Introduction
Climate change has increased the incidence and severity of extreme weather events worldwide, and floods have emerged as one of the most destructive manifestations, particularly in South Asia.Reference Fiaz and Rahman 1 Pakistan, with its fragile infrastructure and high dependence on agriculture, remains highly vulnerable to the public health consequences of these climate-induced disasters.Reference Farooq and Raza 2 Over the last fifteen years, Pakistan has experienced an ever-increasing pattern of large-scale floods—2010, 2011, 2020, 2022, and most recently 2025—each more devastating than the previous one.Reference Raza, Khalil and Fareed 3 Each successive event was associated with structural vulnerabilities within governance, health systems, and environmental management, turning seasonal monsoons into national emergencies. The 2025 floods, following record-breaking monsoon rains and accelerated glacier melt, inundated vast agricultural areas across Punjab, Khyber Pakhtunkhwa, Sindh, and Balochistan, cutting off rural communities from essential health and sanitation services. 4
According to the United Nations (UN) News (16 September 2025), over 6 million people have been affected, 2.5 million displaced, and nearly 1,000 lives lost, including 250 children. The 2022 floods highlighted systemic weaknesses in health, governance, and environmental preparedness.Reference Nazeer, Qadir and Khan 5 Despite extensive damage and international attention, institutional reforms were limited, leaving the country ill-prepared for the 2025 crisis.
Pakistan ranks among the most climate-vulnerable nations worldwide despite contributing <1% of global greenhouse gas emissions.Reference Hussain, Butt and Uzma 6 Previous studies from Pakistan, India, Nepal, Bangladesh, and Sri Lanka have consistently shown that major flood events lead to widespread disruption of essential health services, increased vulnerability among low-income and rural populations, and heightened risks of malnutrition and infectious diseases.
Regional evidence from Bangladesh, Nepal, and India similarly highlights that recurrent floods increased water contamination, reduced food security, and unduly affect women, children, and marginalized groups.Reference Kikuchi 7 –Reference Guragain and Doneys 9 Former floods, including those in 2010, 2011, and 2020, have similarly been shown to cause prolonged disruptions to health services and community recovery. Global assessments, including the World Health Organization (WHO: 2023) and Intergovernmental Panel for Climate Change (IPCC: 2021) reports, further confirm that climate change is intensifying both the incidence and severity of flooding events, with low-emitting countries such as Pakistan bearing a disproportionate health burden. 10 , 11
Despite extensive documentation of flood impacts in Pakistan, existing literature largely remains descriptive, focusing on post-disaster damage rather than systematically examining how health-system resilience can be operationalized across the full disaster management cycle. In particular, there is limited application of integrated frameworks that link disaster preparedness, health systems, environmental degradation, and equity considerations into actionable resilience strategies. This article is a conceptual Perspective (concept note), drawing on peer-reviewed literature, policy documents, humanitarian reports, and international frameworks to systematically examine flood-related health risks and resilience gaps in Pakistan. Our aim is to operationalize health system resilience to recurrent flooding in Pakistan by mapping actionable strategies to mitigation, preparedness, response, and recovery through the Disaster Management Cycle, One Health, Planetary Health, and Doughnut Economy lenses.
