The Sundarbans is one of the largest mangrove forests in the world. Located along the Bay of Bengal the forest spans Bangladesh and India. It is a mix of tidal waterways, mangrove forests, and mudflats. While the area might hold the status of a UNESCO World Heritage Site, it is challenged by poor availability and access to social and development services. In addition, the unique geographical composition of the region makes it vulnerable to climate change, abject poverty, and the threat of uncontrolled commercialization.

The remote and often difficult to access geographical setting of the Sundarbans makes the provision of health and other social services a challenge. In addition, socio-cultural factors (caste, religion and gender), and economic constraints pose as significant barriers in access to health services.

A child born in this region is likely to be at a disadvantage from birth, affected (in all likelihood) by the poor health and nutritional status of the mother at the time of conception and gestation, to its birth. Limited access to health facilities, or skilled birth attendants, and health services put the mother and infant at risk. Socio-cultural contexts and the economic status of the household a child is born into would further impact access to education, nutrition and other opportunities of a child born in this region. Girls often drop out of school to take care of younger siblings while women try and secure a livelihood. Women in the region are also vulnerable to trafficking. Boys too are likely to drop out of school at a young age to join the older men of the community in towns and cities as migrant workers.

Fig 1 – Source: International Institute Of Health Management Research University

Fig2: Source: International Institute Of Health Management Research University

Within such a context the question arises to what extent the provision of even pro-poor health services would be beneficial to people living in marginalized settings, if contextual forces (such as climate impact, livelihood scarcity or food insecurity) are not addressed? The situation demands comprehensive strategies and a conscious, collective effort to address not only physical challenges of delivering health services, but also simultaneously tackling the wider social determinants of health.

UHC is put forward by Dr Tedros as his core objective. We hope the issues of context – social, cultural, economic, and geographic ones, among others – will not be overlooked. Achieving UHC requires broad collective action on health, with an effort to be more inclusive, and with more effective inter-sectoral collaboration. Strengthening the health system, particularly the existing public health system and enhancing human resources for health, as well as tackling issues of poverty, livelihood, and education will be critical towards achieving health and social development indicators. Political will and effective governance are also critical towards health system strengthening. Effective coordination between local stakeholders and higher-level stakeholders will be vital to health care delivery.

Against this backdrop, I would like to argue and illustrate the community’s involvement as being indispensable towards a resilient and equitable health system, and as part of this, frame the community’s engagement as a vital component in the building of resilient health systems as proposed by the WHO and others in their framework for a climate resilient health system. We often have the tendency to miss, or even ignore the community’s perspective on resilience, and focus more on the global definition of resilience. As the health system is a complex system, an understanding of contextual nuances, the community perspective and practices along with the community’s interactions with other components of the health system are also needed to respond better and be resilient towards the external shocks.

I have been part of an ongoing study conducted by IIHMR University under the Future Health System Research programme consortium in the Indian Sundarbans (the largest mangrove delta in the world comprising of 105 islands in eastern India and a recent hotspot of climate change). The study focuses on the impact of climate change on child health. It was here that I came across a slightly different perspective on resilience. Child malnutrition has been a chronic problem in the Sundarbans; the area also has a high burden of communicable and non-communicable diseases with sub-optimal levels of public health services. There are parts of the region which are more vulnerable to climate-related disasters than others, and one such example is that of the island of Ghoramara, which faces severe coastal erosion due to rising sea levels and storm surges. Over the years, the total land mass of the island of 8.51sq. km has dwindled to 4.45sq. km due to a continual rise in sea levels.The region has also seen large-scale migration of its people. Today, the island is home to about 5000 people with 1033 children aged between 0-6 years. Life on the island offers limited livelihood options; vulnerability to diseases and limited access to food has severely impacted the nutritional status of children living on this island. The health system is marked by poor infrastructure and human resources. Public health delivery in Ghoramara is in the form of a ramshackle sub-centre served by frontline health workers, and an NGO-run medical camp held once a week. In addition, there are around ten informal health providers who practice allopathic medicine without any formal degree or training. The community’s demand for health care is evident from the long queues in front of the NGO-run weekly clinic. At the same time the utilization rate of informal providers is also high, especially during climate-related emergencies which render the island inaccessible, preventing formal health providers from reaching the islands. Often, islanders are forced to seek health care from a distant district and city health facilities for basic medical needs. Interestingly, the community members also use traditional home remedies, and continue to practice some  traditional healing systems shamanism. This mixed pattern of health seeking behaviour by the islanders reflects their coping strategies in an environment with poor health services, under continuous pressure by climate-related events, and the expected impact of that on health and social determinants – requiring them to build their own resilience (or rather coping strategies).

Moving away from the community, to those working to deliver health services on the island, health personnel display a degree of fatalism towards the plight of the affected people, particularly within the context of the island dwellers as being few, and as people who survive with the limited options available to them. What is much less understood is the desirable levels of healthcare and services wanted and needed by the community. These are also not reflected in the design of healthcare programmes. The people of Ghoramara are hostage to their circumstances, and climate change– they are people who urgently need the health system to be responsive, to enable them to build the resilience needed in the face of frequent climatic shocks.

