Pathways of resilience: a fuzzy-set qualitative comparative analysis of healthcare systems resilience to extreme weather events

Sylvester, Ruth E., Abwe, Furaha G., Bartram, Jamie, Brainard, Julii, Geere, Jo-Anne ORCID: https://orcid.org/0000-0002-9071-2778, Hanh, Tran Thi Tuyet, Hoyos, Natalia, Hunter, Paul ORCID: https://orcid.org/0000-0002-5608-6144, Kabakama, Severin, Kuchelekana, Kondwani, Mekala, Snehalatha, Longwe, Wezzie, Lukaaya, Dennis, Arroyo, Hugo Andres Macareno, Mapemba, Daniel, Mcconochie, Megan, Montoya Pachongo, Carolina, Muula, Adamson S., Mulogo, Edgar Mugema, Simkonda, Mwizapanyuma, Mwebembezi, Fred, Ngonzi, Joseph, Nikolaos, Nikitas, Ntaro, Moses, Simbewe, Patrick, Sambala, Evanson, Sunday, Patrick, Sedekia, Yovitha M., Trang, Do Thi Hanh, Watson-Jones, Deborah and Hutchings, Paul (2026) Pathways of resilience: a fuzzy-set qualitative comparative analysis of healthcare systems resilience to extreme weather events. BMC Health Services Research. ISSN 1472-6963 (In Press)

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Abstract

Background: Increasing frequency and intensity of extreme weather events (EWEs) threaten healthcare services globally, with particularly acute risks in low-resource settings. While health system resilience is widely discussed, there is limited empirical evidence on how it is enacted in practice across complex, real-world systems, particularly beyond infectious disease contexts. Methods: We analysed 18 case studies from diverse global contexts, examining how EWEs affected four interrelated system levels: healthcare facilities, local health systems, communities, and interconnected infrastructures. We applied fuzzy-set Qualitative Comparative Analysis (fsQCA) to identify configurations of vulnerability, adaptive capacity, and external support associated with two outcomes: service continuity and healthcare facility recovery. Results: Four distinct resilience pathways were identified. These demonstrate that resilience emerges from cross-scale configurations rather than individual system components, with local adaptive capacity playing a key role in maintaining service continuity. Where high vulnerability across multiple system levels exceeded local capacity, resilience depended on external support, which was associated with eventual recovery but not with continuity of services. Across cases, workforce factors—including staff wellbeing, safety, and morale—were critical in shaping system response. Conclusion: This study provides empirical evidence that health system resilience to EWEs is a multi-scalar process. The identified pathways offer practice-based insights for strengthening resilience, highlighting the importance of cross-system coordination, planning for capacity limits and phased operational response escalation, and investing in the health workforce as a central component of effective response and recovery.

Item Type:	Article
Additional Information:	Availability of Data and Materials: The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Data summaries of each case study are provided in the Supplementary Information files.
Uncontrolled Keywords:	shocks,resilience,stability,lmics,sdg 3 - good health and well-being ,/dk/atira/pure/sustainabledevelopmentgoals/good_health_and_well_being
Faculty \ School:	Faculty of Medicine and Health Sciences > Norwich Medical School University of East Anglia Research Groups/Centres > Theme - ClimateUEA Faculty of Medicine and Health Sciences > School of Health Sciences Faculty of Science > Tyndall Centre for Climate Change Research University of East Anglia Research Groups/Centres > Faculty of Science > Research Centres > Tyndall Centre for Climate Change Research
UEA Research Groups:	Faculty of Medicine and Health Sciences > Research Centres > Public Health Faculty of Medicine and Health Sciences > Research Groups > Epidemiology and Public Health Faculty of Medicine and Health Sciences > Research Groups > Rehabilitation Faculty of Social Sciences > Research Centres > Water Security Research Centre
Depositing User:	LivePure Connector
Date Deposited:	13 Aug 2026 12:30
Last Modified:	13 Aug 2026 12:30
URI:	https://ueaeprints.uea.ac.uk/id/eprint/104117
DOI:	issn:1472-6963

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