Climate and Health Vulnerability Assessment MADAGASCAR © 2024 International Bank for Reconstruction and Development/The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory, or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. The World Bank encourages the dissemination of its knowledge; thus this work may be reproduced, in whole or in part, for noncommercial purposes, as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Cover image: Morondava-Madagascar-October-7-2017: Unidentified Malagasy worker harvests rice in the countryside of Madagascar. MADAGASCAR Climate and Health Vulnerability Assessment March 2024 CLIMATE INVESTMENT FUNDS TABLE OF CONTENTS INTRODUCTION..............................................................................................................................5 Country Context.................................................................................................................................................... 5 I. CLIMATOLOGY..............................................................................................................................9 Madagascar’s Topography.................................................................................................................................. 9 Observed and Projected Climatology..............................................................................................................10 Temperature..........................................................................................................................................................10 Precipitation..........................................................................................................................................................10 Climate Hazards....................................................................................................................................................11 Storms.....................................................................................................................................................................12 Floods.....................................................................................................................................................................13 Landslides..............................................................................................................................................................15 Droughts................................................................................................................................................................. 17 Wildfires..................................................................................................................................................................18 Sea-level rises (SLRS).........................................................................................................................................20 Extreme heat.........................................................................................................................................................21 II. CLIMATE-RELATED HEALTH RISKS....................................................................................... 25 Nutrition risks.......................................................................................................................................................26 Waterborne disease risks..................................................................................................................................29 Vector-Borne Diseases......................................................................................................................................30 Malaria....................................................................................................................................................................31 Air quality health risks......................................................................................................................................... 31 Zoonoses.............................................................................................................................................................. 33 III. ADAPTIVE CAPACITY OF THE HEALTH SYSTEM............................................................... 35 Leadership and Governance.............................................................................................................................35 Health Workforce................................................................................................................................................ 37 Health Information Systems.............................................................................................................................. 38 Essential Medical Products and Technologies..............................................................................................39 Service Delivery...................................................................................................................................................40 Health Financing.................................................................................................................................................42 IV. RECOMMENDATIONS.............................................................................................................47 Leadership and Governance............................................................................................................................. 48 Health Financing.................................................................................................................................................48 Health Workforce................................................................................................................................................48 Health Information Systems.............................................................................................................................. 48 Service Delivery...................................................................................................................................................49 ANNEXES........................................................................................................................................ 51 iv | Climate and Health Vulnerability Assessment: Madagascar INDEX OF TABLES Table 1.- Population exposed to landslides by risk level.....................................................................................16 Table 2.- Population exposed to more than 1 day of extreme temperature by the 2030s and 2050s.............................................................................................................................................21 Table 3.- Key policy documents relevant to climate change and health........................................................35 Table 4.- Health System’s Adaptive Capacity Gaps............................................................................................. 44 INDEX OF FIGURES Figure 1.- Administrative boundaries of Madagascar’s regions...........................................................................7 Figure 2.- Madagascar’s topography........................................................................................................................ 9 Figure 3.- Madagascar’s Observed (1991-2020) mean annual temperature (°C), and Projected anomalies under SSP3-7.0 for 2020-2039 and 2040-2059...................................................11 Figure 4.- Observed (1991-2020) mean annual precipitation(mm), and Projected anomalies under SSP3-7.0 for 2020-2039 and 2040-2059..................................................12 Figure 5.- 1980-2020 cyclone paths and main populated places....................................................................13 Figure 6.- 50-year Return Period...............................................................................................................................14 Figure 7.- Projections for the Average largest 5-day cumulative precipitation (mm) for the 2030s and 2050s under an SSP3-7.0 scenario.......................................................................................15 Figure 8.- Rainfall-triggered landslide Index..........................................................................................................16 Figure 9.- Normalized Difference Vegetation Index (NDVI) Anomaly from September 17, 2021, to September 16, 2022................................................................................................ 17 Figure 10.- Projections for Consecutive dry days for the 2030s and 2050s under an SSP3-7.0..............18 Figure 11.- Madagascar forest cover loss 2000-2021 and detected wildfires (red) in 2015......................19 Figure 12.- Wildfire Hazard Intensity and Fire Weather Index...........................................................................20 Figure 13.- Projected change in the number of hot days (>35°C) for 2020-2039 and 2040-2059 and Projected change in the number of tropical nights (>20°C) for 2020-2039 and 2040-2059......................................................................................................................................21 Figure 14.- Food Insecurity in Madagascar from February to September 2022. Source: FEWS Net........................................................................................................................................................ 27 Figure 15.- WHO Operational Framework for Climate Resilient Health Systems......................................... 47 Figure 16.- WHO’s Operational framework for building climate-resilient healthcare systems comprising ten components and their connections to the building blocks of health systems................52 Table of Contents | v ACKNOWLEDGMENTS This Climate and Health Vulnerability Assessment (CHVA) for Madagascar was produced by the Health, Climate, Environment and Disasters (HCED) Program in the Health, Nutrition, and Population (HNP) Global Practice of the World Bank led by Tamer Rabie and Stephen Dorey. The assessment was authored by Mikhael Iglesias, Jessica Flannery, and Malanto Rabary, with contributions from Ana Lucrecia Rivera-Rivera and Loreta Rufo. This work also benefited from the administrative support of Fatima-Ezzahra Mansouri, the editorial work of Kah Ying Choo, and the production of Sarah Jene Hollis. The authors are also highly grateful to the HNP management for their strong support of the HCED program and this product and would like to extend their thanks to Juan Pablo Uribe and Monique Vledder. The authors are thankful to the Climate Investment Funds (CIF) and the Climate Support Facility (CSF) for funding this work. vi | Climate and Health Vulnerability Assessment: Madagascar LIST OF ABBREVIATIONS AAP Ambient Air Pollution AQI Air Quality Index AR6 Sixth Assessment Report BNGRC Bureau National de Gestion des Risques et des Catastrophes BRIO Building Resilience in the Indian Ocean CCKP Climate Change Knowledge Portal CHVA Climate Health Vulnerability Assessment CMIP Couple Model Inter-Comparison Project COUSP Emergency Response Committee CSB Centre Santé Basic (Primary Healthcare Center) CSO Community Supported Organization DALYs Disability-Adjusted Life Years DHS Demographic Health Survey DJF December, January, February GDP Gross Domestic Product GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria GFDRR Global Facility for Disaster Reduction and Recovery GFF Global Financing Facility GHG Greenhouse Gas GIZ German Cooperation Office HAP Household Air Pollution HNP Health, Nutrition, and Population HSS Health System Strengthening IDA International Development Association IOC Indian Ocean Commission IPCC Intergovernmental Panel on Climate Change ITNs Insecticide-Treated Nets MoH Ministry of Health MPA2 Phase 2 of the Multiphase Programmatic Approach on Improving Nutrition Outcomes NAP National Adaptation Plan NDC Nationally Determined Contribution NDVI Normalized Difference Vegetation Index NGO Non-Governmental Organization NOAA National Oceanic and Atmospheric Administration ONN Office of National Nutrition OOP Out-Of-Pocket (Expenditure) List of Abbreviations | vii PAD Project Appraisal Document PET Potential Evapotranspiration PFM Public Financial Management PhaGeCOM Community Managed Pharmacies PhaGeCOM District Pharmacies PHC Primary Health Care PIU Project Implementation Unit PM Particulate Matter PNASS Plan D’Action National D’Adaptation Du Secteur Santé Au Changement Climatique (National Adaptation Action Plan for the Health Sector to Climate Change) PPSB Pandemic Preparedness and Basic Health Service Delivery Project RBF Results-Based Financing SLR Sea-Level Rise SMS Short Message Service