Health system response to climate-related shocks in a lower-middle-income country setting: A comparative study of floods and droughts in Pakistan

Abstract Climate-related shocks increasingly threaten population health in Pakistan, where both rapid-onset floods and slow-onset droughts disrupt essential services and heighten vulnerabilities. Despite an expanding disaster management architecture, the extent to which health systems can anticipate, withstand, and adapt to these shocks remains unclear. This study examined how planning, resourcing, coordination, and service delivery function during floods and droughts, and how communities cope with these pressures across high-risk districts. An exploratory qualitative design was used, drawing on interviews with national, provincial, district, and facility stakeholders; focus group discussions with community members and lady health workers; and a document review. The analysis was guided by the conceptual framework for shock-responsive health systems developed under the Maintains program. The findings show that while Pakistan has established national and provincial disaster management structures, responses remain largely reactive and uneven across shock types. Floods receive comparatively stronger attention, including annual contingency planning, temporary medical camps, and emergency workforce deployment. However, service disruption remains widespread, particularly for routine care, maternal services, and immunization, and reporting systems become fragmented. Droughts expose deeper systemic weaknesses, including geographic remoteness, poor infrastructure, limited outreach, chronic undernutrition, and minimal anticipatory planning. Across both shocks, coordination between disaster and health agencies is inconsistent, financing is triggered late, and essential service packages lack standardization. Communities demonstrate considerable resilience through local solidarity, informal support networks, and small-scale innovations, yet these coping mechanisms are fragile and insufficient substitutes for reliable state support. The study highlights the need to shift from reactive responses toward integrated resilience planning across all phases of shocks, with stronger operational planning, clearer role alignment, standardized service packages, and proactive community engagement to protect essential health services during climate-related events.