Are the health systems adapting and building resilience to climate change?
Key responses to climatic hazards reported
Responses were described according to six different dimensions of climate-resilient health systems: anticipate, respond, cope, recover, adapt and transform. To contextualise the responses reported by participants, we provided a characterisation of the climate hazards, exposure, vulnerability and health risks identified in this health system in Vidal-Cuellar et al.44
Anticipate
Official health systems took various measures to anticipate climate hazards and prevent health risks. First, disaster risk management offices established within the studied health networks delivered information on imminent climate events to health posts and communities to anticipate health assistance delivery. Interviewees reported that sometimes they could not access this information on time due to remoteness and poor connectivity, impairing their preparedness for climate events.
The risk office report extreme climate events, for example, ‘exceptional rains are coming’. They communicate us and all the health posts. They communicate with us and with the communities so that they take the event into consideration and are prevented, right? They communicate that exceptional rain is coming so they are on alert. And particularly if they have to transport an injured of emergency by river because the boats of transportation are small, and an accident can happen. (Official health system, health sector, Loreto region)
The information sometimes does not reach remote health facilities due to the internet connection issue. For example, if the current day very early, they send the risk management office information about a heavy rain, we share it, but sometimes it cannot be disseminated properly because connectivity problems. (Official health system, health sector, Junin region)
Second, health networks and health facilities trained communities in healthy practices to prevent climate-sensitive health risks. These practices included vaccination, keeping warm during cold waves, hand washing and proper food preparation and water treatment (ie, water boiling and chlorination). Finally, both health networks have established Environmental Health Offices, which are responsible for monitoring air and water quality and environmental factors that influence vector-borne diseases. On the other hand, Indigenous health systems used Indigenous knowledge to predict climate events through the observation of nature, helping to avoid climate-sensitive health risks. For instance, Indigenous knowledge of climate variability guided them to temporarily relocate themselves away from the river to avoided the impacts of floodings. Another measure was the use of Indigenous medicine to prevent climate-sensitive health risks. For example, before the windy season had started, Indigenous people used medicinal plants to protect themselves from acquiring airborne diseases.
At the beginning of August, the weather is changing so we have to be prepared. I take a sachawiro, portoncillo, ginger, beehive, and sugar cane, and I crush it and cook it. It is prepared like syrup, so you take it in a teaspoon, like syrup, that helps to treat the cold. (Indigenous health system, wise woman, Loreto region)
Finally, Indigenous communities by themselves or with the support of health posts, performed waste management and cleaning interventions in their communities. For instance, they cleaned the waste and threw out items that hold water to prevent vector-borne diseases, and cleaned water streams to reduce the risk of flooding. Despite our interviewees reporting the official health system taking anticipatory measures, they stressed these were not enough since the majority of responses focused attention on during and after the climate hazard.
Before the events, almost nothing is done… once the event happens, then everyone reacts, but the disaster is already done, the problem is nothing or little is done to prevent it. (Official health system, health sector, Junin region)
Regarding the flooding, there were problems in terms of preparation. No, we haven’t prepared ourselves properly, as if to say, ‘We can deal with such a situation’. (Official health system, health sector, Loreto region)
Respond
To respond to climate hazards, the official health systems in Loreto and Junin had intersectoral platforms that register climate emergencies and provide immediate health assistance. These platforms include representatives of the health networks, local governments, firefighters and the army. Health networks led emergency brigades to provide first aid and medical supplies, perform vaccination campaigns and evacuate individuals located in risky areas to temporary shelters. Also, health networks delivered water bottles and chlorinated the water tanks of health facilities and the populations affected, while local governments provided food or warm clothes if cold waves had started. Challenges for implementing these responses included limited financing to provide material resources and mobilise health brigades, and the unwillingness of some communities to leave risky areas.