SON September, October, November SPEI Standardized Precipitation Evapotranspiration Index SSP Shared Socioeconomic Pathway TB Tuberculosis UN United Nations UNDRR United Nations Office for Disaster Risk Reduction UNFCCC United Nations Framework Convention on Climate Change UNICEF United Nations Children’s Fund USAID United States Agency for International Development WASH Water, Sanitation, and Hygiene WHO World Health Organization WMO World Meteorological Organization viii | Climate and Health Vulnerability Assessment: Madagascar EXECUTIVE SUMMARY Madagascar’s location and distinctive topography makes it vulnerable to climate-re- lated hazards, such as cyclones, floods, droughts, landslides, and sea-level rise (SLR). Current and projected changes in climate patterns increase the likelihood of health risks that are sensitive to temperature and precipitation changes. This Climate and Health Vulnerability Assessment (CHVA) has been prepared to contribute to developing and implementing adaptation and mitigation measures that address cli- mate-related health challenges. It aims to assist decision-makers by identifying the climate hazards, the health risks, and the adaptive capacity of the health system, as well as formulating recommendations to strengthen the health system’s resiliency to climate change. Several climate-related hazards that affect population health in Madagascar are linked to changes in baseline temperatures and precipitation, and their impacts are expected to change in the near- and mid-terms. • Cyclones are the main climate-related hazard in the country: Madagascar experiences an average of 3–4 cyclones a year. With damaging winds of above 200 km/h, these cyclones affect mostly the coastal regions in the northern and eastern parts of the island country. More significantly, they are expected to increase in severity, especially in the 2070s. • Apart from cyclones, Madagascar is also impacted by storm-triggered rainfall, which increases the exposure to floods and landslides. The eastern coast, comprising elevated areas, tends to experience most of the landslides. • At the same time, the country has also been afflicted steadily by droughts over the past five years, with the southern region being the most impacted. It has been experiencing limited precipitation rainfall and the greatest number of consecutive dry days, which are projected to increase in the 2030s and the 2050s. • In addition, wildfires have been triggered by deforestation rates, increased temperatures, and a lack of rainfall. Since 1953, the country has lost around 44 percent of its forest due to anthro- pogenic activity. With a lack of rainfall, it is projected that wildfires may increase concomitantly. Changes in climate affect health risks in Madagascar. Notably, food security and nutrition, waterborne diseases, vector-borne diseases, air quality risks, and zoonotic diseases are sensitive to climatic patterns, as explained below: 1 • Nutrition risks: Stunting and malnutrition are major health challenges in Madagascar: 40 percent of the children in the country experience stunting, 8 percent suffer from wasting, and 23 percent are underweight. Around 1.6 million people are in need of humanitarian assistance — mostly those in the southern region due to the impact of droughts on crops and food availability. It is expected that climate change will worsen the situation by impacting agricultural production. • Waterborne diseases: The prevalence of diarrheal diseases in the country has remained at approximately 10 percent since 2003. In general, the lack of access to improved drinking water and improved sanitation facilities increases the vulnerability of the population, especially children, to waterborne diseases. Moreover, floods, landslides, and droughts can hinder the availability of safely managed water sources, thereby increasing the risks of waterborne diseases. • Vector-borne diseases: Changes in precipitation and temperature patterns are expanding vector’s spatio-temporal suitability. Notably, more than 25 million people (out of 28.9 million) is at high-risk of Malaria. It is projected that by 2070, this figure will increase to 46 million people as population grows, risk of Malaria will grow concomitantly. • Air quality risks: Indoor air pollution is a major concern in Madagascar. Changes in rainfall and temperatures, which alter cooking habits, lead to increased cooking inside the house, where 98 percent of the households use solid fuel for cooking (i.e. coal, charcoal) increasing risks for respiratory diseases. Ambient air pollution (AAP) due to wildfires and brick production also increases the risk of respiratory illnesses that are widely prevalent in the country. • Zoonotic diseases: Because Madagascar is a country characterized by high biodiversity, there is an increased risk of zoonotic diseases, such as plague, which is endemic in the country. With wildfires and deforestation rates changing the habitats of rodents, many are being driven to inhabited areas, thus increasing the risks of infection. In the face of climate-related hazards and health risks, Madagascar is developing policies and plans to strengthen mitigation and adaptation actions and increase its adaptive capacity. The government’s National Adaptation Action Plan for the Health Sector to Climate Change (PNASS by its French acronym) guides the efforts of the Ministry of Health (MoH) in addressing climate-re- lated shocks. The activities to be carried out to increase the health sector’s resilience to climate change are grouped into seven components: (1) risk and capacity assessment, (2) capacity building, (3) integrated monitoring of the environment and health, (4) response, (5) research, (6) monitoring and evaluation, along with (7) program coordination and management. However, the implementation of these activities is hindered by a lack of financing, limited capacities at the district and fokontany (commune)1 levels, a limited health workforce, and cross-sectoral collaboration challenges for health concerns such as food security and nutrition. 2 | Climate and Health Vulnerability Assessment: Madagascar Currently, the country is developing tools to enhance its information systems: climate and health bulletin and an early warning system using SMS services, building codes, and emergency response mechanisms. These efforts highlight the commitment of the country to improve its health system resiliency in the face of climate change. However, there are still additional priorities that need to be addressed. First, the country’s health workforce needs improved incentives to increase distribution to climate-vulnerable areas. Second, information systems are lacking in proposing specific actions and recommendations for the population to adopt. Third, contingency and emergency plans are lagging. Finally, the monitoring of the progress and enforcement of climate and health activities — such as the enforcement of building codes in water, sanitation, and hygiene (WASH) and health facilities — needs to be improved. Madagascar’s endeavor to achieve universal health coverage for its health system and increase its adaptive capacity to a changing climate has been primarily undermined by a lack of financing resources. The central MoH does not have a budget line for climate-related activities, including emergency preparedness and other adaptation measures; climate change work seems to be limited to its Environmental Health department. According to estimates by the PNASS, it would cost USD3.7 million to implement key strategies for the health sector to deal with climate change. However, the strategies and activities outlined in the Action Plan will depend on the financing of development partners for implementation. Moving forward, Madagascar needs to expand its climate and health strategic priorities by incor- porating preparedness mechanisms, enhancing its current efforts, improving the monitoring of its progress, strengthening communication between the district and fokontany levels, and promoting coordination with development partners to ensure the availability of financing sources for imple- menting its PNASS. 3 INTRODUCTION COUNTRY CONTEXT 1. Madagascar experienced modest economic growth of 4.4 percent in 2021 as the Covid-19 pandemic receded2. Nonetheless, the country’s economic and social development remains constrained by low economic growth, inadequate human capital infrastructure, and governance and institutional weakness. In 2021, the country reported a gross domestic product (GDP) of USD14.47 billion and a GDP per capita of USD500.50; with a Human Development Index of 0.501, it ranked 173 out of 191 countries.3 Economic growth averaged 3.5 percent from 2013 until the beginning of the COVID-19 pandemic in 2020. The ensuing recession was three times more severe than most of Sub-Saharan Africa, with its economy contracting by 7.1 percent. 2. Two factors had adversely impacted Mada- 3. Madagascar’s population has steadily gascar’s economy: (a) the COVID-19 pandemic increased since the mid-century. The and (b) its exposure to historic droughts population grew from slightly over 5 million and crop failure in the southern region. in 1960 to more than 28.9 million in 2021, The COVID-19 pandemic led to the closure reflecting an annual growth rate of 2.4 of the mining, tourism, transport, and service percent in 2021.6 As of 2021, there was sectors — key sources of the country’s GDP. an even proportion of women and men.7 Additionally, exposure to droughts, notably The population is relatively young: those in the southern region, has led to livestock aged 0–14 represented 39 percent of diseases and agricultural setbacks. This critical the total population, while those above context led to growing food insecurity, internal 65 years constituted only 3 percent.8 migration, and increased poverty that rose The country’s urban population has been from 69 percent in 1999 — the lowest point growing: the proportion increased from 11 over the last 30 years — to 81 percent in 2012 percent in 1960 to 39 percent in 2021. However, (measured by the poverty line of USD2.15/ 67 percent of the urban population lived in capita/day) and staying at 75 percent in 2022.4 slums, with the majority living in Antanana- Recent economic growth in 2021 was again rivo — the country’s capital and largest city.9 interrupted in 2022 by the adverse effect of the war in Ukraine on the European Union — 4. Madagascar’s location and distinctive Madagascar’s main trading partner, coupled topography make it vulnerable to climate-re- with an increase in fuel prices of 34 percent lated hazards. Madagascar is among the (as of July 2022). Nevertheless, modest most cyclone-prone countries in Africa, annual economic growth of more than 4 with an average of 3–4 cyclones yearly. percent is projected for both 2023 and 2024.5 Its cyclone season runs from November to March. Furthermore, intense rainfall caused 5 by strong storms and tropical cyclones also 6. Adaptation measures covering a 10-year affects the country, leading to significant period are detailed in Madagascar’s National and damaging floods. Shoreline erosion, Adaptation Plan (NAP) that was published caused by sea-level rises (SLRs), is also a in December 2021. The NAP has three main major problem for Madagascar’s coastal ports strategic axes: (a) strengthening governance and beaches. Finally, droughts are common and adaptation integration, (b) implementing in the south — the hottest and driest part of a priority sectoral action program, and (c) the island, with some areas receiving less financing adaptation to climate change. Priority than 400 millimeters (mm) of rainfall each sectors for the implementation of adaptation year, due to large-scale disruptions in the actions include the following: (a) agriculture, atmospheric circulation and exacerbated by farming, and fisheries; (b) water resources; (c) poor land use practices. public health; (d) biodiversity and forestry; (e) coastal zones; (f) the management of territory 5. Madagascar — one of the few countries in and infrastructure; (g) the management of the world that absorbs more carbon than climate-related risks and hazards; and (h) it emits — is committed to tackling climate habitats and new cities. The NAP outlines change. It signed the Paris Agreement of the two strategic public health priorities: (a) United Nations Framework Convention on improving the health sector’s capacity to Climate Change (UNFCCC) on April 22, 2016,10 address climate-related adverse effects and (b) which aims to limit the global mean temperature strengthening the population’s capacity to deal increase to well below 2°C compared with with climate and climate-related health risks.12 pre-industrial levels. Madagascar ratified its commitment and submitted nationally determined contributions (NDCs) to 7. The assessment incorporates subnational the UNFCCC on September 21, 2016.11 considerations for health-related climate The NDCs set out Madagascar’s commitment actions (see annex A for the methodology) and identified priority sectors for mitigation and with regard to its 22 regions (see Figure 1).13 adaptation strategies to reduce the country’s vulnerability to the adverse impacts of climate change. 