Cross-sectoral perspectives on strategies to address climate adaptation and health in cyclone-prone Sofala province, Mozambique

1 Introduction

Climate change poses a significant threat to population health, both in terms of the direct escalation of disease risk and the disruption of health systems. It is estimated that the world will see an additional 250,000 deaths per year in the next 50 years because of climate change [World Health Organization (WHO), 2023]. This staggering statistic is in part due to heightened exposure to climate-related extreme weather events, such as heatwaves, storms, flooding, disruptions to food systems, increases in zoonoses and food-, water-, and vector-borne diseases (Borham et al., 2025; James et al., 2026; Xu et al., 2022). There is a growing realization that these climate stressors disproportionately impact vulnerable groups such as those with chronic communicable and non-communicable diseases (Canda et al., 2026b; Mabuto et al., 2025; Zhu et al., 2026). The direct and indirect effects of climate change disproportionately impact low- and middle-income countries that contributed the least to greenhouse gas emissions. Sub-Saharan Africa is the most vulnerable region in the world to the impacts of climate change, with tens of millions already impacted by rising temperatures, extreme weather events, and the spread of infectious diseases (Soomar et al., 2026; Trisos et al., 2023).

Mozambique was ranked as the country most impacted by climate events in the 2021 Global Climate Risk Index Report (Eckstein et al., 2021). Its geography predisposes the country to repeated extreme weather events, which pose a serious threat to an already weak health system. The frequency of these events is increasing with the advent of climate change. The country witnessed two of the strongest storms to strike the African continent in March and April of 2019 (cyclone Idai in mid-March 2019, followed 6 weeks later by cyclone Kenneth). These both led to significant population displacement, as well as health-related morbidity and mortality due to health-service delivery disruption. These storms led to the direct deaths of more than 600 people and resulted in over $873 million worth of infrastructure damage (Fletcher, 2025). Between 2019 and 2024, Mozambique has experienced at least one major cyclone each year. These cyclic climatic events are associated with significant morbidity and mortality due to disruption in the flow of supply chains, displacement of health professionals, the increase in the frequency of diseases trans-mitted by vectors, rodents and water (malaria, dengue, chikungunya, leptospirosis, diarrheal diseases including cholera and others), respiratory diseases (including COVID-19), mental illnesses and acute and chronic malnutrition in both children and adults (Mugabe et al., 2021a,b). Additionally, these events impact the provision of essential medical services, including maternal and child health, monitoring and treatment of chronic diseases such as HIV/AIDS, cardiovascular diseases, and other non-communicable diseases (NCDs).

A comprehensive national disaster vulnerability assessment conducted in 2019 identified the most vulnerable districts in Mozambique to extreme weather events, highlighting the need to strengthen capacity to respond to these events. Analyses foresee that weather-related events in Mozambique will be increasingly severe, underscoring the need to strengthen resilience to severe weather events at multiple levels of society (individual, community, health facility, and district levels) (Loffreda et al., 2023; Muleia et al., 2024). Experience with recent disasters revealed that Mozambique’s resilience to health service disruption is poor. Furthermore, disaster preparedness and response are focused on containing infectious diseases without attention to NCDs, including mental health, which have been shown to be neglected in disaster preparedness, response, and recovery (Hassan et al., 2020; Chilaule et al., 2024). This is especially troubling given the rising burden of NCDs in Mozambique, now the second leading cause of mortality in the country (Ciccacci et al., 2020; Macicame et al., 2023; Madede et al., 2024) and the growing awareness of these needs and potential opportunities to address them (Canda et al., 2026a).

There is currently a lack of evidence-based strategies to reduce the impact of climate-related disasters on human health in low- and middle-income countries. A recent analysis (Loffreda et al., 2023) across multiple high-risk countries, including Mozambique, identified cross-sectoral drivers of adaptation that should be addressed to strengthen resilience. These included early warning/preparedness systems, agricultural practices, urban planning, health system resilience, and social security. To address these areas and identify potential strategies to strengthen resilience and reduce morbidity and mortality in the face of climate-related disasters, it is imperative to engage an appropriate range of sectors and roles amongst those at the front line of addressing extreme weather events. There has been a call for more engagement by local stakeholders to identify the needs and priorities of the communities most affected when developing adaptation strategies (Hounkpatin et al., 2024; Black et al., 2024). This paper documents a systematic attempt to engage diverse stakeholders in a vulnerable province of Mozambique to understand their experience with recent disasters and to identify adaptation strategies to reduce the health impact of future events on morbidity and mortality.

