Pathways of vulnerability and risk influencing access to maternal and child healthcare in the context of heatwaves and flooding in Zambia

Introduction 

The effects of climatic shocks on access to routine health services are under-theorised. Evidence suggests significant and adverse impacts of climate hazard exposure on maternal and child health outcomes, including through reduced service access. However, prior work has predominantly focused on macro-level (national) health system dynamics for single hazards. There is limited understanding of how shock effects may overlap and interact in space and time and affect local level health care access. We applied qualitative system dynamics modelling to visualise cause-and-effect relationships linking exposure to floods and heatwaves to health service access at community level in a lower-middle income setting at significant, ongoing risk of exposure to heatwaves and flooding.  

 

Methods 

Group Model Building workshops were conducted in November 2024 in Senanga  and Sinazongwe Districts of Zambia, with 70 community members, 10 facility-level  healthcare practitioners, and 50 district-level decision-makers. Causal Loop Diagrams (CLDs) were generated to identify sources and pathways of vulnerability influencing access to maternal and child health services in response to heatwaves and flooding events in these communities. Discussions focused on event experiences during the 12 months preceding the workshops, and on access to antenatal care visits, health facility deliveries and routine childhood immunisation as outcomes. Draft CLDs from each workshop were edited and merged following a stepwise process, and then qualitatively analysed to identify relevant feedback loops and delays. 

 

Results 

We found common vulnerability pathways for health service access linked to heatwaves and flooding exposure. There was also evidence of cascading risk from district to household level influencing health service utilisation. Key demand-side vulnerabilities included impacts on household income arising from damage to crops in communities where livelihoods centred on agricultural production. This reduced care seeking as healthcare was de-prioritised relative to meeting basic needs, and transport costs to access care became less affordable. Lack of access to transport was an additional pathway (e.g. due to infrastructure damage in the case of flooding, or the perceived risk of heat-related illness in the context of heatwaves). On the supply side, there were vulnerabilities arising from disrupted power supplies and logistics (e.g. comprising vaccine cold chain integrity). Heat and flooding also affected healthcare worker delivery of outreach services, and productivity linked both to the effects of climatic stressors and and absenteeism due to challenges in accessing facilities themselves. There were also important trade-offs influencing both health service supply and demand in the context of heatwaves and flooding. Health care providers sometimes deprioritised delivery of routine maternal and child healthcare where demand linked to increases in water-borne disease, heat exhaustion and other hazard exposure impacts rose.    

 

Conclusion 

Results from this analysis suggest a key role for adaptation strategies addressing livelihoods, critical infrastructure and procurement to reduce disruption to routine maternal and child health care access during floods and heatwaves in Zambia. Future work should consider the generalisability of these findings to other contexts and evaluate the impact and cost-effectiveness of different adaptation interventions to support preparedness, response and recovery.