6 | Climate and Health Vulnerability Assessment: Madagascar FIGURE 1. Administrative boundaries of Madagascar’s regions. COMOROS FRANCE MOZAMBIQUE Diana MOZAMBIQUE Sava CHANNEL Sofia Boeny Betsiboka Melaky Bongolava Itasy Vakinankaratra Menabe FRENCH SOUTHERN Amoron Imania AND ANTARCTIC LANDS (FR.) Haute Matsiatra Ihorombe Atsimo Andrefana INDIAN OCEAN Anosy Androy 0 200 400 Kilometers Source: World Bank’s Cartography Unit Introduction | 7 KEY MESSAGES Temperature → Temperatures have increased by 0.52°C since the 1960s. → Temperatures are projected to increase by 0.65–0.69°C during the 2030s in the south in Ihrombe and Atsimo Andrefana and by 1.3–1.5°C in the southeast in Atsimo Andrefana and Menabe. Precipitation → Mean precipitation at the national level has decreased by 59.38 millimeters (mm) over the last half-century, with the most substantial decreases occurring on the northern side of the eastern coast in the Analanjirofo region (-158.35 mm). → It is projected that precipitation will continue to decrease by 200 mm during the 2030s and 2050s, especially in the central areas of Alatora Mangoro and Boeny and in the northern regions of Sava and Diana. → Although Madagascar’s average precipitation levels are projected to decrease for the 2030s and the 2050s, intense precipitation patterns are expected to increase, especially during January and February. Intense rainfall is projected in the 2030s for Androka and Antanarativo as well as for the entire country in the 2050s except for the eastern and western coasts. Climate Hazards → Although temperatures are expected to increase in the 2030s and 2050s, projections show that the country will not experience extreme daytime heat conditions (>35°C). However, it will experience an increase in the number of tropical nights (>20°C), specifically in the regions around the central highlands. → Madagascar has one of the highest cyclone risks in the continent, with an average of 3–4 cyclones per year. Projections estimate intense cyclonic activity. Damaging cyclonic winds (>200 km/h) are the most common in the northern regions of the Tsaratanana Massif of Diana and Sava. → Intense rainfall events, along with forest loss, put the elevated areas of the eastern coast at high risk of landslide events. → Drought risk is high in Madagascar: the country has been steadily affected by droughts over the past five years. The regions of Betsiboka, the northern area of Analamanga, and the south in Androy are projected to have the greatest number of consecutive dry days during the 2030s and 2050s. → Madagascar also experiences frequent wildfires. Since 1953, the country has lost around 44 percent of its forest due to anthropogenic activity. The projected increase in the maximum number of consecutive dry days may increase wildfire risks. Wildfire intensity is expected in western areas of the country, particularly in Sofia. 8 | Climate and Health Vulnerability Assessment: Madagascar SECTION I. CLIMATOLOGY MADAGASCAR’S TOPOGRAPHY 8. Located in the Indian Ocean off the coast to the east of southern Africa and Mozambique, Madagascar is the fourth-largest island country in the world.14 The terrain comprises five topo-geographical areas: the east coast, the Tsaratanana Massif, the central highlands, the west coast, and the southwest region (see Figure 2). Madagascar has a complex topography: with central highlands surrounded by coastal lowlands, it is characterized by a variety of bioclimatic zones — each presenting distinctive human-environmental challenges. FIGURE 2. Madagascar’s topography. Source: Natural Earth, ASTER GDEM Version 3 9 OBSERVED AND PROJECTED and 9.68°C. Only slight variations exist between the average monthly temperatures during CLIMATOLOGY the warm and cool seasons. 9. Madagascar has two seasons: a hot, rainy-cy- clonic season from November to April and 11. Under the SSP3-7.0 scenario15, mean national a cooler, dry season from May to October. temperatures are expected to increase by According to the 1991–2020 observed data, 0.61°C (with a 10th and 90th percentile range precipitation values fall within the range of of 0.32–0.86, respectively) during the 2030s 102 mm from November to April, peaking and by 1.24°C (0.97–1.74) during the 2050s. at 312 mm in January, and decreasing to 88 The mean annual temperature nationwide mm in April, with the most rainfall resulting is expected to increase to 23.30°C (23.0– from the cyclonic season. Temperatures, 23.6°C) during 2020–2039 and to 23.93°C however, show minor variations — ranging (23.7–24.4°C) during 2040–2059. Projected from 23.9°C in November to a maximum of temperature changes will vary minimally by 24.9°C in February (the warmest month) and subnational unit and season; however, the decreasing to 23.7°C in April. From May to expected maximum temperatures will rise October, precipitation values are at the lowest, significantly during the spring months by the ranging from 32 mm in September to 51 mm mid-century (see Figure 3). in May. During this period, temperatures vary from 21.9°C in May to a low of 19.3°C in July (the coolest month). PRECIPITATION 12. National mean precipitation decreased by 59 mm from 1971 to 2020. Statistically TEMPERATURE significant (>95%) trends during the spring 10. Madagascar has been experiencing a general months of September, October, and November warming trend since the 1960s. Though (SON) showed decreased precipitation in the Madagascar’s mean temperature increased southwest region (-11.87 mm per decade in by 0.23°C per decade between 1971 and Atsimo Andrefana), the central highlands 2020, its maximum temperature rose by (-30.66 mm per decade in Vakinankaratra), and 0.31°C per decade within the same period. the savanna region in the interior of the west During the observed period of 1991–2020, coast (-14.21 mm per decade in Betsiboka). The March and May had the highest temperature summer months of December, January, and increase of 0.61°C. The hottest month occurred February (DJF) have consistently experienced in January: it ranged from an average maximum the greatest interannual precipitation variability of 31.26°C to a minimum of 23.61°C in Boeny across the island over the last half-century, on the coastal northwest, while Vakinankaratra with the wettest month being January and atop the central highlands had a range that the driest month varying between May and extended from a maximum of 25.83°C to a October by region and volume. minimum of 16.54°C. During the coolest month of July, the average maximum and minimum temperatures were 29.40°C and 17.79°C in the case of Boeny, while the corresponding temperatures in Vakinankaratra were 20.01°C 10 | Climate and Health Vulnerability Assessment: Madagascar FIGURE 3. Madagascar’s observed (1991–2020) mean annual temperature (°C) and projected anomalies, under SSP3-7.0, for 2020–2039 and 2040–2059. Source: World Bank’s Climate Change Knowledge Portal (CCKP) 13. National mean precipitation is expected to CLIMATE HAZARDS decrease by the end of the century, with a 14. Several climate-related hazards affecting high degree of uncertainty and significant population health in Madagascar are linked regional variations. Projected precipitation to changes in baseline temperatures and anomalies are projected to decline by a precipitation. The most common climate-re- median of -1.25 mm but with a wide range lated hazards affecting Madagascar are storms from -110.46 mm to 120.44 mm compared (cyclones), floods, landslides, droughts, with the 1995–2014 reference period. This wildfires, SLRs, and extreme tempera- trend is far more nuanced at the regional tures. The overall impacts of such events in levels during the wet summer months when Madagascar should not merely be attribut- all the regions receive roughly half of their able to changing environmental conditions; annual precipitation amounts. In the north, they are also compounded by anthropogenic the Diana region is projected to experience causes including rapid deforestation, mining, a decline in precipitation. Analamanga, in the urbanization, and inadequate housing. higher elevations, is forecasted to experience an increase in summer month precipitation compared with the reference period (see Figure 4). Climatology | 11 FIGURE 4. Observed (1991–2020) mean annual precipitation (mm) and projected anomalies, under SSP3-7.0, for 2020–2039 and 2040–2059. Source: World Bank’s CCKP STORMS percent).18 Back in 2011, it was estimated that the country experienced direct storm-related 15. Madagascar has one of the highest risks of losses of USD87 million on a yearly basis, cyclones on the continent — averaging 3–4 with most losses occurring at the household cyclones per year. Storms in Madagascar — levels.19 classified at a “high” hazard level by the World Bank Global Facility for Disaster Reduction By the end of the century, cyclone frequency 16. and Recovery (GFDRR) — constitute the most over the Indian Ocean is projected to damaging and frequent natural hazard in the decrease; however, its intensity is projected country,16 particularly on the east coast (see to increase. Climate change is expected to Figure 5). Between 1980 and 2020, storms interact with the risks of cyclones and extreme made up 63 percent of the country’s total weather events in complex ways, including the natural hazards. The 51 storms, which occurred possibility of generating increased windspeed during the 1991–2022 period, mostly during and precipitation intensity, which are currently the storm season of November to March, poorly understood. Global modeling of climate affected more than 12.5 million people and left change impacts on cyclone intensity and more than 2,000 dead.17 Moreover, storms also frequency points to a general trend of reduced generate significant losses and damages, with cyclone frequency but increased intensity and high-speed winds, on average, contributing frequency of the most extreme events. Specif- to over 68 percent, followed by storm surges ically, models suggest that storm intensity will (20 percent) and storm-related flooding (12 12 | Climate and Health Vulnerability Assessment: Madagascar FIGURE 5. 1980–2020 Cyclone paths and main populated places.20 increase by 46 percent and shift toward the FLOODS north of the country by 2100.21 Additionally, 17. Floods constitute 11 percent of the total hurricane return periods22 data acquired from natural hazards in the country, leading to the UN Office for Disaster Risk Reduction losses of lives and damages. In the past (UNDRR) — shows that over a 50-year return 30 years, more than 30 flood events have period, cyclonic winds would range from 105 occurred, which have killed more than 150 km/h in the southern region to 197 km/h in the people and affected almost 10 million. Flood northeastern areas — a spatial pattern that events commonly occur during the rainy season is replicated in all return periods (see Figure from November to March, when the country is 6). Winds above 200 km/h would result in prone to cyclonic activity, due to the intense the widespread destruction of infrastructure precipitation. Floods in the country have been and crops. classified by GFDRR as a high-level hazard: this means that a life-threatening flooding event will occur at least once every 10 years. In 2011, it was estimated that the country Climatology | 13 FIGURE 6. 