{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T18:42:20Z","timestamp":1790707340207,"version":"4.1.0"},"reference-count":50,"publisher":"Ubiquity Press, Ltd.","issue":"1","license":[{"start":{"date-parts":[[2025,7,22]],"date-time":"2025-07-22T00:00:00Z","timestamp":1753142400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/100000061","name":"Fogarty International Center","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000061","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["89"],"abstract":"<jats:p>Background: Adapting health systems for climate change can lessen the negative impact of climate change on human health. Even when not targeting climate-health links explicitly, broad health system strengthening interventions (HSSis) can ensure that the health workforce, infrastructure, and networks are robust enough to respond to and recover from climate-driven shocks.\nObjective: We explored the ability of an HSSi in a rural health district of southeastern Madagascar to serve as a climate change adaptation in response to Cyclone Batsirai in 2022.\nMethod: We conducted interrupted time series analyses of eight indicators of infectious disease and health system performance to assess the impact of Batsirai on two zones of the HSSi. We then examined how traditional domains of HSS, such as physical and human resources, combined with less formal domains, such as collective values, influenced health system resilience during this time.\nFindings: We found that the majority of indicators were resilient to Cyclone Batsirai, with only vaccination rates affected in the two months following the cyclone, particularly in the zone where the HSSi had only begun eight months prior. Changes in long-term trends were rare, and, when observed, revealed a slight slowing of progress, but not a regression to historical levels. After re-establishing the road network and providing additional supplies through an emergency response, the health system was able to resume routine service delivery without further external input, and health system indicators continued to improve. The agility and responsiveness of the health workforce were enabled by formalized protocols, a culture of flexibility, open communication, and data-informed action.\nConclusions: HSSis that are designed to encourage local adaptation may increase health systems\u2019 resilience to extreme weather events, resulting in health systems better adapted to climate change overall.<\/jats:p>","DOI":"10.5334\/aogh.4759","type":"journal-article","created":{"date-parts":[[2025,7,22]],"date-time":"2025-07-22T12:47:57Z","timestamp":1753188477000},"page":"40","source":"Crossref","is-referenced-by-count":3,"title":["Designing and Evaluating a Health System Resilient to Extreme Weather Events in Rural Madagascar"],"prefix":"10.5334","volume":"91","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5628-0502","authenticated-orcid":false,"given":"Michelle V.","family":"Evans","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elinambinina","family":"Rajaonarifara","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andres","family":"Garchitorena","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fianamirindra A.","family":"Ralaivavikoa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paulea Eugenie","family":"Rahajatiana","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9007-5417","authenticated-orcid":false,"given":"Karen E.","family":"Finnegan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura","family":"Cordier","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luc","family":"Rakotonirina","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"B\u00e9n\u00e9dicte","family":"Razafinjato","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tokiniaina M.","family":"Randrianjatovo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christophe","family":"R\u00e9villion","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Malazafeno Jocelyn","family":"Mbimbisoa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew H.","family":"Bonds","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"3285","published-online":{"date-parts":[[2025,7,22]]},"reference":[{"key":"key20250722124754_r1","unstructured":"IFRC. Tropical Storms and Cyclones DREF Final Report. 2024. Accessed July 15, 2024. https:\/\/reliefweb.int\/report\/madagascar\/madagascar-tropical-storms-and-cyclones-dref-final-report-mdrmg018."},{"issue":"3","key":"key20250722124754_r2","first-page":"E304","article-title":"Tropical Cyclones and climate change assessment: Part II: Projected response to anthropogenic warming","volume":"101","year":"2020","journal-title":"Bull Am Meteorol Soc"},{"issue":"1","key":"key20250722124754_r3","first-page":"1","article-title":"Uncertainties and sensitivities in the quantification of future tropical cyclone risk","volume":"4","year":"2023","journal-title":"Commun Earth Environ"},{"issue":"10108","key":"key20250722124754_r4","doi-asserted-by":"crossref","first-page":"2171","DOI":"10.1016\/S0140-6736(17)31758-0","article-title":"Mapping under\u20115 and neonatal mortality in Africa, 2000\u201315: A baseline analysis for the sustainable development goals","volume":"390","year":"2017","journal-title":"Lancet"},{"issue":"10159","key":"key20250722124754_r5","doi-asserted-by":"crossref","first-page":"1736","DOI":"10.1016\/S0140-6736(18)32203-7","article-title":"Global, regional, and national age\u2011sex\u2011specific mortality for 282 causes of death in 195 countries and territories, 1980\u20132017: A systematic analysis for the Global Burden of Disease Study 2017","volume":"392","year":"2018","journal-title":"Lancet"},{"issue":"3","key":"key20250722124754_r6","doi-asserted-by":"crossref","first-page":"13","DOI":"10.25303\/1503da1320","article-title":"Analysis of tropical cyclones 2000\u20132020 in Madagascar","volume":"15","year":"2022","journal-title":"Disaster Adv"},{"key":"key20250722124754_r7","volume-title":"University of Notre Dame Global Adaptation Index","year":"2015"},{"issue":"12","key":"key20250722124754_r8","doi-asserted-by":"crossref","first-page":"2626","DOI":"10.3390\/ijerph15122626","article-title":"Assessing health vulnerabilities and adaptation to climate change: A review of international progress","volume":"15","year":"2018","journal-title":"Int J Environ Res Public Health"},{"issue":"2","key":"key20250722124754_r9","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1001\/dmp.2011.30","article-title":"Preventing disasters: Public health vulnerability reduction as a sustainable adaptation to climate change","volume":"5","year":"2011","journal-title":"Disaster Med Public Health Prep"},{"issue":"11","key":"key20250722124754_r10","doi-asserted-by":"crossref","first-page":"e625","DOI":"10.1016\/S2214-109X(14)70313-4","article-title":"Planning adaptive health systems: The climate challenge","volume":"2","year":"2014","journal-title":"Lancet Glob Health"},{"key":"key20250722124754_r11","unstructured":"Madagascar ministry of the environment and sustainable development. Plan National d\u2019Adaptation Au Changement Climatique (PNA) Madagascar. Government of Madagascar; 2021. https:\/\/unfccc.int\/documents\/488094."},{"key":"key20250722124754_r12","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1186\/s12992-023-00965-2","article-title":"Strategies to strengthen a climate\u2011resilient health system: A scoping review","volume":"19","year":"2023","journal-title":"Glob Health"},{"issue":"12","key":"key20250722124754_r13","doi-asserted-by":"crossref","first-page":"2643","DOI":"10.3390\/ijerph15122643","article-title":"Assessment of risk, vulnerability and adaptation to climate change by the health sector in Madagascar","volume":"15","year":"2018","journal-title":"Int J Environ Res Public Health"},{"issue":"3","key":"key20250722124754_r14","doi-asserted-by":"crossref","first-page":"e0002888","DOI":"10.1371\/journal.pgph.0002888","article-title":"Evaluation of a novel approach to community health care delivery in Ifanadiana District, Madagascar","volume":"4","year":"2024","journal-title":"PLOS Glob Public Health"},{"key":"key20250722124754_r15","article-title":"Do stronger health systems reduce mortality rates? 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