Why is it that health functionaries seem to overlook the needs and experiences of the islanders while preparing health plans? Are there no mechanisms in our existing health system that allow for a peoples’ (or a community’s) demand for healthcare to be voiced, and thus better engage with them in the health system? This can raise the question as to whether a general and uniform health plan for the islanders’ problems (based on average population data) is likely to be embedded in local factors of climatic variability. If such is the case, then how do people deal with it? How does this exclude island dwellers from existing and future plans?

I use the case of Ghoramara here to illustrate the need for understanding and taking into account the different contexts towards health system responsiveness and resilience. Continuous dialogues among multiple stakeholders which include the community and a multisectoral approach may offer alternative pathways to making a resilient health system also a people-centred one. One can only hope that the upcoming HSR conference would be a platform for the same.

A similar kind of negotiation process can also be witnessed at the local level. In local settings around the world, communities, policy makers and other stakeholders already and increasingly have to deal with climate change in their own context, against the backdrop of global (macro) changes and high-level multi-stakeholder negotiations. However, the way experts, natural scientists and modelers conceptualize climate change at the global level may have very little to do with how men and women (poor or rich, urban or rural) live with, understand and cope with the changes already taking place in everyday settings. The specific lenses through which problems are framed and actions are taken in these local contexts, deserve particular attention.

A classic case in point may be the Indian Sundarbans.

The Indian Sundarbans, literally  ‘beautiful forest’ in Bengali, is the largest mangrove delta in the world, spread over the southern end of both West Bengal (India) and Bangladesh. Recently, this area is gaining more and more prominence, not only as a UNESCO heritage site or as the largest remaining natural habitat of the ferocious Bengal Tiger, but also as one of the early victims of climate change. The islanders of the Sundarbans already live and (try to) cope with the clear and more hidden impact of climate change on the basic drivers of life like health, livelihood or shelter.  Let’s elaborate a bit on what this entails.

As for the immediate impact, climate change in the Sundarbans, in the form of a sudden climatic shock, like  floods or a cyclone, deals direct damage to livelihoods and shelter and causes breaching of earthen embankments. It also often leads to a sudden rise in the incidence of water borne diseases. Simultaneously, climatic shocks erode the opportunities for maintaining livelihoods and trigger food insecurity at household level.  As for the long term impact, the slow and gradual changes in sea level and weather patterns (like erratic rainfall or extended summers), deplete the traditional agro-fishing economy, which leads to male migration in search of an alternative livelihood. Women are more likely to face a double burden of taking care of the children and having to depend on available low-wage unskilled labour. The mothers’ increasing burden of work disrupts the (already precarious) balance of the social determinants of child health like food security, psycho-social care, seeking quality health care etc.

Now the question is which actors share responsibility (and how much responsibility) for the changing climate in the new Anthropocene” era, in which human activities have a significant impact on ecosystems worldwide. Relatedly, what kind of impact does climate related coping behaviour have in the Sundarbans?

The Sundarbans region features five different kinds of actors who are working and functioning in the local socio-ecological system. First, the islanders, who were forcedly migrated into the region around 200 years ago. Till recently, they lived mainly from harnessing nature – cutting up jungle forest for settlements, engaging in overfishing and collecting tiger prawn seed around the coast, …. These activities indeed disrupt the bio-diversity of the region. Most islanders didn’t use a conservationist approach until the major cyclone Aila struck the Sundarbans in 2009. Things have been slowly changing since then. Aila  has also pushed a bit the Government – another important actor within the system, towards taking climate change more seriously. Till then, the government had been mainly interested in infrastructural development, building roads and bridges… Although this kind of infrastructural development is clearly needed in a geographically inaccessible region like the Indian Sundarbans, people’s voices were routinely ignored while planning for “development”. For example, till now, when building concrete embankments, the government does not have any master plan for the rehabilitation of displaced people in the densely populated Sundarbans region. However, a group of other actors –the climate scientists – offer a solution to this issue by suggesting to relocate all people living in the Sundarbans into nearby towns and the mega city Kolkata. Their conservationist approach starts from the assumption of the shrinking of a major part of the delta around 2020, due to the increasing sea level. They reckon the land is better left to the tigers, in other words. This view has been challenged by another group of actors –the river scientists – who claim that the Sundarbans is an active delta and that erosion and accretion are part and parcel of the process and ecosystem. They think the people of the Sundarbans are resilient enough to tackle the changes in the climate and related consequences with the help of the other actors. When it comes to helping common people by providing services in vital spheres like health, education and disaster risk reduction, local and national civil society organizations, another key actor in the system, have been playing an important role for the last four or five decades. Although they started as voluntary organisations, the work of many of these civil society organizations has now become donor driven.

These five different actors are in continuous tension with each other, all with their own interests, incentives and power dynamics, occasionally aligning with one or another. The similarity with the global level is obvious.

A key question is: what does the Sundarbans area need to cope with its changing (climate) scenario, or at least what would be a way forward? One of the answers may lie in the creation of a common knowledge platform whereby actors from each of these five different sets would have a stake in improving the minimum knowledge base necessary to combat the huge challenges posed by a changing climate.