50-year return period.23 experienced USD13 million in direct losses of nearly 50 mm in the Itasy region. By the from flooding yearly, with emergency costs for 2050s, most of the country will experience an flooding of approximately USD3.1 million per increase in 5-day cumulative precipitation,25 year24. Moreover, the construction of homes indicating intensifying rainfall events, with on hilltops and the build-up of waste in drains maximum values of 96.7 mm in the southern and culverts have further exacerbated the and northwestern regions (see Figure 7). With damages and vulnerability of communities intense precipitation over short periods, flash to floods, particularly in residential areas. flood events would be particularly common in urban areas where permeability is low and Madagascar’s average precipitation levels 18. in low-lying areas such as the west coast and are projected to decrease in the 2030s and the southern region, where intense rainfall 2050s; however, intense precipitation is is projected to increase. projected to increase, particularly in January. In Madagascar, in the 2030s, intense precip- itation is expected to increase in the central plains and southern areas, reaching a maximum 14 | Climate and Health Vulnerability Assessment: Madagascar FIGURE 7. Projections for the average largest 5-day cumulative precipitation (mm) for the 2030s and 2050s, under an SSP3-7.0 scenario. Source: World Bank’s CCKP LANDSLIDES the Diana region (see Figure 8). Under the SSP3-7.0 scenario, the population under the 19. Though most of the country is classified very high-risk level is expected to increase as having a low risk of landslides, with the from 10.6 to 15.7 million (see Table 1). southwestern areas having a very low risk, Madagascar’s increased intense precipitation for the 2030s and 2050s could further trigger landslides, particularly in high-slope areas with eroded soils. Very high-risk areas are mainly located along the east coast with its elevated areas, the region of Vakinankaratra, the highest point of the central highlands, and Climatology | 15 TABLE 1. Population exposed to landslides by risk level. 2020–2039 2040–2059 LANDSLIDE RISK LEVEL POPULATION PERCENTAGE POPULATION PERCENTAGE (IN MILLION) (IN MILLION) 1 10.6 30.3 15.7 30.3 2 17.6 50.3 26.1 50.2 3 5.7 16.3 8.5 16.4 4 1.1 3.1 1.6 3.1 Source: NASA – International Disaster Charter FIGURE 8. Rainfall-triggered landslide index. Source: NASA – International Disaster Charter 16 | Climate and Health Vulnerability Assessment: Madagascar DROUGHTS 21. Projected erratic rainfall patterns, extended dry seasons, and the lack of improved land 20. The risk of drought in Madagascar is high. use practices will exacerbate the effects Already, droughts have exerted a dramatic of droughts in the country. Based on the impact on the southern part of the country. Climate Change Knowledge Portal’s (CCKP) Over the past 30 years, there have been reports estimates, the annual Standardized Precip- of eight droughts in the country — leading to food itation Evapotranspiration Index (SPEI)28 for shortages and famine, which have affected more Madagascar are projected to be -1.9 and -3.7 than nine million people. In 2022 — the fourth for the 2030s and the 2050s, respectively. consecutive year of drought, the vegetation Furthermore, even when storms and floods are in the southern region, which was impacted expected to increase in intensity during the due to water scarcity, severely impacted the same periods, the dry season is expected to food system.26 Using the Normalized Difference be prolonged with an approximate 15 percent Vegetation Index (NDVI) — a quantitative method national decrease in monthly precipitation, for measuring the level of healthy vegetation particularly in July and October during the and a drought indicator,27 the analysis shows 2050s. The number of consecutive dry days that plants in the southern part of Madagascar is also projected to increase by 4.5 (to 142 have been more water-stressed than their maximum days with less than 1mm annual historical values. This is due to the reduction average) and by 7.4 (to 146 maximum days with of the water used for agricultural irrigation as less than 1mm annual average) in the 2030s a result of the lack of rainfall (see Figure 9). and the 2050s, respectively (see Figure 10). FIGURE 9. NDVI Anomaly from September 17, 2021 to September 16, 2022.29 Climatology | 17 FIGURE 10. Projections for consecutive dry days during the 2030s and 2050s, under the SSP3-7.0 scenario. Source: World Bank’s CCKP Most of these dry days are expected to occur WILDFIRES during the dry season (May to October). The 22. Madagascar also experiences regular regions of Androy in the south, Betsiboka, wildfires, which decreases air quality, and the and the northern area of Analamanga are risks may grow due to the projected increase projected to have the greatest number of in the maximum number of consecutive consecutive dry days (22 days) during the dry days. A key contributing factor to the 2030s and 2050s. By the 2050s, most regions country’s wildfires is deforestation. Since 1953, in the country are expected to have more than the country has lost 44 percent of its forests five consecutive dry days. Exceptions are (see Figure 11) — mostly due to anthropogenic some areas in Diana, Sofia, Sava, and Boeny fires used for agricultural land clearing (slash located along the northeastern coast: they and burn). Most of the forest cover loss has will have negative dry days (that is, increased occurred along the eastern coast, with the precipitation). secondary impact experienced along the western coast — particularly in the Diana and Menabe regions. 18 | Climate and Health Vulnerability Assessment: Madagascar FIGURE 11. Madagascar’s forest cover loss 2000–202130 and detected wildfires (red) in 2015.31 GFDRR classifies wildfires in Madagascar 23. Wildfires can be exacerbated by climate change as a high-level hazard: this means there is a through increased temperatures and reduced greater-than-50-percent change in weather rainfall, and the literature suggests that wildfire conditions that support wildfires (see Figure seasons may lengthen due to climate change. 12).32 From 2012 to 2019, satellites detected an Decreased precipitation patterns, increased average of 356,189 fires per year, amounting consecutive dry days, and high deforestation to 0.6 fires/km2 per year on average. Most of rates would increase wildfire frequency, thereby these fires occurred in the country’s western affecting human health and endangering biodi- and northwestern regions (see Figure 11). Areas versity. Although studies have not yet been near Toliara and Morondava have experienced published on predicting the impact of wildfires the highest density of fires in the country. In in Madagascar, projections on temperature fact, wildfires are prevalent in most regions of and precipitation indicate that they would the country, except for the central highlands enable wildfires.34 Projections of future climate and areas in the southern region.33 estimate an increase in the frequency of fire occurrences, an increase in the duration of the fire season, and the severity of the fire.35 Climatology | 19 FIGURE 12. Wildfire Hazard Intensity and Fire Weather Index. Source: GFDRR SEA-LEVEL RISES (SLRS) 1.3 mm/year between 1901 and 1971 and 1.9 mm/year during the 1971–2006 period. 24. Over the past century, the rate of SLRs has roughly tripled in response to global warming 25. Projections for SLRs are complex: while there of 0.8°C. SLRs pose a significant threat to is high confidence that extremes in sea level islands across the globe, including Madagascar. will increase, there is low confidence in the Historical sea-level data for Madagascar is region-specific projections on storm surges. limited, though some estimates state that SLR projections for Madagascar indicate an between 1994 and 2008, the sea level rose by increase of 34 cm (50th percentile) by 2059 (29 0.6 centimeters (cm) per year in Madagascar.36 cm and 43 cm for the 10th and 90th percentiles) As reported in the Sixth Assessment Report under the SSP3-7.0 scenario. of the Intergovernmental Panel on Climate Change (IPCC) in 2021,37 the mean global sea surface rose by 0.20 meters (m) between 1901 and 2018 — equivalent to an average SLR of 20 | Climate and Health Vulnerability Assessment: Madagascar EXTREME HEAT the summer months than Analanjirofo, the 26. Temperatures are projected to continue to majority of the hot days will increase during rise, though near- and mid-term projections the fall months in both cases (see Figure (2030s and 2050s) show that only coastal 13). In contrast, Analanjirofo will experience areas will experience extreme daytime an increase in tropical nights annually by a heat conditions, but most of the country median of 74.76 (29.72, 97.64) compared with will experience warmer nights. Upland Analamanga’s 21.08 (3.24, 35.07), mostly Analamanga will experience a mean increase during the summer months (see Figure 13). of 58.36 summer days annually (40.68, 86.13) In general, the total number of tropical nights compared with coastal Analanjirofo’s mean will decrease as one moves from the coast increase of 47.54 summer days annually (26.54, toward higher elevations, which means that 77.00) by 2040–2059. Though Analamanga’s the capital region will still act as a refuge for summer months will have a much greater evading the hottest nights that the coastal change in the number of hot days during regions will endure more frequently. TABLE 2. Population exposed to more than 1 day of extreme temperature by the 2030s and 2050s. DEPT, >1 2020–2039 PERCENTAGE 2040–2059 PERCENTAGE Number of Hot Days 4,643,000 13 13,604,500 25 Number of Tropical Nights 25,537,000 70 48,767,600 90 Total Projected Population (SSP3) 36,317,000   53,897,800   Source: World Bank’s CCKP FIGURE 13. Projected change in the number of hot days (>35°C) for 2020–2039 and 2040–2059 and projected change in the number of tropical nights (>20°C) for 2020–2039 and 2040–2059. Source:World Bank’s CCKP Climatology | 21 KEY MESSAGES Nutrition Risks: → Stunting and malnutrition are major climate-sensitive concerns in Madagascar: approximately 40 percent of children experience stunting, 8 percent suffer from wasting, and 23 percent are underweight. → More than 1.6 million people are food insecure and in need of humanitarian assistance, particularly in the regions of Androy, Anosy, and Atsimo Andrefana. → Poor agricultural practices, a lack of adequate hydro-agricultural infrastructure, and a dearth of education are the main drivers of malnutrition in the country. → Climate change has exerted a largely negative impact on rice production in Madagascar, partic- ularly due to severe droughts, leading to significantly below-average soil moisture conditions. → Changes in precipitation and temperature will affect fisheries and coastal communities where marine products are the main source of protein. Waterborne Diseases → Madagascar has reported a prevalence level of diarrhea of 8–10 percent among children since 2003. → Subnationally, diarrheal prevalence is highest in the Androy region at 16.2 percent, followed by Vatovavy Fitovinany (14.7 percent), Menabe (13.8 percent), and Antananarivo (13.3 percent). → Less than half of the households have access to improved drinking water sources (48 percent). → Fifty-three percent of the households are not using any methods for treating water before consumption. → Less than 35 percent of the households have improved sanitation facilities. → Areas with limited access to safely managed drinking services will likely experience greater vulnerability to waterborne diseases in the face of increased precipitation, floods, droughts, and storm events. 22 | Climate and Health Vulnerability Assessment: Madagascar Vector-Borne Diseases → Malaria is the main vector-borne disease in the country, with more than 25 million people (88 percent) at high risk. → Malaria transmission and vector reproduction are sensitive to seasonal changes in rainfall and temperatures, as well as extreme weather events. It is projected that by 2070, 46 million people will be at risk of malaria. Air Quality Health risks → According to the Air Quality Index (AQI), which measures the concentration of Particulate Matter (PM) 2.5 and PM1.0, Madagascar had an AQI value of 77 in 2023. Though it is considered to be moderate, it is still 2.7 times above the World Health Organization’s (WHO) recommended guidelines. Ambient air pollution (AAP) is notably affected by wildfires and brick production and burning, which tend to increase during the dry season. → Indoor air pollution is a major concern in Madagascar: two out of five households (42 percent) cook indoors and 98 percent use solid fuel for cooking. → Both AAP and household air pollution (HAP) increase risks for acute respiratory infections — the top morbidities affecting children. Zoonoses → Plague is endemic in Madagascar. Wildfires have increased due to conducive temperature and precipitation conditions, compounded by deforestation rates. These conditions have altered the natural habitats of rodents and driven them to inhabited areas, thus increasing the risk of zoonotic infections. In the context of high biodiversity, such as in Madagascar, coupled with decreasing natural habitats due to wildfires or droughts, increases interaction between animals and humans, therefore increasing risks for zoonotic diseases. Climatology | 23 SECTION II. CLIMATE-RELATED HEALTH RISKS 27. Madagascar suffers from significant health challenges, particularly commu- nicable, maternal, neonatal, and nutritional diseases that have been further exacerbated by the socioeconomic environment of the country. The three main contributors to the country’s burden of disease had been constant between 1990 and 2019: respiratory infections and tuberculosis (TB), enteric infections, and maternal and neonatal diseases.38 The burden of disease in Madagascar is affected by socioeconomic determinants of health such as income, environmental factors, access to basic services, and urbanization. Although the healthcare system has improved as reflected in the increase in the life expectancy of males from 56 to 63 years and of females from 58 to 68 years,39 it has been hit hard by the COVID-19 pandemic. To date, the country has administered less than 2.5 million doses of the Covid-19 vaccine and it is projected that more than two million people could fall below the poverty line due to the economic crisis caused by the pandemic.40 28. The current burden of disease could be 29. Health outcomes resulting from the increased exacerbated due to climate change, with intensity and frequency of climate hazards climate-related health risks not evenly induced by climate change exhibit strong distributed across the population, leaving spatial variations, putting some groups at some groups more exposed and vulnerable higher risks than others. In Antananarivo, than others. The factors affecting a popula- those living in informal urban settlements tion’s vulnerability to climate are often similar are at a high risk of mortality due to flooding to those that affect health more broadly.41 and landslide events during the cyclonic However, climate change may exacerbate months. In the southern regions such as the health inequalities, especially among certain Ambovombe-Androy district,42 children are vulnerable population groups including the at high risk of malnourishment and enteric poor, rural populations, those living in informal diseases due to the impact of the droughts urban settlements, women and young children, on edible crops and access to safe water. the elderly, those living with pre-existing conditions and disabilities, and displaced 30. Madagascar’s CHVA assesses five climate-re- populations. Notably, rural communities, lated health risk categories: (a) nutrition, (b) children under five years old, women, and poor waterborne disease risks, (c) vector-borne communities in Madagascar are already at high disease risks, (d) air quality health risks, risk. Therefore, investments in adaptation and and (e) zoonotic diseases. Each category mitigation measures must carefully consider is assessed in terms of current and future groups who would directly benefit from or risks, with considerations for national and may be disadvantaged by adopted measures. subnational peculiarities wherever possible. 25 NUTRITION RISKS  government’s estimates in 2021, approxi- mately 40 percent of children experience Weather and climate are the foundational 31. stunting, 8 percent struggle from wasting, drivers of healthy and sustainable diets. The and 23 percent are underweight.44 Out of the mechanisms by which climate change affects 22 regions in Madagascar, all but two have a nutrition via the food system are profound. very high prevalence of stunting — defined Specifically, they can exert acute and chronic by WHO as greater than 30 percent.45 Of effects on agricultural production, storage, these regions, the highest levels of stunting processing, distribution, and consumption. are found in Vakinankaratra (60 percent), Notably, global food production can be affected Amoron’i Amoron’i Mania (55 percent), Haute via changes in crop yield, changes in biomass Matsiatra (54 percent), and Bongolava (52 food composition and nutritional quality, and percent). It is also important to point out that via the disruptions of food supply chains and the regions with high prevalence of stunting transportation. Furthermore, short-term shocks are agriculturally productive regions, therefore (for example, natural disasters) can drastically highlighting that the malnutrition challenge reduce yields or redefine the spatio-temporal is also linked to feeding practices and social patterns of crop suitability. dynamics, which are beyond the scope of this assessment. 32. Climate-related and natural hazards have intersected with human factors to exacerbate In terms of malnutrition in Madagascar, the nutrition risks for the population. The United Nations’ (UN) estimate is nearly 50 Malagasy government has identified natural percent.46 A 2021 assessment by the United hazards (including climate-related), poor Nations Children’s Fund (UNICEF) found agricultural practices, a lack of adequate that half a million children under the age hydro-agricultural infrastructure, and a dearth of five are expected to be malnourished in of education as the main drivers of malnutrition Madagascar (with over 20 percent severely in the country. In the southern region, which malnourished); this is four times the number has been experiencing prolonged droughts, of malnourished children in 2020.47,48 The around 80 percent of the population depends consequences of malnutrition, especially in on rainfed agriculture, increasing the risks of children, are far-reaching, with profound impli- adverse nutritional outcomes. Overall, extreme cations for human and physical capital, which weather events, coupled with vulnerabilities can constrain a country’s overall economic in generating agricultural outputs and severe growth and development. multidimensional poverty, exacerbate risks for Madagascar’s food supply chain.43 While 34. Regarding food insecurity, 1.64 million people this assessment does not analyze the stunting are food insecure and need humanitarian percentage attributable to climate change, it assistance. Notably, the southern part of the does examine climate and nutrition linkages country — particularly the regions of Androy, in Madagascar through a food security lens, Anosy, and Atsimo Andrefana49,50 — has been focusing on the weather and climate impacts chronically food insecure since the 1980s on agricultural and fishing productivity. (see Fig 14).51 The “lean season” or kere (meaning “hunger”) typically arrives around 33. Stunting and malnutrition are major health September and October in the southernmost challenges in Madagascar. Based on the 26 | Climate and Health Vulnerability Assessment: Madagascar FIGURE 14. Food Insecurity in Madagascar from February to September 2022. Source: FEWS Net region of Madagascar, with minimal rains insecurity at the household levels. Quantity — exerting a devastating impact on the poorest both in terms of food availability and calories communities, as it dries up crop fields and the consumed — and the quality of food products grasslands that feed cattle. As consecutive dry play a considerable role in nutrition outcomes. days are projected to increase in the 2030s Additional drivers of malnutrition include poor and 2050s, the potential for food insecurity feeding practices and infectious diseases such to increase will also be likely. as diarrhea. 35. The impact of climate and climate change on 36. Impacts on cereal crop production, particu- Madagascar’s food insecurity is exacerbated larly rice, will be an especially critical climate by the significant dependence of the country risk factor for nutrition in Madagascar. The and the population on agriculture, forestry, main stable crop in Madagascar is rice, followed and fishing. The value added by agriculture, by maize, cassava, and sweet potato, which forestry, and fishing to the country’s national also play large roles, while pulses and major GDP is 24.8 percent.52 Moreover, it is estimated cash crops such as vanilla, sugar, coffee, that approximately 90 percent of Madagascar’s cocoa, cloves, and pepper constitute important population depends on agriculture, livestock, sources of plant protein.54 Research and docu- and fishing activities.53 Therefore, production mentation from previous years suggest that shortfalls are very likely to aggravate food climate change has had a largely negative Climate-related health risks | 27 impact on rice production in Madagascar, Hawai’i and the civil society organization Blue particularly due to severe droughts leading Ventures.59 to significantly below-average soil moisture conditions, which can impact root and tuber However, rising sea temperatures and acidifica- crop production.55,56 In the highlands, cold tion, which influence the abundance, migratory stress and blast disease — a fungus commonly patterns, and mortality rates of marine life, known as rice rotten neck — have reduced rice have led to adverse health, economic, and yields, thus adding to the challenges of poor social consequences for people dependent soil fertility, droughts, and weed infestation on fisheries and aquaculture.60 In 2016, the in the lowlands where the majority of rice decline in rainfall due to the El Niño weather production takes place in Madagascar.57 patterns resulted in a 95 percent loss in Changing temperature and precipitation harvests,61 which consequently led to approx- baselines, coupled with climate shocks (for imately 30–60 percent of the population to example, droughts and floods), have affected become food insecure, including 35,000 agricultural production and yield. This has children who were moderately malnourished not only impacted price and profit but also and 12,000 who were severely malnourished.62 personal consumption at the household levels. In 2021, droughts connected with climate change contributed to severe food insecurity 37. Climate change effects on food security and in southern Madagascar, plunging 1.1 million agriculture are interlinked with the effects people into food insecurity and doubling the on the jobs and income of smallholders, number of malnourished children in the region as trade from agriculture and livestock compared with 2020.63 constitute the largest share of disposable income. Overall food production is expected 39. Cyclones and tropical storms, projected to to be lower than normal by 63 percent due worsen due to the severe, prolonged droughts to weather, pests, and elevated costs from during the dry season and intense rainfall agriculture equipment or supplies.58 Specifi- patterns during the wet season,64 as well cally, the lack of rain and droughts are among as pests, have been destroying crops and the top shocks impacting households in the infrastructure across Madagascar. Notably, south of Madagascar, leading to crop losses tropical storms Ana and Dumako have affected due to pests and the concomitant rises in Anamalanga, Antananarivo, and the vanil- food prices. Labor productivity has also been la-growing areas in the north, while cyclones affected due to heat exposure. Batsirai and Emnati have struck the south- eastern areas. Madagascar’s agricultural 38. Changes in precipitation and temperature production has also been impacted by locust are projected to affect fishing and food plagues and other crop pests such as the fall production in coastal communities, where armyworm,65 which can be climate-sensitive: marine products are an important source of they occur in tandem with climate-related protein. In southwest Madagascar, small-scale hazards such as droughts.66 fisheries employ 87 percent of the adult population and provide the sole protein source 40. To counter the adverse agricultural effects, for 99 percent of households, according to farming techniques will need to be adapted in a study by researchers at the University of order to prevent food insecurity. To that end, 28 | Climate and Health Vulnerability Assessment: Madagascar common adaptation measures — irrigation, of 9 percent of diarrhea among five-year-old the application of fertilizers to reduce plant children and those younger. susceptibility, the adoption of drought-re- sistant and nutritious short-cycled crop 42. Just as significantly, not all children suffering varieties (such as sorghum), farmer capaci- from diarrhea are receiving the medical ty-building around climate-smart agroecological treatment they need. According to the DHS, techniques, and marine conservation efforts 41 percent were taken to a health facility, for sustainable fisheries management — have while 20 percent did not seek treatment. come under consideration as a response to Among the children who had diarrhea and climate change.67,68 Without adaptation, sought medical attention, only 28 percent climate change is likely to substantially attended to a health facility for treatment. aggravate food insecurity and compromise The mother’s level of education also plays nutrition outcomes in Madagascar. While an important role in whether treatment is there is uncertainty on the precise number sought: approximately 39 percent of those of individuals in Madagascar who will be at who had no education sought treatment for risk of food insecurity because of climate their children in contrast to 49 percent for variability, recent findings suggest that globally, those