As a challenge, I have always said: the budget. Because without money you do nothing. Sending a health brigade to an Indigenous area is very difficult. It is expensive, It is also difficult to find health workforce who want to go and are committed. This has been a weakness for us. (Official health system, health sector, Loreto region)
Finally, another response was the design of contingency plans by disaster risk management offices. The official health system implemented all these responses in coordination with Indigenous representatives since the latter could provide insights into community health needs and the populations affected, and help identify what kind of support was required. Indigenous peoples also took measures by themselves to respond to climate hazards. These included using mechanisms to evacuate affected areas based on their experience from previous climate disasters.
Cope
The official health system coped with climate hazards by performing arrangements in the organisation and distribution of the health workforce and medical products to maintain healthcare delivery. For instance, in the Loreto region, when flooding damaged the walls of the health posts, the health workforce was moved to a health facility located in an area that could not be reached by the water. If the capacity of the health posts was exceeded, the regional government or the Ministry of Health may provide support with additional resources. The Indigenous health system coped with climate hazards by implementing healthy practices, such as wearing warm clothes during cold waves and long-sleeved shirts during heat waves, and avoiding going to their farms during heavy rains. They also used Indigenous medicine to treat climate-sensitive diseases, namely skin injuries, snake bites and malaria, and used Indigenous practices to make climate hazards less dangerous (eg, using bows and arrows to reduce the impacts of strong winds on their communities).
We do not forget our traditions, when the winds come, the strong winds. We have to have faith, and put our arrows, bows, and ballistae, in the direction in which the wind is coming. Our ancestors have done it that way, right? Let’s say, this is my bow, and where does the wind come from? I plant my bow where the wind is blowing, so It can calm down. (Indigenous health system, community health agent, Junin region)
Finally, Indigenous people relied on the forests and rivers to obtain food when they have lost their crops due to climate hazards. They protected their food systems by hunting wild animals, gathering fruits and fishing. In some communities that are more used to monetary transactions, they used their savings to buy food from stores. The preference of Indigenous people for their own medicine and practices represented a challenge for health officers because the former may avoid using official healthcare services to treat climate-sensitive diseases.
The worldview of Indigenous peoples is that malaria can be treated with other types of medicines or preparations that are not what the official health system manages. Sometimes we struggle with that situation but it is in a minimal way. In general, the majority of people accept the official treatment given by the health establishments. (Official health system, health sector, Loreto region)
[When the health brigade visited the community after the health hazard], we did a haemoglobin test to see who was anaemic, and then we realised everyone was anaemic. And we left them sulfate. But the issue is we go and leave the medicine, but it’s not their own medicine, so we lack someone informing us which are the medicine and the food they prefer. (Official health system, health sector, Junin region)
Recover
After the occurrence of climate hazards, the official health systems provided material resources and humanitarian aid to support the recovery of affected communities. The local governments and the Civil Defense Institutions were responsible for delivering household materials (eg, cookware, roofs, blankets and tents), food or seeds and cash aid, according to local needs. Local governments were also in charge of restoring transportation access and infrastructure in damaged areas. However, our Indigenous participants reported these aids arrived late, were insufficient, did not arrive at all or could not be claimed because of connectivity gaps.
It arrives late, it is not instantly. There is flooding, and the food aid is not coming tomorrow or today. It arrives in one month or two months. (Indigenous health system, community leader, Loreto region)
If I don’t have a cell phone or something to take a photo for the evidence, how can they assist you? They are never going to assist you. ‘You must be lying’ they will say. It is with technology, and Ashaninka people do not know it, they’ve used a smartphone (Indigenous health system, community leader, Loreto region)
The State takes a long time to provide the aid, about 15-20 days to send the support. They have a certain bureaucracy. Until they send all the documentation, the reports, and the collection of information. (Official health system, private sector, Junin region)
Moreover, in some cases, the resources provided were not culturally appropriate for remote Indigenous communities, for instance, processed food, or suffocating clothes. Indigenous peoples recovered from climate hazards by organising themselves to clean and restore affected paths, community infrastructure and households. Furthermore, they shared or exchanged food and seeds in their communities to help each other. Since climate hazards generated crops and livestock losses, which were the main source of economic income for Indigenous families, and because the official aid is perceived as insufficient, this mechanism was considered an essential measure to support affected families in recovering from climate hazards.
