Towards health systems resilience to extreme weather events : managing health needs during floods in Cambodia

Background: Extreme weather events like floods are expected to become more common as climate change continues, putting health at risk. Knowledge on what health needs are expected after such events is needed for health systems to be able to provide health services. Resilient health systems have the capacity to maintain their functions and change when experiencing events like floods which enables them to continue delivering essential health services. Enabling resilience in health systems requires an understanding of what capacities create resilience.

Aim: To assess the effects of flooding on health and the capacity of the public health system to manage health needs during floods in Cambodia, with a view to identifying capacities that foster health systems resilience to extreme weather events.

Methods: Study I was a systematic review of epidemiologic articles (n=113) to identify changes in health outcomes of affected people after flood or storm disasters globally, analysed by narrative synthesis. Study II was a time series analysis of monthly visits to public healthcare facilities in eleven districts in Cambodia for acute respiratory infections, diarrhea, skin infections, noncommunicable diseases, injuries, and vector-borne diseases between 2008 and 2013. Poisson regression models were used to quantify their relationship with the extent of flood water in each district. In Study III, focus group discussions (n=8) and semi-structured interviews (n=17) with community members who had experience with pregnancy or childbirth during floods were used to understand if and how the public health system’s capacity to absorb, adapt, or transform is linked to the community’s own capacity when managing antenatal and childbirth care needs during seasonal and occasional floods. The data were analysed by thematic analysis. In Study IV, 23 semi-structured interviews were conducted with public sector staff with experience providing or managing antenatal or childbirth care services during floods. They were analysed by thematic analysis to generate knowledge on the influences on public sector health service delivery in Cambodia during seasonal and occasional floods that are related to the system’s capacity to absorb, adapt, or transform.

Results: There is some evidence that flood and storm disasters affect health for up to two years, and that floods and storms may affect health differently (Study I). In Cambodia, visits to healthcare facilities for diarrhea, acute respiratory infections, and skin infections increased immediately and up to three months after seasonal and occasional floods (Study II). The community was primarily capable of absorbing the impact of seasonal and occasional floods on their antenatal and childbirth care needs, which was linked to their responsibility to balance the expectations placed on them to receive care during floods but with limited support and help (Study III). Collaboration and relationships have created boundaries around decision-making that allow a stable but flexible approach to public antenatal and birth health services in Cambodia when regularly exposed to floods (Study IV).

Conclusions: Floods had a prolonged effect on health, increasing new and routine health needs globally and increasing new health needs in Cambodia for up to three months after repeated seasonal and occasional floods. The public sector of the Cambodian health system appeared to have the capacity to absorb and adapt in order to manage antenatal and childbirth health needs during seasonal and occasional floods. They were aided by the community’s own capacity to absorb that helped relieve the health system’s responsibility to manage health needs. Strategies that enhance stability and flexibility in contexts where extreme weather events are perceived as strains rather than shocks may enhance system capacities for resilience. Public health system support to communities during floods and involvement in decision-making may generate resilience capacities in the community, strengthening the health system’s resilience to repeated extreme weather events.

List of scientific papers

I. Saulnier DD, Ribacke Brolin K, Von Schreeb J. No calm after the storm: A systematic review of human health following flood and storm disasters. Prehospital and Disaster Medicine. 2017; 32(5):1-12.
https://doi.org/10.1017/S1049023X17006574

II. Saulnier DD, Hanson C, Ir P, Alvesson HM, von Schreeb J. The effect of seasonal floods on health: Analysis of six years of national health data and flood maps. International Journal of Environmental Research and Public Health. 2018;15:665.
https://doi.org/10.3390/ijerph15040665

III. Saulnier DD, Hom H, Thol D, Ir P, Hanson C, von Schreeb J, Mölsted Alvesson H. Staying afloat: A qualitative study of community perspectives on health system resilience explored through the management of pregnancy and delivery care during floods in Cambodia. [Accepted]
https://doi.org/10.1136/bmjgh-2019-002272

IV. Saulnier DD, Hom H, Thol D, Ir P, Hanson C, von Schreeb J, Mölsted Alvesson H. Generating knowledge on health systems resilience: A qualitative study of health worker perspectives on antenatal and childbirth services during floods in Cambodia. [Manuscript]