who had secondary education. the population at risk could increase by up to 30 percent as a result of climate change 43. Subnationally, diarrheal prevalence is highest between 2010 and 2050.69 in the Androy region at 16.2 percent, followed by Vatovavy Fitovinany (14.7 percent), Menabe (13.8 percent), and Antananarivo WATERBORNE DISEASE RISKS  (13.3 percent). The regions of Atsinanana, Alaotra Mangoro, and Bongolava have the Water quality, which is in part affected by 41. lowest prevalence levels — 5.3 percent, 5.4 climate-related hazards such as floods or percent, and 5.7 percent, respectively.71 The landslides, has been associated with an regions with the higher levels of diarrheal increased incidence of waterborne diseases prevalence are mostly lacking in improved in Madagascar. Current drivers of waterborne water sources and manifest higher rates of diseases throughout the country are attribut- open defecation. This is seen in the case of able to many factors including water sources, Androy: the proportion of improved water the quality and quantity of drinking water, sources is just 36 percent, non-improved toilet sanitation facilities, and hygiene practices — facilities constitute 41 percent, and the open each of which can be negatively affected by defecation rate is 49 percent. climate-related factors, in particular, floods and landslides. Madagascar is faced with a 44. However, in other regions, the percentages significant burden of waterborne diseases of diarrhea, water sources, and sanitary such as diarrhea, dysentery, cholera, food facilities at the subnational levels offer a poisoning, and parasitic infections, partic- mixed picture. For example, although Anta- ularly affecting children under five years of nanarivo has high proportions of improved age. Specifically, the prevalence of diarrhea in water sources and sanitation facilities, as well Madagascar among children has been 8–10 as a relatively low rate of open defecation, percent since 2003.70 In 2021, the Demographic diarrhea is still highly prevalent. Conversely, Health Survey (DHS) reported a prevalence Climate-related health risks | 29 even though Betsiboka has low percentages relative risk of diarrhea by 10 percent by the of improved water sources and sanitation 2030s.73 In Madagascar, changes in precip- facilities, along with a high rate of open itation and temperature patterns are likely defecation, the prevalence of diarrhea is to cause the re-emergence of water-related lower than that of Antananarivo. diseases, as floods in urban and rural areas result in the mixing of waste and sewage 45. Water sources, waste, and sanitation services with fresh water, thus enabling water-related can be impacted by climate-related hazards, disease outbreaks.74 Furthermore, more intense thus increasing waterborne and water-re- droughts, particularly in the southern region, lated diseases in the country. Less than half would reduce water quality, as the lack of fresh of the households have access to improved rain would prevent the flushing of stagnant drinking water sources (48 percent); moreover, waters.75 The remaining water sources would 86 percent of these households are in the become over-used, thus increasing the risk urban areas. Access to drinking water in of diseases being spread from person to urban areas is primarily through public taps person. Informal settlements and poor water or standpipes (38 percent) and tap water in sanitation and hygiene (WASH) infrastructure the dwelling yard or plot (23 percent). On would multiply the risk of climate-sensitive the other hand, approximately 27 percent waterborne diseases. Further research use surface water and 22 percent rely on is needed to understand the direct and unprotected spring sources. In addition to indirect effects of climate-related hazards challenges with access to safe drinking water, on waterborne diseases in the context of treatment practices are not widespread in the Madagascar. Malagasy population: 53 percent of households do not treat their water before consumption. VECTOR-BORNE DISEASES Apart from the lack of access to safe water 47. Vector-borne diseases are expanding sources, limited sanitation and hygiene their spatio-temporal suitability due to practices also exacerbate the risks of diarrhea changes in precipitation and temperature and other water-related diseases. Less than 35 patterns.76 Diseases such as dengue, chiku- percent of the households have an improved ngunya,77 malaria, and the Rift Valley Fever,78 sanitation facility, 22 percent have limited which are currently present in Madagascar, access to sanitation services, and 32 percent are susceptible to climate change. While engage in open defecation. Coupled with a neglected tropical diseases, such as dengue lack of sanitation access, approximately 70 and chikungunya, represent 0.1 percent of percent of the households have inadequate total disability-adjusted life years (DALYs) in handwashing facilities — lacking in soap and/ the country, malaria contributes to almost 4 or water.72 percent.79 This assessment focuses on malaria 46. While the climate-related hazards’ impact due to its burden of disease and data avail- on waterborne diseases is complex, studies ability on the impact of climate on malaria’s on different regions in the world, including prevalence and vector suitability. northern and southern Africa, estimate that warming temperatures would increase the 30 | Climate and Health Vulnerability Assessment: Madagascar MALARIA   to stagnate and the warm temperature enables vector reproduction.84 48. Malaria is the main vector-borne disease in the country, with more than 25 million 50. Without adaptation measures, ongoing people (88 percent of the population) at high climate change is likely to increase malaria risk. In Madagascar, malaria is transmitted by prevalence, especially along the highlands the Anopheles funestus, Anopheles gambiae, in Madagascar.85 Changes in temperature, and Anopheles arabiensis mosquitoes;80 precipitation, and humidity affect the life cycle further research has also found the presence of vectors and their spatio-temporal suitability. of Anapheles coustani.81 Subnationally, the Projections for the short and medium terms in Anosy region has the highest prevalence at Madagascar are going to be different at the 32 percent, followed by Atsimo Atsinanana subnational levels. Currently in the highlands (27 percent) and Ilhorombe (21 percent). Each (including Antananarivo), which have cooler year, 1–2 million people are diagnosed with temperatures, there is a low risk of malaria due malaria: there is an increase in the incidence to the low temperature decreasing mosquito of the disease from 31 percent in 2017 to 70 suitability.86 However, rising temperatures and percent in 2020. By 2020, approximately 674 changing precipitation patterns are expected deaths were related to malaria, affecting mostly to increase suitable areas for the Anopheles children 5 years old or younger. Children under mosquitoes at higher altitudes.87 Furthermore, 5 years old and pregnant women are key research estimates that by 2070 and under vulnerable population segments, as malaria the high-emissions scenario, about 46 million infection can cause maternal anemia, fetal people will be at risk of malaria due to optimal loss, premature delivery, intrauterine growth weather conditions for mosquito reproduc- retardation, and the delivery of low birth-weight tion.88 Moreover, toward the end of the century, infants.82 To deal with the high prevalence it is estimated that an average increase of of malaria, approximately 69 percent of an additional 1.6 months of vector suitability the households have at least one insecti- in the highland areas (altitude >1,000 m) in cide-treated nets (ITN). the African region when compared with the 1970–1999 period.89 49. Malaria transmission and vector reproduction are sensitive to seasonal changes in rainfall and temperatures, as well as extreme weather events.83 Agricultural communities are notably AIR QUALITY HEALTH RISKS at risk of malaria, as flooded rice farming Ambient air pollution (AAP) and household air 51. increases the exposure of the population pollution (HAP), which pose a health risk and to suitable areas for vector reproduction. exacerbate respiratory illnesses, are highly Moreover, ponds created by humans are prevalent in the country. Exposure to urban also a malaria transmission source. Between air pollution, as well as smoke from indoor January 2008 and 2012, a study highlighted a cooking, wildfires, and dust storms, can affect covariation between rainfall and temperature health by contributing to the development and vector suitability — highlighting a trans- of severe chronic health conditions. This mission peak of March–April, right after the is due to the inhalation of fine particulate peak of the raining season when water tends matter at 2.5 micrometers or smaller (PM2.5) and other toxins that can enter the deeper Climate-related health risks | 31 sections of the lungs and bloodstream. phonologies, and while this is not well-doc- People who are particularly vulnerable to umented in Madagascar, recent research particulate air pollutants include those with in other countries has shown that poor air asthma and chronic obstructive pulmonary quality is significantly associated with the diseases (COPDs), children, and those with risk of autoimmune diseases.90,91 Predicted close exposure to the sources of air pollution air quality deterioration is linked to the risk such as women who cook with biomass and of autoimmune diseases such as connective firefighters who combat wildfires. tissue disorders, inflammatory bowel diseases, and rheumatoid arthritis. 52. The Air Quality Index 2023 shows a moderate concentration of PM2.5 and PM1.0 in 53. Indoor air pollution is a major concern in Madagascar (AQI=77), which is 2.7 times Madagascar. Two out of five households (42 above WHO’s recommended guidelines. percent) cook indoors and 98 percent of Antananarivo, the capital, has the highest the households use solid fuel — made up of exposure to outdoor air pollution with a PM2.5 coal/lignite, charcoal, straw/branches/grass, concentration of 27 micrograms per cubic or agricultural residues — for cooking. In meter (µg/m³). This is in contrast with WHO’s rural areas, only 2 percent of the households recommended 15 µg/m³ as the mean threshold use non-polluting fuels such as electricity, oil, PM2.5 concentration for a 24-hour period. Air natural gas, or biogas — a figure that rises to quality notably deteriorates during the rainy 6 percent in urban areas. Approximately 71 season. In urban areas such as Antananarivo, percent of the households in urban areas use increased temperatures can result in “heat charcoal for cooking, while the rural proportion island” effects with an increased risk of smog is around 17 percent. Rural households (77 formation where the air containing increased percent) also tend to use wood for cooking. levels of ozone and PM stagnates, thereby impacting health acutely and chronically Exposure to indoor air pollution can also be through damages to the cardiovascular and affected by changes in precipitation patterns respiratory systems. due to climate change. Exposure to biomass air pollution can change during the storm/cyclonic Ambient air quality is also impacted by smoke months in Madagascar — mainly January and from wildfires as well as brick production February. During these months, cooking must and burning — both of which typically occur be done indoors in rooms, which may have during the drier months of May to October in poor or no ventilation. Further, during heavy Madagascar. Brick production constitutes an rains, there is limited access to dry wood for additional source of income. Droughts and fuel, and wet firewood is not only harder to increased temperatures can increase the burn but also produces more smoke, thereby frequency, intensity, geographic proximity, and increasing air pollution. Although there are no length of the wildfire season in the country, projections on indoor air pollution exposure worsening wildfire-induced air pollution. due to climate change, it is essential to better understand the exposure pathway and the Additionally, increasing temperatures and impact of climate change, due to the high atmospheric carbon dioxide can extend the prevalence of respiratory illnesses in the allergy season due to its impact on plant country.92 32 | Climate and Health Vulnerability Assessment: Madagascar ZOONOSES 54. Madagascar is among the countries with the highest levels of biodiversity, thus increasing the interactions between humans and animals and the risks of zoonotic diseases such as plague, which is endemic in Madagascar. In particular, the country has experienced small and