2 Materials and methods

2.1 Setting

The study took place in Sofala province, a province with high vulnerability to climate-related extreme weather events and a low level of adaptive capacity (Muleia et al., 2024). Sofala was the most impacted province by the 2019 cyclone Idai and has witnessed a major cyclone event annually between 2019 and 2024. It has an estimated population of 2.4 million inhabitants, a literacy rate of 56%, an infant mortality rate of 62 per 1,000 live births, a life expectancy of 57 years, and an HIV prevalence of 14% [Instituto Nacional de Estatística (INE), Ministério da Saúde (MISAU), and ICF, 2023; World Health Organization (WHO), 2026] NCDs in this province are contributing to longer hospital stays and higher treatment costs when compared to communicable diseases, with higher rates of prevalence of hypertension and diabetes in Beira urban area, the capital city of the province [Verykiou et al., 2026; World Health Organization (WHO) African Region, 2023]. The province has 166 health facilities and a total number of 361 community health workers [Ministério da Saúde (MISAU), 2020].

The study focused on three Districts in Sofala province identified as having a high health vulnerability index (HVI): a peri-urban district (Dondo), a more rural district (Buzi), and an adjacent district (Nhamatanda) where ongoing research regarding NCDs promised added value (Figure 1). In all three districts most of the population reside in rural villages where income is dependent on agriculture, housing is mostly rudimentary, sanitation and access to clean drinking water is poor, and health services provision is through primary level health care facilities and community health workers. These districts host a total of 23 resettlement camps: 16 in Buzi, 4 in Dondo, and 3 in Nhamatanda. These camps were established in 2019 and currently accommodate approximately 70,760 inhabitants—52,189 in Buzi, 7,035 in Dondo, and 11,536 in Nhamatanda.

2.2 Study design

A stakeholder mapping exercise was conducted by the research team to identify all-of-society stakeholders that needed to be interviewed. This mapping was enhanced with snowball sampling whereby interviewees were asked if additional people should be included in the interview list. This started from the provincial level with representative from key sectors, that supported in identifying the key informants at the district level. Individuals identified through the stakeholder mapping exercise were contacted by phone or email to ask if they would be interested in participating in the study. If interested, interview time and location were identified.

An interview guide was developed and pilot tested. Domains addressed by the interview guide included access to health services in the context of disasters (access to medications and healthcare providers), health conditions most affected, challenges in managing health conditions during disaster, barriers and facilitators to the management of health conditions during disasters, and recommendations on promoting access to health care during a disaster.

Interviews were conducted by trained staff in each of the three districts of interest. Interviews were conducted in person, in Portuguese, in a private setting during approximately 50–60 min. Interviews were recorded and then transcribed manually by research staff. Interviewers also completed field notes at the end of the interview that were also used in the analysis.

2.3 Data analysis

A trained bilingual English and Portuguese analyst reviewed all transcripts in Portuguese in detail and analyzed them using the established rapid qualitative methods approach. The rapid qualitative analysis approach allows for a shorter turnaround time while maintaining scientific rigor and generating valid findings (Gale et al., 2019). Following the rapid analysis approach, a standard summary template was first developed and tested by two researchers SH and GF. Once the template was optimized, key points from each transcript were summarized by GF with illustrative quotes translated into English. The information from each summary template was then transferred to a matrix where results were viewed side-by-side to allow for synthesis and identification of the main themes. To identify main themes, SH and GF reviewed the matrix and the field notes looking for patterns in the data that answered the main research question. Any conflicts in consensus on the main themes being derived from the matrix by SH and GF were discussed with the listed coauthors to agree upon a final list of themes. Main themes and subthemes were summarized and described with example quotes.

The study was approved by the National Public Health Institute Institutional Ethics Review Board (Reference number: 066/CIE-INS/2024).

3 Results

3.1 Stakeholders’ characteristics

A total of 40 interviews were conducted (4 from Beira city, 11 from Nhamatanda district, 12 key informants from Buzi district, and 13 from Dondo district). Key informant interviews across the three districts represented diverse perspectives of stakeholders with different roles as depicted in Table 1.

Table 1. Stakeholder interviewees characteristics per district.

3.2 Emergent themes

Six major themes were identified through data analysis. Table 2 summarizes these themes and related subthemes.

Table 2. Summary of participants responses by corresponding theme and/or subtheme.

3.2.1 Theme 1

Increased frequency of extreme weather events with varied levels of impact has heightened the urgency for preparedness and response.