We supported each other, we gave food, and if we had cassava or plantain we would share, so we could be able to resist, right? Until our crops would produce again. That is how we supported each other, we helped each other. (Indigenous health system, community health agent, Junin region)
Adapt
After the occurrence of climate hazards, the official health systems in Loreto and Junin have taken measures to recover their functions and take advantage of the situation in the long term. These measures were the development of climate change adaptation policies, community training strategies, promoting forest conservation, adapting health and household infrastructure and implementing health programmes targeted to climate-sensitive diseases. In 2021, policy roadmaps were developed by the Ministry of Health to guide the implementation of climate change adaptation measures in the Loreto and Junin regions by 2025. Each region had its own policy roadmap, has prioritised adaptation measures and indicators according to the local situation, and has defined the level of risk for each province and district by assessing the exposure, vulnerability and climate hazards. These measures were aligned with Peru’s National Adaptation Plan for Climate Change, also launched in 2021.27 Besides, both Loreto and Junin had Regional Strategies for Climate Change developed by regional governments, which contained adaptation and mitigation measures, and proposes coordination with public and private actors. Furthermore, the official health system has implemented community training strategies to improve the preparedness of vulnerable populations to respond to future climate emergencies. Forest conservation is another response taken to reduce the impacts of climate hazards on health in the long term. This was a response performed jointly by the official health system and the Indigenous health system in both Loreto and Junin. Indigenous peoples protected the forests by participating in reforestation projects developed along with forest conservation programmes led by Ministry of Environment and supported by NGOs, prohibiting logging, avoiding renting or using their lands for intensive agriculture, recovering the soil after intensive agriculture, legalising the property of their territories and adapting their economic activities to be less harmful to the forest.
The first thing we have done is to identify the eye of water that supplies the Indigenous community and the fish pond, so we have reforested that eye water. We have also articulated with other institutions to promote the reforestation (Official health system, NGO, Junin region)
We have worked with 15 communities, through a financial fund, planting yacushimbillo, a plant with lots of roots, that provides shade, protects the shore of the rivers and prevents landslides. (Official health system, local government, Loreto region)
We are conserving our forests because that is where our medicine is. There is all. Our market has always been there, It is related. (Indigenous health system, community health agent, Junin region)
Efforts to adapt healthcare and household infrastructure to climate conditions were also reported in both regions. In Loreto, there were intentions (not implemented yet) to maintain service delivery in the health posts even during flooding and rainy seasons. Moreover, in Satipo, the local government was working on developing household infrastructures resistant to cold waves. Finally, the studied health networks have developed health programmes targeted to climate-sensitive diseases, such as malaria. The approach included close coordination with Indigenous leaders and community health agents, local plans developed in joint with the community, and providing training, implements and incentives for community health agents to eradicate malaria.
On the other hand, Indigenous peoples adapted to climate change by conserving the forest, modifying their livelihoods according to climate conditions and incorporating healthy practices. Indigenous communities also adapted their livelihoods to better prepare themselves for climate hazards. As a learning outcome after experiencing flooding or landslides, they lived and cropped away from the rivers or places prone to climate events, built river defenses, modified the altitude of their houses and enlarged their boats for their transportation. Finally, they also have adopted healthy practices to protect themselves from climate hazards in the long term, such as washing their hands and keeping well-fed to maintain themselves healthy if another hazard comes.
Transform
Indigenous communities have been transforming their livelihoods to be better prepared to face climate and environmental shocks. With the support of NGOs and public agencies, Indigenous peoples were implementing agroforestry, garden projects, fish farms and chicken rearing, for selling and consuming, as an alternative to fishing and hunting.