isolated outbreaks of primarily bubonic plague. Climate change has exacerbated the outbreaks of plague by creating suitable conditions for vectors of the infection to thrive. For instance, in 2019, plague was reported in parts of the country not previously impacted by the disease; this is likely linked to climatic factors underpinning the change in trans- mission patterns.93 Similarly, Madagascar has been experiencing the rapid spread of pneumonic plague due to the emergence of optimal climatic conditions that enable rat populations — the vectors of the infection — to thrive.94 In 2017, Madagascar experienced a record-level pneumonic plague outbreak that afflicted two densely populated cities including the capital, Antananarivo, resulting in 2,417 reported cases and 209 deaths, with considerable health and socioeconomic consequences.95 The increase in wildfires due to adequate temperature and precipitation conditions, coupled with deforestation rates, has also altered the rodents’ natural habitats and driven them to inhabited areas, thereby increasing the risks of zoonotic infections. Given the context of high biodiversity and decreasing natural habitats leading to increased interaction between animals and humans, zoonotic diseases will continue to be a critical risk for the country.96,97 In August 2021, a new surge of plague cases was reported. Climate-related health risks | 33 SECTION III. ADAPTIVE CAPACITY OF THE HEALTH SYSTEM LEADERSHIP AND GOVERNANCE 55. Aware of the current and potential negative impacts of climate change on health and its health system, the Government of Madagascar has been actively devel- oping policies and plans to support mitigation and adaptation actions. Among the sector policies and plans relevant to climate change and health, there is a special emphasis on capacity building and information systems. These documents provide the overarching national policy, mostly focusing on adaptation. Documents include the National Adaptation Plan (NAP), the National Adaptation Action Plan for the Health Sector to Climate Change (originally Plan D’Action National D’Adaptation Du Secteur Santé Au Changement Climatique à Madagascar or PNASS), the Strategic Plan for Climate Change, Nationally Determined Contributions (NDCs), and the Communica- tions to the United Nations Framework Convention on Climate Change (UNFCCC). TABLE 3. Key policy documents relevant to climate change and health. AGENCY POLICY DOCUMENT National Adaptation Action Plan for the Health Sector to Climate Change (2016) National Health Security 2020–2024 National Malaria Control Policy (reviewed in 2020) Ministry of Health (MoH) National Action Plan for Nutrition 2017–2021 National Policy for Health and Environment Strategic Plan for Adaptation to Climate Change in the Health Sector Inte- grating the Transparency of the Paris Agreement (2021) Third Communication to UNFCCC National Bureau of Climate National Determined Contributions (NDCs) — 2016 Change Coordination (NBCC) National Adaptation Plan Contingency Plan on Cyclones and Floods 2019–2020 Ministry of Interior National Risk and Disaster Management Strategy 2016–2020 Source: Elaborated by the World Bank Adaptive Capacity of the Health System | 35 56. The PNASS aims to strengthen the technical, The monitoring of the implementation of institutional, and organizational capacities strategies and activities of each ministry is of the health sector in the face of climate also lagging. change. The activities to be carried out to increase the health sector’s resilience to 58. MoH’s Environmental Health Department is climate change are grouped under seven in charge of climate change and health, and components: (a) risk and capacity assessment, it maintains engagement and coordination (b) capacity building, (c) integrated monitoring up to the regional levels. In executing its of the environment and health, (d) response, responsibility of implementing the PNASS, the (e) research, (f) monitoring and evaluation, and Environmental Health Department has focused (g) program coordination and management. mostly on implementing activities related to However, most of the activities being capacity building, information systems, and implemented are related to surveillance emergency response. For example, the and the integration of information systems; department recently conducted training they are dependent on external financing sessions for 33 focal points that are aimed mechanisms. Activities focusing on prepared- at providing technical support for developing ness and climate-resiliency98 systems are not subnational action plans for climate change and included in the Action Plan, while performance health. However, there is limited integration and progress monitoring is lagging. of the climate adaptation activities in other departments within MoH, thus constraining the integration of these activities into the health AUTHORITY AND ACCOUNTABILITY system. Other activities being coordinated from 57. The NBCC is the main government agency the Environmental Health Department, include charged with developing the key policy the development of early warning systems guidelines and promoting efforts to integrate via SMS, and the mobilization of key public climate change into the policies and programs and private stakeholders for emergencies, of other ministries such as the Ministry of notably for nutrition programs. Health (MoH). The NBCC focuses mostly on the elaboration of the overarching national 59. Implementation challenges can mostly be documents on climate change adaptation attributed to the limited budgets being and mitigation. It has developed the National allocated to the Action Plan and the lack of Adaptation Plan, the NDCs, and the commu- human resource capacities at the district and nications to the UNFCCC, and provided local levels. For example, financial support and different ministries with technical support capacities for technical guidance on emergency on sector-specific strategies. However, the response and preparedness at the local levels, Bureau lacks a monitoring and performance as well as for the development of contingency system to track the progress of the imple- plans in case of extreme weather events, are mentation of climate-related strategies by the limited. Even for strategies currently being different ministries. Moreover, it has neither implemented, monitoring mechanisms for the enforcement capacity and budget lines overseeing the use of resources are absent. to allocate resources for implementation nor In addition, enforcement mechanisms and the systems in place to ensure the adoption budgets to ensure that the regional or local of the NAP or other key policy documents. levels carry out the development of action 36 | Climate and Health Vulnerability Assessment: Madagascar plans or implement any other climate-related Approach on Improving Nutrition Outcomes efforts are limited; thus, implementation is by the World Bank. left at their discretion. 61. The effectiveness of cross-sectoral coor- dination and the level of participation has CROSS-SECTORAL COORDINATION been curtailed by the lack of clear roles and 60. There is cross-sectoral collaboration between limited budgets for furthering collaborative ministries such as WASH, nutrition, health, work frameworks for climate and health. and meteorologic services though it is incon- Monitoring and accountability systems to sistent across the sectors. An example of ensure cross-sectoral implementation are collaboration is the one between MoH and the limited, thus undermining the possibilities Ministry of Water Hygiene and Sanitation to of improving a collaborative response to formulate a Master Sanitation Plan for strength- climate-related health challenges. ening water and sanitation infrastructures in the more populous cities where water tends to be more polluted than in other locations. HEALTH WORKFORCE They are also focusing on specific plans for the 62. Madagascar’s health workforce faces southern and eastern regions, as the latter’s numerous challenges including insufficient frequent exposures to climate-related hazards staffing levels, urban-rural maldistribu- make them key priorities for the country. tion, the lack of a proper skill mix, limited educational access, poor absorption capacity, In the case of the collaboration between and rural retention issues. Overall, in health MoH and the Department of Meteorological facilities, there are only 1.99 doctors available Services, this has mostly focused on data per 10,000 inhabitants and 2.98 nursing and collection and information systems, such as midwifery personnel99 per 10,000 inhabitants; the development of the climate and health this is well below the recommended WHO bulletin. Regarding nutrition, there are collab- standard of 44.5 health workers per 10,000 oration mechanisms with other sectors such people.100 Furthermore, many primary health as Agriculture and the Department of Mete- care (PHC) facilities are not headed by doctors orological Services. However, some sectors, who follow the health sector’s regulations. A such as Education, are not engaged in food small-scale survey conducted by the World security and nutritional efforts (as in incorpo- Bank in 2020 found that 75 percent of the rating educational programs for healthy diets surveyed PHC heads were not medical doctors and good agricultural practices in schools) due but nurses, midwives, or volunteers, who were to limited budgets. not formally part of Madagascar’s public health service. Furthermore, many doctors change Overall, food security and nutrition risks have between health facilities frequently. been highly projectized, which has hindered large-scale cross-sectoral and multi-stake- Moreover, current existing gaps in staffing holder collaboration. However, current efforts positions are mostly in rural areas, thus are in place to address the situation and increasing the vulnerability of rural improve coordination, such as the upcoming communities. The skill mix is also maldis- Phase 2 of the Multi-Phase Programmatic tributed, with only 28 percent of all doctors Adaptive Capacity of the Health System | 37 operating in rural areas, where 79 percent HEALTH INFORMATION SYSTEMS of the population lives.101 Furthermore, no 66. Integration of climate data with climate-sensi- incentive programs have been identified to tive diseases is done through the surveillance shift the distribution to rural areas. system by the Environmental Health 63. Madagascar’s health workforce has limited Department within MoH, in collaboration knowledge, technical capacity, and resources with the Department of Meteorological to prevent and manage current and future Services and the German International climate-related health risks. Yet, a systematic Cooperation Office (GIZ). However, the use approach to developing the capacity of the of this data seems to be underutilized, as it health workforce to integrate climate change has not been incorporated into actionable with emergency preparedness and response is plans at the national, regional, district, or absent. Notably, medical education is focused community levels. The use of data is limited on the clinical aspect while technical training to the production of the climate and health on public health is limited — a deficit that is bulletin that serves as an early warning further compounded by the lack of prioritiza- system. The bulletin provides monthly mean tion of climate change in the medical school’s temperature and precipitation forecasts and curricula. a list of diseases sensitive to those weather conditions at the subnational levels (regions). 64. Healthcare personnel are also exposed to Weather data on the monthly temperature and at risk of climate-related hazards and and the forecasted precipitation in average extreme weather events. This can further millimeters are provided by the Department of constrain how the health system is able to Meteorological Services. The list of diseases respond to climate shocks. Further research includes malaria, diarrhea, malnutrition, acute is thus required to analyze the geographic respiratory infections, intoxication from marine distribution of healthcare personnel and their animals, and plague, which coincide with the exposure to climate-related hazards. climate-related health risks previously analyzed in this CHVA (see Section III). 