Public Health Impacts of Flooding in Pakistan
The 2025 floods in Pakistan once again demonstrate that what are often perceived as natural or environmental catastrophes are, in fact, public-health crises that expose the interdependence of ecosystems, health systems, and communities. Beyond the immediate destruction of homes and infrastructure, the floods have exacerbated malnutrition and disrupted food chains, particularly across Punjab, Sindh, and Khyber Pakhtunkhwa, where more than 2.2 million hectares of cropland were submerged and wheat-flour prices rose sharply amid supply disruptions. 4
A systematic review of flood impacts in low- and middle-income countries found increased stunting and undernutrition among children under 5 years of age following flood events, a pattern now re-emerging in Pakistan’s 2025 humanitarian assessments.Reference Agabiirwe, Dambach and Methula 12 Similarly, field reports describe widespread water-borne and vector-borne infections, including malaria and dengue, reflecting the same vulnerabilities documented globally. Long-term effects, including chronic diseases, disability, food insecurity, and psychological distress, remain neglected in national recovery plans.Reference Iqbal, Sheikh and Ali 13
Although reproductive health services were prioritized in disaster response plans after 2022, implementation in 2025 remained weak; thousands of pregnant women in Sindh and southern Punjab still lacked access to hygiene supplies, safe-delivery facilities, and antenatal care.Reference Waseem, Ahmed and Ahmed 14
These recurrent outcomes reflect persistent gaps in disaster preparedness. Despite lessons from 2022, Pakistan’s strategies in 2025 remain largely reactive, mobilizing and offering relief only after disasters occur. Health system responses were incomplete, slow, and poorly coordinated. Although evacuation was improved, mitigation and resource mobilization remained inadequate, and routine services such as maternal care and vaccination were again disrupted.Reference Abdullah, Shaikh and Sikander 15
Conceptual Framework for Flood Resilience
The disaster management cycle of mitigation, preparedness, response, and recovery provides a structured approach to operationalize flood resilience, allowing assessment of health system capacity before, during, and after flood events.Reference Rana, Asim and Aslam 16
Flood resilience also requires recognizing health risks that extend beyond infrastructure damage. The One Health framework works on human, animal, and environmental well-being enabling identification of flood-related disease risks arising from ecosystem disruption.Reference Danasekaran 17
Planetary health at the broadest level positions Pakistan’s floods within global inequities linking environmental degradation, climate drivers, and population health outcomes.Reference Mago, Dhali and Kumar 18
The Doughnut Economy model developed by Kate Raworth suggests an additional perspective to interpret Pakistan’s flood-related health vulnerabilities by integrating ecological limits with minimum social and health needs. Reference Fanning and Raworth 19
These frameworks were applied deductively to documented failures and health impacts observed during the 2022 and 2025 flood events. This structured application allows resilience to be examined as an operational construct rather than a normative aspiration.
Operationalizing Health System Resilience Across the Disaster Management Cycle
The following sections translate abstract resilience concepts into operational, phase-specific actions, structured according to the disaster management cycle and informed by observed failures during Pakistan’s recent flood events. Each framework offers a valuable yet incomplete perspective. The disaster management cycle highlights critical gaps in preparedness, response, and recovery within emergency systems. One Health demonstrates the simultaneous breakdown of human, animal, and environmental health, while the planetary health framework explains the broader ecological and climatic factors underlying the increasing frequency and intensity of floods.
The 2025 floods in Pakistan indicate that the results of the separate treatment of these frameworks highlighted the need for practical implementation.
The integration of these 3 frameworks provides a path forward that was outlined after the 2022 floods as a necessary approach for transforming risk governance and building resilience across health, environment, and socio-ecological systems. At the International Conference on Climate Resilient Pakistan in 2023, Pakistan and international partners outlined the Resilient, Recovery, Rehabilitation, and Reconstruction Framework to coordinate multisectoral action—including disaster risk reduction, ecosystem restoration, and health systems strengthening—that reflects elements of these integrated frameworks, but its implementation remained limited by institutional fragmentation, delayed response mechanisms, and weak cross-sector coordination well into 2025. 20
Building resilience requires embedding this integration into national policy beyond academic discourse. These resilience functions provide an analytical lens for assessing how flood management measures operate across the disaster management cycle. These frameworks were applied to specific flood-related challenges observed during the 2022 and 2025 events.
The Disaster Management Cycle was used to categorize gaps in mitigation (e.g., wetland degradation), preparedness (e.g., early-warning failures), response (e.g., service disruption), and recovery (e.g., governance fragmentation).
The One Health framework informed analysis of post-flood disease outbreaks linked to water contamination and livestock loss, while the Planetary Health and Doughnut Economy frameworks were used to interpret how ecological degradation and unmet social needs amplified health vulnerabilities.