The Indigenous community used to consume fish from the river, and today the fish have diminished due to environmental pollution, there isn’t much anymore. There are no longer fish so now they are breeding in their fish farms. (Indigenous health system, community health agent, Junin region)
The mayor is very concerned about how to support the families affected by the flooding. Maybe chicken rearing, because chickens grow very quickly, they can also make fish farms, or give food […] We are thinking about which solution can be faster to provide to the feeding of the affected families (Official health system, local government, Loreto region)
Within the community, they were also opting for modifying their crops to increase their resilience to climate variability and hazards, for example, changing their coffee plantations to pineapple.
what crop to produce? For example, we used to crop coffee, but because of the climate variability it is not longer suited. So, what is the alternative for our income? Pineapple and raising smaller animals. So that’s what we’re doing, because of climate change (Indigenous health system, community health agent, Junin region)
The process of building health systems resilience and informing building blocks
We found that both health systems (the Indigenous and non-Indigenous) were active on responding and adapting to climate hazards; however, only Indigenous responses were identified in the dimension of transformation. Since these responses were implemented on a temporal scale from anticipation of the climatic hazard to transformation after the hazard impact, figure 3 illustrates how the process of building health system resilience in this Amazon Peruvian health system was informed for the six response dimensions. We also found that responses from both official and Indigenous health systems have informed different building blocks of the health system (see table 1 in online supplemental material 5). In leadership and governance, Indigenous organisations were named as part of the climate change governance platform but only at the national level, with still little or non-participation at the district level or community level. For emergency preparedness, Indigenous responses were mostly oriented to prevent and anticipate, while responses in the official health system were for management once the climate hazards had already occurred. Attention to key environmental determinants of health differed across responses: the official health system was more oriented to providing safe air and water, while Indigenous responses were focused on protecting forests and cleaning the communities. For climate-informed health programmes and vulnerability and adaptation assessment, information indicated that official health systems had trained communities on the management of climate-sensitive diseases, although adaptation assessments were not yet performed. Indigenous and non-Indigenous health systems have used their own knowledge and information to predict climate hazards at community level, while research on health and climate was reported as a need to inform the implementation of adaptations in each region. Loreto and Junin recognised the importance of researching and implementing new technologies that reduce greenhouse gas emissions, while Indigenous technologies in their health systems were essentially based on the use of nature resources and sharing cultural practices.
The process of building health system resilience in this Amazon Peruvian health system.
Key pathways to strengthen the climate resilience of health systems
This section of the results aimed to provide recommendations to increase the climate resilience of health systems in the Peruvian Amazon. We identified resilience pathways according to the WHO health systems building blocks. This section was prepared predominantly on the recommendations of the in-person workshops complemented with key findings included in Appendix A and B.44 45
Leadership and governance
Participants highlighted that strengthening leadership and governance of health systems in the face of climate change requires three main actions. First, it was proposed to enhance Indigenous representation in intersectoral governance platforms linked to climate change and health, mainly local governments, and disaster risk management platforms. Although regional health networks already have Indigenous offices to work jointly with Indigenous representatives and communities, there is still a need to strengthen the participation of Indigenous leaders in decision-making spaces. Proposed mechanisms to achieve this included establishing in-person dialogue spaces between Indigenous leaders and local decision-makers and formalising partnerships between Indigenous organisations and local authorities. Local Indigenous organisations could strengthen health and climate governance by providing insight into community health needs, vulnerabilities and capacity before and after climate events. Also, Indigenous knowledge regarding weather variability and climate hazards would help local governments take preventive measures. Besides, although the Peruvian government has created a platform formed by national Indigenous organisations to cope with climate change,45 there is still a need to strengthen communication channels between Indigenous local organisations and national and regional governance platforms to ensure that remote communities receive governmental support and humanitarian aid before and after climate disasters. Second, it was proposed to promote Indigenous women’s participation in the development of the climate change and health agenda at the local level. Since women were identified as vulnerable to climate change in both regions, participants in the workshops highlighted the need to engage women in regular meetings with local governance platforms to identify and assess women’s specific health needs in the climate change context. Indigenous women were recognised as the primary care takers before, during and after an extreme climatic event. Besides, it was noted that women’s participation requires to be enhanced not only at the policy level but also at the community level by recognising women’s role in food governance and food security interventions. Participants stressed that these interventions need the support of health and other health-determining sectors at the governmental level to ensure they are feasible and constant over time. Finally, strengthening cross-sectional collaboration between the health, environment and agriculture sectors was also recommended as a pathway to increase the climate resilience of health systems. In both regions, participants reported that there is a lack of articulated policies and strategies involving both the health and the environmental sectors to address the impacts of climate change on health. This is particularly important to address food insecurity and biodiversity loss, which were identified as key climate-sensitive health risks in both regions. Actions proposed to achieve this goal were mainly to strengthen local governments’ leadership in disaster risk management platforms and improve articulation with private enterprises involved in environmental management.
