Pathways of resilience: a fuzzy-set Qualitative Comparative Analysis of healthcare systems resilience to extreme weather events

Ruth Emily Sylvester, Furaha G. Abwe,, Jamie K. Bartram, Julii Brainard, Jo-Anne Geere, Do Thi Hanh-Trang, Natalia Hoyos, Paul Hunter, Severin Kabakama, Kondwani Kuchelekana, Snehalatha Mekala, wEZZIE Longwe, Dennis Lukaaya, Hugo Andres Macareno Arroyo, Daniel Mapemba, Megan Mcconochie, Carolina Montoya Pachongo, Adamson S. Muula, Edgar Mugema Mulogo, Fred Mwebembezi, Mwizapanyuma Simkonda, Joseph Ngonzi, Nikolaos Nikitas, Moses Ntaro, Sunday Patrick, Evanson Sambala, Patrick Simbewe, Yovitha M. Sedekia, Tran Thi Tuyet-Hanh, Deborah Watson-Jones, Paul Hutchings

Background
Increasing frequency and intensity of extreme weather events threaten healthcare services globally, with particularly intense risks to low-resource regions. Evidenced pathways for building and enacting resilience in complex health systems are under researched. Literature on resilient healthcare is dominated by infections disease outbreaks and lacks synthesised insights from weather-related disruptions and real-world practice.

Methods
This paper responds to these gaps by presenting findings from a novel dataset of 18 case studies conducted in a range of global contexts. The cases were built around understanding how extreme weather events have impacted and interacted with four interrelated systems – a central healthcare facility, local healthcare system, community and interconnected systems – building on the WHO’s operational framework for climate resilience healthcare systems. The study applied a fuzzy-set Qualitative Comparative Analysis to assess the complex configuration of conditions related to two outcomes: service continuity and healthcare facility recovery state.

Results
The results demonstrated four distinct pathways through which resilience was enacted, with different configurations of vulnerability, adaptative capacity and external support. The pathways show that local adaptive capacity is crucial for ensuring service continuity during disruptive weather phenomena. Where local adaptive capacity is not present, or it is overwhelmed by the scale of the extreme weather event, external support from national and international responders can support resilience indicated by a successful final system state but not service continuity. Local experiences show the critical importance of staff wellbeing and institutional coordination for absorbing and responding to weather-related disruptions.

Conclusion
The pathways presented in this paper represent reliable modes of resilience in the dataset and provide novel insight into the gap of practice-based, locally relevant knowledge on building healthcare resilience.