Resilient health systems in action: How actor relationships and organizational adaptation shaped the health sector's response to the 2015–2018 Western Cape drought

Abstract Climate change is making droughts more frequent and severe, creating serious challenges for health systems and vulnerable communities worldwide. From 2015 to 2018, the Western Cape Province, South Africa, faced an extreme drought that nearly led to “Day Zero”—a point when water supplies would run out. Despite this crisis, documentation of the drought overlooks the health sectors response. To understand how health decision-makers managed this drought, in-depth interviews with 31 people from the health sector and other related fields were conducted. Transcripts were anonymized, transcribed, and deductively and inductively coded. A thematic analysis grouped the findings into four large themes with sub-themes of enabling factors. The study revealed that the health sector played a vital role by ensuring hospitals and clinics had water, reducing water use in facilities, and working closely with other sectors to protect community health. Interestingly, the most critical factors in managing the crisis were not just physical resources like procuring water tanks or fixing pipes in hospitals but the “software” of the health system: strong relationships, good communication, and shared values among health workers and decision-makers. These elements, albeit complex, enabled quick and effective action during the drought, and remained responsive to population needs that allowed for an effective health system response. The findings provide important lessons for making health systems more resilient to future droughts and other climate-related challenges.