Health workforce
Building trust with Indigenous communities is one of the key challenges experienced by the health workforce in the Peruvian Amazon, and it becomes particularly important in the context of climate change, in which coordinated action is needed. For example, in the survey from 13 health facilities visited, all of them reported the need to coordinate with community health workers for health emergencies, however, only 3 (23%), coordinated with Indigenous healers such as ‘curandero’, ‘partera’, ‘sobador’ and ‘vaporera’. Participants reported that they did not trust Indigenous healers because they did not meet them before, did not know how Indigenous medicine works or Indigenous healers did not trust on the health sector either. Given that Indigenous healers are the custodians of knowledge about Indigenous medicine, there is a lost opportunity to articulate the Indigenous and non-Indigenous systems if this relationship is not improved. Moreover, in the survey, only two health facilities (15%) had at least one health worker trained on intercultural health approaches and three (23%) had health workers that spoke an Indigenous language, reflecting the gap of knowledge about Indigenous people’s culture and medicine that persist in the Peruvian health work force. A potential mechanism proposed to strengthen this relationship is to incorporate Indigenous health workers in health centres and health posts, as this would increase the acceptability of health interventions as well as the utilisation of health services by Indigenous peoples. Formally incorporating Indigenous health workers would help improve the organisational capacity of Amazon health systems to cope with climate change, and would also enhance the ability of official health systems to partner with community members. Another recommendation relevant to this building block was to develop training interventions on climate change and health addressed to official authorities and disaster risk management platforms. These recommendations could help local health systems and other health-determining sectors develop communication and awareness-raising strategies on climate change and health. Participants highlighted the need to raise awareness among private enterprises that contribute to deforestation and water contamination. Also, participants proposed to develop awareness-raising interventions on climate change and health targeted to Indigenous communities. Some actions suggested for achieving this goal include creating radio programmes for remote communities and designing visual materials on climate change and health culturally appropriate for Amazon Indigenous peoples. This latter measure would facilitate reaching out to illiterate Indigenous adults and young children. Finally, it was recommended to increase the number of specialists in healthcare facilities located in remote areas, mainly mental health professionals, dermatologists and nutritionists. In our study, only 1 out of the 13 health facilities surveyed reported having nutritionists (a hospital located near the main urban centre of the Junin region). Increasing the number of medical specialists is considered important to manage specific climate-sensitive health risks, namely, mental health outcomes resulting from experienced climate disasters, skin lesions produced by extreme temperatures, and severe malnutrition cases resulting from food insecurity and biodiversity loss. Only 1 out of 13 (8%) health facilities reported to have a nutritionist and 4 (31%) did not have a any type of physician to provide healthcare in situ.
Health information systems
Participants emphasised that strengthening health information systems requires creating mechanisms to share local data on climate change and health vulnerability assessments with communities. This pathway would help raise awareness among communities about their current and projected situation in the face of climate change, thereby facilitating community engagement in disaster risk management. Moreover, this pathway also emphasises the importance of enhance the communication for health emergencies, since only 3 (23%) out of 13 health facilities reported to have any type of communication systems working all day, and 4 (31%) had access to internet.44 Another pathway proposed to improve health information systems was to strengthen the scientific evidence on the use of Indigenous medicine and Amazonian foods for managing climate-sensitive health risks. Incorporating this topic into the research agenda in the Peruvian Amazon could provide insight into local solutions and capacities and make scientific evidence relevant to local contexts. Also, considering Indigenous health practices and priorities would open opportunities to establish transdisciplinary teams in the health research field. In our cross-sectional survey, only 3 out of 13 health facilities reported coordinating with Indigenous medicine agents for health interventions.
