A Study Protocol to Co-develop and Evaluate Interventions that Strengthen Healthcare Resilience to Extreme Weather Events in Three African Countries: The ASTRA Study

Tonderai Mabuto^1*Kingsley Stephen Orievulu²Virginia Bond³Musonda Simwinga³Erofili Grapsa²Thandeka Khoza²Samantha Khan-Gillmore²Londiwe Nzimande²Marlies Craig²Sammy Khagayi²Taonga Chirwa³Rogerio Chiau⁴Ezequiel Ossemane⁴Christopher Hoffmann^5,6Janet Seeley^2,7,8Dominic Kniveton⁹Saeideh Babashahi⁹Azeeza Rangunwala¹⁰Nkululeko Mthembu¹¹Callum Oberholzer¹²Salome Charalambous⁶Collins Iwuji^13,2,9

• ¹Aurum Institute, Johannesburg, South Africa
• ²Africa Health Research Institute, Durban, South Africa
• ³Zambart Project Limited, Lusaka, Zambia
• ⁴Fundacao Aurum, Maputo, Mozambique
• ⁵The Johns Hopkins University School of Medicine, Baltimore, United States
• ⁶The Aurum Institute, Parktown, South Africa
• ⁷London School of Hygiene and Tropical Medicine Global Health and Development Department, London, United Kingdom
• ⁸University of KwaZulu Natal School of Nursing and Public Health, Durban, South Africa
• ⁹University of Sussex, Brighton, United Kingdom
• ¹⁰Groundwork, Pietermaritzburg, South Africa
• ¹¹Pista Ventures, Durban, South Africa
• ¹²Black Box Design and Development, Durban, South Africa
• ¹³University of KwaZulu-Natal School of Nursing and Public Health, Durban, South Africa

Extreme weather events (EWEs) are becoming more frequent and intense due to climate change, disrupting healthcare systems and increasing risks for vulnerable populations. In low- and middle-income countries, these disruptions threaten progress in HIV and tuberculosis (TB) care by limiting access, straining services, and worsening health outcomes. Building health system resilience through environmentally sustainable infrastructure and processes, adequate and skilled workforce, and community engagement is essential to ensure continuity of care. In this four-year study (ASTRA), we aim to co-design, prioritise and evaluate interventions to strengthen community and health system resilience to EWEs for people with HIV/TB. This multi-phase, mixed-methods study will be conducted in Mozambique, South Africa, and Zambia, countries which are highly vulnerable to EWEs such as storms, cyclones and flooding and bear a high burden of HIV and TB. Phase 1 will focus on understanding the context through stakeholder mapping, scoping interviews, a Delphi consensus process, and assessments of community and health facility vulnerability and adaptive capacity. We will carry out rapid ethnographic assessments (also known as Broad Brush Surveys (BBS)), spatial and statistical modelling, and a policy and programme analysis in this phase. Phase 2 will involve four sequential co-creation workshops in each country to produce prototype interventions that will be refined and prioritised for evaluation. In Phase 3, we will evaluate selected interventions using system dynamics modelling and economic analysis. Using systems dynamics modelling, we will model the final set of interventions, individually and in combination, to explore their potential effects on service delivery during EWEs. The economic evaluation will estimate the costs of inaction, assess the benefits of interventions through multi-criteria decision analysis, and determine their value for money to inform priority setting and policy action. Overall, the innovative use of participatory co-creation processes, system dynamics modelling, and economic evaluation, provides a model for designing and assessing adaptation interventions that are both evidence-based and locally relevant. ASTRA will inform national policy and planning and offer transferable knowledge for other climate-vulnerable settings facing similar challenges.