From a resilience perspective, flood management requires strengthening three complementary capacities: absorptive, adaptive, and transformative resilience. Absorptive resilience refers to the ability of health systems and communities to maintain essential functions during flood shocks, adaptive resilience reflects adjustments that reduce future vulnerability, and transformative resilience entails structural changes that address the root causes of risk.Reference Karrasch, Restemeyer and Klenke 21 In Pakistan, responses to recent floods have largely focused on absorptive capacity through emergency relief, while adaptive and transformative dimensions remain restricted in scope or inconsistently implemented.
Mitigation (Reducing Future Flood Risk)
Concept
Within the disaster management cycle, mitigation and preparedness primarily strengthen adaptive and transformative resilience, response reflects absorptive resilience, and recovery offers an opportunity to consolidate long-term transformation.
What failed in 2025
Degradation of wetlands, deforestation, and unsustainable land use increased runoff, erosion, and downstream flooding.
What to do
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1. Restoration of wetlands to protect ecosystems (Planetary health)
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2. Reforestation and sustainable agriculture to reduce environmental degradation
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3. Integrate land-use regulation to lower flood risk (Disaster preparedness).
Preparedness (Anticipating Health Impacts)
Concept
Preparedness strengthens anticipatory capacity by enabling early detection of hazards and health risks before floods escalate.
What failed in 2025
Fragmented data systems prevented real-time forecasting and early-warning dissemination, leaving high-risk districts unprepared.
What to do
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• Integration of meteorological data (rainfall, glacier melt), hydrological modeling, and ecological and disease surveillance (vector populations, water quality, and animal health).
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• Using Geographic Information System (GIS) and Artificial Intelligence (AI) tools for mapping flood zones and predicting disease outbreaks could strengthen early warning and response.
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• Include standardized disaster medicine training for frontline health workers around core competencies—clinical surge response, public-health functions, One Health risk recognition, and climate-driven disaster awareness for frontline health workers
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• Protection of safe motherhood services particularly antenatal care, skilled delivery, emergency obstetric care, and postnatal follow-up, within disrupted flood settings.
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• Contingency planning for climate-resilient facilities including uninterrupted power and water supply, flood-safe access routes, protection of essential equipment, and continuity of critical clinical services.
Response (Maintaining Essential Health Services)
Concept
Response focuses on sustaining essential services during flood events.
What failed in 2025
Health services were disrupted in cut-off communities, with delayed deployment of supplies and personnel.
What to do
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• Mobile clinics, temporary health posts, and telemedicine can help restore access to maternal and child health services, outbreak management, and emergency care in cut-off communities.
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• Emergency supply chains for oral rehydration salts, antibiotics, vaccines, and reproductive health kits must be activated at district level.
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• Coordinated deployment of health workers and rapid disease surveillance are critical to limit preventable morbidity and mortality during the acute phase of flooding.
Recovery (Building Back Better and Fairer)
Concept
Recovery focuses on rebuilding systems in ways that reduce future vulnerability and promote equity.
What failed in 2025
Fragmented governance and limited intersectoral coordination slowed recovery and reinforced existing inequalities
What to do
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• Effective resilience requires a joint data platform linking health surveillance, climate and flood early-warning systems, and environmental and animal-health data, shared contingency planning such as surge capacity planning, service continuity, pre-defined referral and evacuation pathways, and unified accountability through formally mandated governance structures that assign cross-sector responsibility, enable data sharing, and ensure oversight of preparedness and response outcomes.
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• Integration of One Health surveillance into disaster plans and inclusion of community and environmental indicators such as zoonotic disease signals, vector density changes, water contamination risks, livestock morbidity or mortality, and community displacement patterns in decision-making remain key priorities.
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• Monitoring, evaluation, and equity must be central to recovery planning.
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• Metrics must extend beyond mortality to include outbreak timelines, mental-health burden, and animal losses.
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• Equity consideration requires focused attention to pregnant women, displaced populations, children, and rural communities, who have borne the heaviest toll.
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• Establishing a National Resilience Audit ( periodic, independent, system -wide assessment of a country’s capacity to anticipate, withstand, respond to, and recover from climate-related and disaster-related shocks) could support monitoring of these indicators and ensure that future flood responses are evidence-based and equitable (Table 1) (Fig. 1).
