'We have a plan for that': a qualitative study of health system resilience through the perspective of health workers managing antenatal and childbirth services during floods in Cambodia.

Objective: Health system resilience can increase a system's ability to deal with shocks like floods. Studying health systems that currently exhibit the capacity for resilience when shocked could enhance our understanding about what generates and influences resilience. This study aimed to generate empirical knowledge on health system resilience by exploring how public antenatal and childbirth health services in Cambodia have absorbed, adapted or transformed in response to seasonal and occasional floods.

Design: A qualitative study using semi-structured interviews and thematic analysis and informed by the Dimensions of Resilience Governance framework.

Setting: Public sector healthcare facilities and health departments in two districts exposed to flooding.

Participants: Twenty-three public sector health professionals with experience providing or managing antenatal and birth services during recent flooding.

Results: The theme 'Collaboration across the system creates adaptability in the response' reflects how collaboration and social relationships among providers, staff and the community have delineated boundaries for actions and decisions for services during floods. Floods were perceived as having a modest impact on health services. Knowing the boundaries on decision-making and having preparation and response plans let staff prepare and respond in a flexible yet stable way. The theme was derived from ideas of (1) seasonal floods as a minor strain on the system compared with persistent, system-wide organisational stresses the system already experiences, (2) the ability of the health services to adjust and adapt flood plans, (3) a shared purpose and working process during floods, (4) engagement at the local level to fulfil a professional duty to the community, and (5) creating relationships between health system levels and the community to enable flood response.

Conclusion: The capacity to absorb and adapt to floods was seen among the public sector services. Strategies that enhance stability and flexibility may foster the capacity for health system resilience.