Stakeholders throughout all three target districts perceived an increasing frequency and severity of extreme weather events, including flooding, cyclones, and drought. There was also a realization that with every event, different parts of the country could be affected to differing degrees. This realization led stakeholders to recognize that discussions around preparedness and response were urgently needed.

“We have other cyclones that I spoke about before Idai, it was little talked about, but it happened and created some stress for us, Idai, which was of extreme magnitude, created several damages, deaths and destruction of infrastructures. Chalane also affected the district of Buzi and a part of Machanga, Eloise also caused damage to our province, Ana, Freddy despite having affected the province of Zambezia more.”—Stakeholder in Beira

BD: “They increased in number and magnitude, just look at Idai in 2019, before 2019 we had one or two cyclones or storms, but not at that frequency, only after Idai did more than seven, eight events occur in a row”—Stakeholder in Buzi

3.2.2 Theme 2

Cyclones and floods result in significant disruption to healthcare delivery and healthcare access that have negative health consequences for those with chronic disease.

Subtheme 1: physical destruction of hospital and clinic buildings impacted healthcare delivery.

There was clear recognition that cyclones and floods caused significant damage to the physical infrastructure of hospitals and clinics. This not only displaced patients but also limited their ability to access care.

“…some services we know had to stop, because their infrastructures were promptly destroyed, practically everything including documents was lost”—Beira provincial level stakeholder

Subtheme 2: physical impact on roads disrupted healthcare access.

Stakeholders emphasized that even when clinic buildings and hospital facilities remained intact, roads were often impassable. They found that this limited transportation was beyond the usual challenge of access. With limited modes of transportation, people seeking regular follow-up care as well as those with more acute issues, could not access care.

“We saw that some of our infrastructure was destructed, so this is one of the impacts, our streets were closed, we are saying the streets are the means to have communication when the roads were closed trees fell on our roads it is an impediment to our circulation, this is a phenomenon that affected people a lot.”—Dondo Emergency Committee Member

Subtheme 3: disruption of medical supply and medication supplies limited quality healthcare delivery.

Stakeholders emphasized the added complication of disrupted medication supply chains. They discussed their experiences with the destruction of critical infrastructure leading to medication shortages in remote districts. These medications are needed to control many chronic diseases and prevent serious complications.

“And when there is destruction of the infrastructure of the health unit itself, there is also this difficulty in making, getting this medicine. Or when there is destruction of the medicines themselves because of the event, they get wet or destroyed during the event, because they were not well-packaged, this can also create this limitation in getting or having this medicine.”—Nhamatanda Stakeholder

Subtheme 4: human resource limitations limited healthcare delivery.

Participants perceived that the baseline low ratio of health professionals to patients is exacerbated in the face of extreme weather events. This impacts the ability of health professionals to report to work and the wellbeing of their own selves and their families; this in turn they found impacted their own physical and mental ability to perform their duties. As one stakeholder in Dondo put it:

“…the great challenge that the health center here in the district of Dondo still faces is creating or otherwise having the largest number of health professionals to respond to the demand of the service itself.”

3.2.3 Theme 3

Food insecurity and Infectious disease outbreaks are priority conditions in times of extreme weather events.

Subtheme 1: waterborne diseases are an overarching concern—cholera and diarrhea were repeatedly mentioned as main perceived health threats during these disasters.

Participants reported that they experienced repeated cholera outbreaks after disasters in Sofala province have heightened concern and attention given to diarrheal and water-borne illnesses.

“The main town due to its geographical location, it is right in the Buzi River basin, so it always suffers from waterborne diseases such as diarrhea and malaria, it always suffers from these diseases, but with the cyclone it only got worse, we started to have outbreaks of cholera because the sanitation infrastructure also suffered.”—Buzi Stakeholder

The concerns around water, sanitation, and hygiene practices were heightened at resettlement camps where limited resources were made for challenging health conditions. This prompted much of the attention of NGOs and government agencies to focus on providing access to safe water.

“…we had to create resettlement centers, create basic conditions first of all for water and sanitation, then food provision.” Nhamatanda stakeholder

“The services that were available, that were needed at that time were issues of diarrhea because people were already living in tight spaces, they lived in the same place, and their habits were different…”—Nhamatanda stakeholder

Subtheme 2: Limited access to food threatens lives and worsens illness.

Food insecurity is a significant concern for all post-disasters. Participants perceived that the limited access to food worsens health conditions but also threatens livelihoods. They reported that dependence on agriculture for both food and income makes disasters that destroy crops a significant threat.

