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

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.