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Paper short abstract

This study shows that stronger local governance, not infrastructure alone, shaped India’s health system response to COVID-19, highlighting the role of governance in managing crises using a systems-based approach.

Paper long abstract

This study applies the Complex Adaptive Systems (CAS) perspective, integrated with the Control Knobs framework, to examine how health systems adapt to large-scale health shocks. Using India as a case study, it explores the non-linear dynamics that arise during crises such as the COVID-19 pandemic. The paper has two main objectives. First, it empirically assesses the relationship between the strength of local governments, their capacity to deliver health services, and health outcomes during the early phase of COVID-19. Three hypotheses are tested: (i) stronger local governments are associated with more robust healthcare infrastructure; (ii) stronger local governance leads to a more effective initial pandemic response; and (iii) stronger infrastructure alone does not ensure improved outcomes. Second, a theoretical model supported by simulation illustrates how baseline capacity, service delivery, and disease burden interact to produce complex system behaviour. The results confirm that health systems exhibit non-linear and adaptive characteristics, which intensify under crisis conditions. Evidence supports the first two hypotheses, highlighting that governance strength, rather than infrastructure alone, enhances resilience. The study underscores the importance of local governance in risk management and demonstrates the utility of systems-based modelling for understanding and strengthening disaster and health system resilience.