“There is no food in the community, we have to wait to enter our malnutrition ward, and we have many children arriving with malnutrition because our population lives off agriculture”—Nhamatanda stakeholder

3.2.4 Theme 4

Reliance on outside agencies and other governments for health-related relief aid.

All stakeholders recognized the prominent and crucial role of non-governmental agencies in the aftermath of a disaster to provide health-promoting and lifesaving resources.

“We ended up having support, Doctors Without Borders was here, many non-governmental organizations were here to support because the impact was greater”—Nhamatanda stakeholder

“After Idai, floods in 2019, we had great support from the government, then the Doctors Without Borders community, the Samaritans Captamuli, and the Samaritans set up a campaign at the health units level and it ran for close to 2 months, so they gave very important help, they set up tents and we had several wards and even the operating room managed to set up tents”—Buzi Stakeholder

In addition, several stakeholders recognized that some of that relief came from governmental entities outside of Mozambique, such as Angola and Korea.

“Thanks to some partners there, who came and gave a hand. Yes. In fact, they came with transport, we had help from Angolans, we had help from Koreans, if they are Koreans, if they are who, then, they came here, set up their tents, with a helicopter, at some point, they moved, they were going to provide assistance, people who could not get out of there, who were far away.”—Dondo Focal Point for District Development Control.

3.2.5 Theme 5

Improved disaster preparedness is needed in the health system, community, and individual levels.

Across all districts stakeholders recognized that improved disaster preparedness was urgently needed at multiple levels. They recognized that preparedness and response do not fall solely to one group of individuals, but rather it is a collective responsibility that requires improved coordination to be successful.

Subtheme 1: The need for effective preparedness communication with individuals.

Individuals within the community are the most vulnerable and need to be better informed about how to prepare for disasters, both in terms of long-term planning, such as where they live and livelihoods, but also short-term planning in advance of an incoming storm. One stakeholder in Dondo explicitly stated the importance of this in-formation dissemination:

“Disseminate information to the community in advance, so that it can prepare for these climate change (effects) before they happen”—Stakeholder in Dondo

Subtheme 2: The need for strong meteorological data to inform communities.

Critical to mobilizing effective preparedness plans is accurate and timely information regarding incoming storms. Stakeholders recognized the importance of meteorological data that can be efficiently conveyed to those most in need. A stakeholder in Nhamatanda emphasized the importance of this information getting to the community:

ND: “With floods, the first lesson we learn is that whenever we have information about the weather forecast or the occurrence of an event like that, we must go to safe areas so as not to lose out, so that the damage is not too serious. This is the first very important lesson, and we always must try to get information through the radio and mobile phones.”—Stakeholder in Nhamatanda

Subtheme 3: The need for improved coordination of efforts to strengthen the preparedness of the health system.

Stakeholders in all three districts recognized that effective disaster response has multiple actors across multiple sectors. They recognized the importance of improving coordination between these different facets to enhance disaster response. One stakeholder in Beira recognized the importance of the response team communicating with those on the ground:

“…. leading the technical team, that was exactly it, mainly organizing those relief teams, preparing where the requests for help would come from, identifying the team that will support that particular community.”

Another stakeholder in Nhamatanda recognized that this response must in-volve a complicated coordination effort: “The issue is also of coordination between various sectors, each one really knowing what their activity is, when we are faced with a forecast of the occurrence of an extreme event, before, during and after. Each sector knows exactly what it must do and carry out this multi sectoral coordination.”

4 Discussion

Climate-related disasters are a growing threat to low- and middle-income countries. The current limited adaptive capacity of LMICs to these threats increases the impact of extreme weather events on the health and well-being of their populations. Our study examines the multi-level impact of disasters on health in the highly climate-vulnerable country of Mozambique, with a focus on potential adaptation strategies to enhance resilience at multiple levels. This rapid qualitative analysis provides timely information on the major threats to well-being in disaster settings and potential areas of focus for adaptation. The emergent themes from the qualitative study highlight the co-occurring stressors of chronic and infectious diseases in the aftermath of a disaster, which are compounded by limited access to quality healthcare and inefficient coordination between community, health, and disaster response personnel. This is worsened by a dependency on non-governmental organizations and foreign aid for disaster relief, a critical vulnerability with increasing funding constraints in the global humanitarian system (Fletcher, 2025).

