Adaptive governance for climate-resilient urban health systems: qualitative insights from stakeholders in Dar es Salaam, Tanzania.

Background: Climate change poses growing risks to urban health systems, particularly in rapidly growing cities in low- and middle-income countries. Although strengthening climate resilience has become a global priority, evidence remains limited on how governance processes support adaptation within urban health systems. This study explored stakeholder perspectives on adaptive governance for climate change within Dar es Salaam's urban health system in Tanzania. Methods: An exploratory qualitative study was conducted in Dar es Salaam, Tanzania, between October and November 2025. Data were collected through 38 in-depth interviews and five focus group discussions involving participants from municipal health management teams, public health facilities, and academia. Participants were purposively selected based on their roles in health governance, service delivery, climate change adaptation, and research. Interviews and discussions were conducted in Kiswahili, audio-recorded, transcribed verbatim, translated into English, and analysed thematically using ATLAS.ti software. The Adaptive Governance Framework guided the interpretation of the findings. Findings: Three interrelated themes emerged from the analysis. Interpretation: The findings highlight adaptive governance within urban health systems as a process of relational coordination, knowledge integration, and learning-oriented leadership, rather than solely the presence of institutional structures or resources. Strengthening climate resilience requires governance arrangements that promote collaborative relationships, enable knowledge exchange between communities and institutions, and support leadership practices that promote learning and adaptive responses. These insights extend current understanding of adaptive governance by revealing how stakeholders perceive and experience governance processes in the context of urban health systems in sub-Saharan Africa. However, the findings reflect the perspectives of institutional stakeholders in a single urban context and do not include direct perspectives from community members.