars to express their potential yield. While many octoploid triticale genotypes had an excellent WH a priori, mainly due to the rye germplasm, the hexaploid triticale required much breeding effort to achieve an adequate WH. During the selection process, the multiple crosses also using spring rye and spring wheats and the introduction of spring triticales in many environments have often generated cultivars that have lost the initial advantage acquired from the rye parent. Therefore, exploring the genetic diversity for WH and the developmental traits that determine the crop adaptation should have high priority. It was shown that the phenotyping for this trait can take the advantage of a laboratory test for frost tolerance evaluation . Using sAmong agronomic factors that can contribute to the yield, fertilization is a key one; nitrogen fertilization has a direct effect on the plant uptake and, consequently, on the protein in animal feed. Cazzato et al.  found thA further point of interest for triticale sustainability has been individuated by Lestingi et al. : in ItalAzotobacter chroococcum seed inoculation allowed for the reduction in the mineral nitrogen rate to 50% without sacrificing the forage and grain yields. These authors underlined that in Mediterranean countries, a triticale dual-purpose production system was profitable due to the competitive prices of triticale green forage in the region.Similar results have been obtained in other Mediterranean environments. Salama et al.  reportedA further point of economic relevance for triticale cultivation is the opportunity to include this cereal in a double-cropping system; in Italian environments, triticale can be harvested around the middle of May, allowing for the sowing of a next crop. In Northern Italy, double cropping often occurs as triticale silage, followed by soybean or corn. An interesting innovation was developed by a consortium of 600 Italian farmers organized as the Italian Biogas Consortium; the two harvests are ensiled and later fed to the digester to produce biogas . Negri eA further interesting study supporting the economic value of triticale as carried out by Severini et al. . The stu2 in the high rainfall regions for both short and tall cultivars. In particular, the adoption of short cultivars with a reduced radiation use efficiency but elevated early vigor can potentially increase the current triticale yields across different regions, seasons and management options in the Mediterranean climate [In addition to the list of recommended varieties, another useful support for triticale cultivation comes from the availability of a forecasting system, as reported by Bassu et al. . The APS climate .triticale could satisfy many of the hopes originally placed upon it”.From the experience gained in Italy on triticale cultivation, it is agreed with McGoverin et al.  that “trThe varietal traits that are best suited for production under changed climatic conditions and targets for further selection need to be identified in relation to the following:The projected climate change trends indicating, especially for Southern Europe, potentially increasing limitations of agricultural production by drought and high temperature stresses. The use of winter-grown, cold-resistant small-grain cereals , yieldinThe exploitation of the superior crop sustainability and the adaptability of triticale for cultivation in marginal areas subjected to risks that are destinated to increase: waterlogging, extreme temperature and water scarcity. The possible expansion of winter crops to higher latitudes or elevation with global warming requires sufficient frost tolerance capacity to cope with the extreme climatic fluctuations, whose frequency has already increased in recent years.How can one further explore and exploit the wide genetic variability existing in Europe and in the world for the (unique) cultivated germplasm generated by using rye, bread wheat and durum wheat as original parents in different environments and for different purposes? A deep characterization of the existing materials optimized for adaptation and yield performance is proposed as a necessary pre-breeding step for the identification of plant ideotypes that are able to optimize the production for different destinations and for cultivation in different European regions, according to the present and future environments and market demands.