These findings mirror other work on disasters in sub-Saharan Africa that have identified multi-sectoral coordination as critical. The previously discussed work of Loffreda et al. (2023) highlighted the importance of looking outside the health sector at sectors such as agriculture, which have a direct impact on health. Our findings illustrate growing awareness amongst stakeholders of how climate disasters can impact agricultural systems, resulting in food insecurity as well as impacting people’s livelihoods. The interdependence of risks, vulnerabilities, and strategies across traditional sectors is a major theme underpinning contemporary climate adaptation policy analysis (UNFCCC, 2025) and the research required to inform local, contextually appropriate interventions. Findings also underline the importance of not only considering alternate livelihoods not susceptible to climate change but systems that can address food security in the setting of a disaster (Gini et al., 2024; NIHR, 2024).

This study thus has significant policy and practice implications for disaster preparedness and response in Mozambique. The work emphasizes the importance of multisectoral coordination to ensure that disaster preparedness and response address not only chronic and infectious diseases but also acknowledge the role of agricultural and food security in health. Furthermore, our findings stress the need to raise awareness that chronic conditions, in addition to infectious diseases, need to be prioritized in disaster preparedness and response. This is critical to inform preparedness with regards to medication stockpiling and trained healthcare providers. This work emphasizes that communication methods need to be strengthened to ensure that those most vulnerable not only know what to do in the event of a disaster but are also appropriately informed of incoming threats promptly.

These findings are now being fed into national deliberations of strategies to address the health consequences of climate change as well as district-level planning in Buzi, Dondo, and Nhamatanda regarding interventions supporting local adaptation. For the latter, the identified themes have served as an initial framing of participatory group consultations to formulate, prioritize and develop interventions (Maholela et al., 2026). These include proposals at the community level for enhanced evacuation preparedness, at the local health system level for training in psychosocial and chronic disease support, and at the district-level for strengthening cross-sector co-ordination across health, education, public works etc.

On a larger scale, this rapid analysis elucidates the complexity of health in disasters—the many interconnected factors, across multiple levels and multiple sectors, that determine the health of a population in the aftermath of a large-scale event. Determining approaches that can strengthen resilience and improve health outcomes after disasters must engage all-of-society stakeholders in understanding the complexity of the system and defining multi-level solutions. There is a growing body of literature emphasizing the importance of engaging those with lived experiences to identify solutions to reduce the impact of climate stressors on health (Black et al., 2024). This is particularly relevant for vulnerable groups such as pregnant women and newborns, the elderly, and those with NCDs (da Silva et al., 2025; Lusambili et al., 2023; Mabuto et al., 2025). The identification of feasible and acceptable community-driven solutions will lead to the implementation and evaluation of interventions to strengthen health system resilience and improve health outcomes in the face of extreme weather events (Mabuto et al., 2025).

There are a few limitations of this study to note. The first limitation is that this work focuses on three districts in Mozambique, which restricts the generalizability of these findings to other contexts. The emergent themes align well with work in other parts of the world that have looked at resilience post-disasters. Secondly, the rapid qualitative analysis, despite its strength in providing a systematic approach to quickly define themes from qualitative data, does not provide the same level of in-depth analysis that other analytic methods within qualitative research, such as thematic content analysis, may provide. Another limitation is that the stakeholder mapping exercise, having been defined by the research team, may have missed some key partners to include. We tried to mitigate this limitation by adding a snowball sampling component. In addition, we recognize that many stakeholders were public officials being interviewed about their own performance and therefore responses may suffer from desirability bias. Also, this work does not include the perspective of community members or people with chronic related diseases, which may have brought forth additional thematic areas. Lastly, some nuances of the original quotations may have been lost in translation.

5 Conclusion

This study furthers our understanding of barriers, facilitators, and potential adaptation strategies to improved health outcomes after extreme weather events in Mozambique. Stakeholders across three high-risk districts identified persistent challenges such as infrastructure damage, medication and supply shortages, limited hu-man resources, food insecurity, and a rising burden of both infectious and chronic diseases that collectively hinder effective disaster response. Our findings highlight the importance of a coordinated, multisectoral approach that integrates improved community-based communication strategies and health service continuity plans that include non-communicable disease management. As climate-related events become more frequent and severe, proactive engagement of all-of-society actors is essential to safeguard population health and reduce the devastating health impacts of future disasters in low-resource, climate-vulnerable settings like Mozambique.

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Footnotes

Edited by: Raji Pushpalatha, Amrita Vishwa Vidyapeetham (Amritapuri Campus), India

Reviewed by: Efa Nugroho, Universitas Negeri Semarang, Indonesia

Nunzio Zotti, University of Pisa, Italy