Table 1. Lessons from flood-resilient countries and conceptual implications for flood preparedness in Pakistan
Figure 1. Integrated framework for climate-resilient health systems in Pakistan.
Discussion
Analysis of the 2022 and 2025 floods indicates that despite growing global recognition of climate-linked disasters, Pakistan’s response to recurrent flooding remains largely responsive focused on emergency relief after impact—rather than preventive through sustained risk reduction and anticipatory planning. As shown in other climate-vulnerable countries, health crises following major floods often expose longstanding systemic weaknesses in coordination, early warning dissemination, and resource allocation.Reference Alied, Salam and Sediqi 22 Rather than isolated failures, these recurring gaps indicate a persistent inability to translate risk awareness into preventive and anticipatory action.
Although the availability of established frameworks offers complementary lenses to understand flood-related health risks, their integration has remained limited in practice. Policy efforts remain uneven, with ministries responsible for health, environment, agriculture, water resources, and disaster management operating independently. This lack of intersectoral collaboration leads to duplicated efforts, delayed decision-making, and inefficiencies in mobilizing resources during emergencies.
Strengthening resilience therefore requires more than improvements to emergency response systems. Experiences from other flood-prone settings, including Bangladesh, Vietnam, and the Netherlands, show that investments in early warning systems, land-use regulation, and community-based preparedness have strengthened adaptive and transformative resilience—approaches that remain fragmented or underdeveloped in Pakistan. It demands structural modifications that institutionalize data sharing, joint risk assessments, and coordinated planning across sectors. Cross-sectoral platforms that include meteorological data, ecosystem indicators, disease surveillance, and local community knowledge can increase preparedness and decrease health impacts.Reference Raza, Fatima and Habiba 23 , Reference Gilfillan, Nguyen and Pham 24 At the same time, community-level capacities—often the first to respond during floods—require formal recognition, training, and linkage to national systems to ensure that local action complements rather than substitutes for state responsibility.Reference Crawford and Morrison 25
The analysis also highlights the importance of localized adaptation. Pakistan’s ecological diversity means that flood risks and health impacts vary considerably across provinces. Strategies that reflect local hydrology, infrastructure gaps, and population vulnerabilities—such as wetland restoration in Sindh, urban drainage improvements in Punjab, or reinforcement of health facilities in Khyber Pakhtunkhwa—are essential for effective resilience-building.
A climate justice perspective makes these trends even more imperative. Pakistan disproportionate health burden from climate change despite contributing less than 1% of global greenhouse gas emissions; internally, the greatest impacts fall on populations with the least capacity to adapt or recover. These overlapping global and domestic inequities emphasize the need for justice-based approach (reframes flood resilience as an issue of equity and accountability, recognizing that marginalized populations bear a disproportionate burden of climate-related flooding while having limited influence over preparedness and recovery decisions) to both climate adaptation and disaster recovery, including equitable national resource allocation and predictable international loss-and-damage financing.
Conclusion
The 2025 Pakistan floods highlighted structural connection between climate change, health disparities, and social injustice. Disaster preparedness ensures operational readiness, One Health addresses cross-sector biological and environmental risks, and Planetary Health anchors long-term, justice-based prevention. This integrated framework provides a pathway from reactive disaster response toward a just and sustainable Pakistan that protects human health, ecosystems, and future generations.
Author contribution
JA and KZ conceptualized the study, conducted the literature review, drafted the manuscript, and coordinated revisions. HQ and SMHM contributed to literature synthesis and drafted the manuscript. TG contributed to methodological review and editorial revisions. All authors approved the final version of the manuscript.
Acknowledgments
None.
Funding statement
No funding was provided.
Competing interests
No conflict of interest.
Ethical declaration
This study did not involve human participants or the collection of identifiable private data and was based solely on analysis of published literature, publicly available reports, and secondary aggregated data. Therefore, it was exempt from institutional review board (IRB) review in accordance with international research ethics guidelines.
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