Introduction
Floods are the most common type of weather-related disaster, affecting >34 million people globally and billion dollar economic losses in 2018.1 If global warming continues at its current pace, the number of floods per year is expected to increase worldwide.2 Floods are not always disasters, but repeated seasonal flooding and less frequent occasional floods are still damaging and deplete economic and developmental resources.3
A resilient health system has the capacity to continue providing health services when shocked, for both new health needs caused by the shock and routine health needs.4–6 Floods are a typical example of a shock to this capacity.7–9 The Dimensions of Resilience Governance framework (figure 1) posits that if a health system is able to integrate and process knowledge, anticipate and cope with uncertainty, manage interactions with other systems at multiple levels (interdependence) and create a socially and contextually accepted system (legitimacy), it is then capable of managing shocks.10 This is done by absorbing shocks like floods using existing strategies and resources, adapting to them by temporarily adjusting how resources are used or transforming the structure of the system in the long-term to avoid shocks.11–13
Strengthening absorptive, adaptive and transformative capacities can make a system less vulnerable to shocks. This can be achieved through a variety of actions and means that are dependent on the system’s context and governance, the implicit and explicit rules that guide the relationships, decisions and actions among people and groups in the health system.5 12 14–16 The strength of the health system’s capacities depends in part on the dynamics between actors inside and outside the health system, such as policymakers and the population it serves.10 17 People living in affected communities use formal health services and employ their own strategies and resources to meet their health needs. For instance, trust affects their utilisation of services, interactions with the system and ultimately the system’s ability to withstand shocks.18 19 Involving the population was essential to containing the West Africa Ebola outbreak, but difficult relationships between the population and health systems led to avoidance of formal health services, affecting both the population’s health and the health system’s response.5 20–22 How the community copes with new and routine health needs during floods indicates both the extent that the health system is meeting their needs and the community and health system’s joined capacities for resilience.4 18
The literature has called for a better understanding of how the community’s capacity to manage their health needs during shocks influences health systems resilience.5 21 23–25 Although developed to analyse the supply side of the health system, we apply the Dimensions of Resilience Governance framework to the community’s capacity because of its focus on the interactions that create the capacity to manage resilience. The aim of this study was to understand how the actions of the community and their interactions with the health system during seasonal and occasional floods in Cambodia are contributing to the system’s capacity to absorb, adapt or transform, viewed through the framework. Although neither pregnancy nor childbirth or emergency pregnancy complications are causally linked to floods, they are typical routine and new health needs and can be used to indicate a health system’s ability to cover other new and routine health needs after a shock. Pregnancy is representative of routine health needs that do not change because of floods but still require preventive and promotive care that can be planned in advance, while deliveries and complications are representative of new health needs that can emerge during floods, occur suddenly or unexpectedly and require skilled management and emergency care.26 27 The research question was: how do community members manage care for pregnancy and childbirth during seasonal and occasional floods in rural Cambodia? A concurrent study on antenatal and childbirth service provision and management during floods from the health worker perspective is in manuscript.28