Service delivery
To strengthen health service delivery in a climate change context, participants proposed to expand the scope of health promotion interventions by encouraging environmental protection practices (mainly forest protection and care of natural water sources) as healthy behaviours among Indigenous communities. This pathway was recognised to be particularly relevant for local communities since Indigenous leaders reported that some community members still adopt behaviours that perpetuate environmental hazards due to multiple factors (eg, deforestation practices reinforced by economic needs). In this context, the official health system could play a key role in raising awareness of the health benefits of environmental protection practices and contributing to joint monitoring of environmental exposures and outcomes along with other health-determining sectors. Under the WHO operational framework, this pathway would contribute to the management of environmental determinants of health and help to promote a ‘Health in all policies’ approach by engaging affected communities.22 Other actions suggested for managing environmental determinants of health included implementing recycling projects to improve solid waste management in remote communities to reduce mosquito breeding sites. We observed that 10 (77%) out of the 13 health facilities surveyed in Loreto and Junin burn and/or bury common waste regularly, and 7 (54%) have access to a municipal garbage service. Another action proposed was to create a community-based monitoring system to supervise river cleaning and water quality in remote communities. All these actions require not only the participation of health-determining sectors at the policy at programmatic levels but also active coordination and engagement with communities.
Finally, it was also proposed to strengthen the training of CHAs and equip them with medical products to respond to climate disasters. CHAs in Loreto and Junin were reported to have a key role in delivering health promotion information to Indigenous communities.
Essential medical products and technologies
The first pathway proposed to strengthen this building block was to ensure access to water and sanitation in healthcare facilities located in remote communities. Data from our cross-sectional survey showed that 11 (85%) out of 13 health facilities have no access to drinkable water, 7 (54%) have no or no functioning showers and 4 (31%) lack a water supply for hand washing. Improving access to water and sanitation would require the participation of local governments and health systems to plan investments in the construction and improvement of healthcare facilities according to current and projected climate risks. Second, since food insecurity and biodiversity loss were recognised as key climate-sensitive health risks for Indigenous peoples, another relevant pathway proposed was to promote the participation of Indigenous communities in the use and implementation of new technologies to strengthen food security systems. These technologies may include fish farms, organic gardens, bird breeding projects and the implementation of climate-resilient agriculture practices according to local climate conditions. Although the implementation of food adaptation technologies is usually managed outside the conventional health sector, strengthening the articulation with the health sector for these interventions could help reach out to remote communities and facilitate resource mobilisation. For example, health promotion offices of the regional health networks regularly perform demonstrative sessions, in which the health workforce teaches how to prepare healthy foods with the support of these new technologies. Besides, this pathway would strengthen the service delivery component by contributing to managing the environmental determinants of health.
Financing
One of the most relevant financing gaps identified is the lack of financial support for CHAs, considering their key role in supporting the prevention and control of climate-sensitive health risks. This gap affects various other health system building blocks as it exacerbates CHAs’ workload and impairs their engagement with the official health system. For instance, in Loreto, it was reported that CHAs are changed every 1–3 years due to this reason, affecting the coordination and implementation of health promotion interventions in communities in the mid and long term. Another recommendation identified in this building block was to increase the budget of local governments and health systems to enable health workers and disaster risk management officers to perform technical visits to remote communities before, during and after a climate disaster. Before climate events, these visits would help ensure that community households are located in safe zones, and also deliver education interventions about climate and health risks (eg, implementing emergency and evacuation drills and developing emergency protocols). During and after the events, facilitating visits to remote communities would help provide them with material resources and humanitarian aid to ensure their recovery and manage adverse health outcomes. Figure 4 shows the each building blocks pathways to strengthen the climate resilience of health systems in the Peruvian Amazon,
Key pathways to strengthen the climate resilience of health systems in the Peruvian Amazon.