65. Promising examples of education and training in climate-related health risks have Besides providing the data, the Department of been identified. In 2016–2017, the midwifery Meteorological Services provides training and curriculum was revised with the inclusion equipment to focal points at MoH so that the of a module on public health highlighting latter can access the data and use it to enhance climate-related health risks. As mentioned their climate-sensitive disease preparedness. earlier, 33 focal points at the district level However, there are no mechanisms to ensure on climate change and health were trained that the climate data is being used and incor- by the Environmental Health Department to porated into the decision-making process for develop capacities for formulating detailed preparedness and response to climate-related action plans that are targeted at climate-re- events at MoH. lated health risks at the district level. Since 2009, a real-time service platform 67. via mobile text message (SMS) provided through AirTel — the main mobile carrier in the country — has been implemented as an early 38 | Climate and Health Vulnerability Assessment: Madagascar warning system by MoH, the Department humidity, and precipitation through the of Meteorological Services, and Viamo — a technical support and funding of the World private consulting firm. Airtel provides the Meteorological Organization (WMO), the 3-2-1 SMS service, which provides information National Oceanic and Atmospheric Admin- on climate and health risks free of charge to istration (NOAA), and the Indian Ocean the Malagasy population. Users only need to Commission (IOC). There are ongoing efforts type “321” on their mobile phones to receive by the Department of Meteorological Services information on current warnings for climate-re- to install new weather stations to increase the lated hazards and health risks similar to what granularity of data obtained. However, there is is provided through the climate and health a lack of budgets and resource allocations for bulletin. Between December 2020 and Nov the maintenance of current weather stations. 2022, this service reached around 130,000 The department is also working with IOC to users. However, these users are mostly in the develop models for climate projections under central area of the country (Vakinankaratra and the Building Resilience in the Indian Ocean Analamanga regions) — representing more (BRIO) project to use the ALADIN-Climat tool, than 25 percent of the users — thus leaving which provides climate projections with a the most climate-vulnerable populations 12km resolution. However, these climate underserved. projections do not include climate-sensitive disease considerations. Viamo and Airtel also provide a hotline with automated real-time SMS alerts and audios for 69. The Department of Meteorological Services disaster risk preparedness in case of climate also collaborates with the Ministry of or natural shocks. The data is available on Agriculture to provide information on a web-based dashboard, which enable the climate-sensitive crops through the Agro-Bul- Bureau National de Gestion des Risques et letin. It sends Information on the crop calendar des Catastrophes (National Bureau for Disaster and the weather forecast (the average precipi- Risk Management, BNGRC) and development tation and temperature) — mostly for crops that partners to access the data for better coor- are sensitive to changes in weather conditions, dination and response. In 2022, around 8 such as rice, maize, and sorghum — at the million users received information regarding beginning of the rainy season to allow farmers cyclone-related risks. to plan accordingly.102 Although these services are free and open to the public, there are no climate and health ESSENTIAL MEDICAL PRODUCTS AND information mechanisms at the district and TECHNOLOGIES fokontany levels, hindering the capacity of communities to establish or develop prepared- 70. Essential medicines and medical equipment ness mechanisms in the face of climate-related are purchased and procured by a nonprofit hazards or climate-driven outbreaks of health organization through a pull system that risks. is decentralized at the district level and distributed to health facilities. A procurement 68. The Department of Meteorological Services system established by the Malagasy is currently collecting data on temperature, government called SALAMA, oversees the delivery of drugs from the National Essential Adaptive Capacity of the Health System | 39 Drugs List to the district pharmacies (PhaGDis). One of them is transportation challenges. While The PhaGDis are wholesale pharmacies SALAMA has quarterly delivery schedules to managed by non-governmental organiza- organize and manage the transportation from a tions (NGOs) that are contracted at the health central warehouse to districts, delivery delays district level. The district pharmacies then occur due to the distance for transportation or distribute the drugs to community managed the accessibility of health facilities, resulting pharmacies (PhaGeCOM) located in basic in stockouts. In 2015, a USAID report showed health centers (CSBs). However, medicines that only 60 percent of Level-1 CSBs (CSB1) and are not consistently free which is partially 70 percent of the Level-2 CSBs (CSB2) were attributable to SALAMA’s lack of subsidies from accessible by car at some point during the the Ministry of Health and their dependence on year, mostly due to limited road infrastructure the sale of their products, as it is an financially and climate-related hazards that affect road autonomous entity. accessibility.104 SALAMA also manages products for specific The second factor contributing to stockouts programs such as family planning, malaria, HIV is due to the health facilities’ challenges with and AIDS, child health, and maternal health. managing stock levels. Health facilities at the The pull system allows health facilities to community or district level have not develop ensure preparedness activities that account for protocols for their stock levels. Another related seasonal outlooks and climate-related health issue leading to stockouts is that the health risks. While there is a user fee for medicines, facilities do not consider distribution time and those participating in specific programs, such thus fail to account for safety stocks.105 At the as malaria and family planning, can obtain same time, even when health facilities tend them for free. For instance, in the case of to request more medicines to prepare for climate-sensitive diseases such as malaria, increased cases of malaria during the rainy the supply chain is organized by funding season, the central level and SALAMA may sources managed through SALAMA. Organi- not accommodate these requests, as these are zations such as USAID and the Global Fund to adjusted based on monthly averages. Finally, Fight AIDS, Tuberculosis and Malaria (GFATM), the absence of pre-positioning of supplies among others, have contributed to the supply protocols or estimations for climate-related of malaria commodities.103 health risks — as in the case of malnutrition during the lean season, malaria, diarrhea, or Despite having a pull system that is decen- 71. respiratory infections — would also lead to tralized at the district level, health facilities the health facilities experiencing stockouts. face constant stockouts. As of 2014, an assessment found that generic medicines had stockouts of 25–49 percent at health centers SERVICE DELIVERY and 10–29 percent at hospitals. In the case of 72. Madagascar’s health service delivery is malaria commodities, the figures were 17–54 strained by an external environment that percent and 11–22 percent, respectively. The is exacerbated by climate change and the assessment highlighted two key factors for capacity constraints of its health system. this situation. There is a critical drought-driven food insecurity situation in the south region of 40 | Climate and Health Vulnerability Assessment: Madagascar the country, affecting more than 1.5 million facilities. The Ministry of Water has focused its people. In addition, constraints in the supply efforts primarily on increasing water access, chain — in terms of medical products, the with less of a focus on sanitation systems. lack of a sufficient health workforce, and Although the existing codes for water and limited resource allocations — also weaken sanitation infrastructure seek to ensure the the country’s health service delivery. The resiliency of WASH services and incorporate vulnerability of the country’s health system subnational considerations that integrate and its service delivery are reflected by the climate-related risks (that is, droughts in the country having one of the lowest COVID-19 south and cyclones in the east), enforcing and vaccination rates. This increases the risks monitoring the adoption and implementation of outbreaks and related-morbidities and of these codes has been inconsistent and mortality, while impacting service delivery, challenging. The Ministry of Water also lacks especially immunization and family planning adequate plans for strengthening sanitation services.106 It is estimated that more than two in the face of climate-related hazards. Overall, million people could fall below the poverty current WASH projects have limited budgets line due to the economic crisis caused by the and depend mostly on external partners for COVID-19 pandemic. Rural areas are even executing their activities. more vulnerable due to the gaps in the number of health facilities, the availability of basic and specialized services, affordability due to HEALTH FACILITY PREPAREDNESS out-of-pocket (OOP) expenditures, and the Though health infrastructure codes on 75. quality of care. climate-related hazards exist, there is limited information on the retrofitting require- 73. Additional shocks and stressors related ments for the infrastructure of facilities to to climate change have the potential to ensure climate-resilient features. Despite exacerbate existing issues and barriers to the existence of mandatory building codes, quality health service delivery. Nonetheless, detailed guidelines on retrofitting existing the PHC Directorate — the entity in charge of facilities to encompass climate-resilient developing quality norms for health service features are absent. In addition, budgets to delivery — has not included climate change adopt and implement these codes are limited. risks as key considerations for norms that Finally, there are no mechanisms to monitor ensure quality of service amid climate-related the uniform adoption of these codes or to hazards. Moreover, the directorate lacks the enforce them. technical capacity to further efforts that can strengthen the resiliency of PHC services. The Contingency Plan for Cyclones and 76. Floods 2019–2020 includes the health sector as a key area of emergency preparedness WATER, SANITATION, AND HYGIENE (WASH) and response. However, MoH does not have The resiliency of WASH to climate change is 74. a specific health system emergency response pivotal for preventing outbreaks of water-re- contingency plan. Although emergency plans lated diseases. However, many households are expected to be developed at the facility lack the basic water and sanitation infrastruc- level, they are not consistent across facilities. ture: only 34 percent use improved sanitation Moreover, there are no monitoring mechanisms Adaptive Capacity of the Health System | 41 to ensure the development of these plans or projectized — occurring mostly at the local the business continuity of the health system level as well as characterized by limited coor- amid climate-related hazards. At the same dination and a lack of an overarching strategy time, there are limited funds for health facilities for the projects (though UNICEF is currently to prepare for climate hazards. In the face of conducting a nutrition mapping project). climate hazards, health facilities have to rely mostly on informal plans and informal roles Nonetheless, positive changes are afoot. in close coordination with the commune-, Development partners are implementing district-, and fokontany-level administrations limited monitoring and oversight of projects. In to address climate shocks when they occur. addition, there are currently efforts (including the World Bank-financed nutrition program, The Environmental Health Department is 77. Multiphase Programmatic Approach 2) to developing guidelines for incorporating increase the multi-sectoral integration of mitigation and adaptation features at the nutrition programs: it is bringing together facility level. These efforts are centered on Agriculture; MoH; and the Office of National developing eco-responsible health centers Nutrition (ONN), which sits directly under the — focusing on electricity and water-saving President. features as well as the correct management of stocks. Currently, there is guidance on improving green areas (that is, by planting HEALTH FINANCING trees) near the health facilities, as well as 79. The main challenge undermining the imple- installing solar panels at health facilities as mentation of strategies to achieve universal a measure to strengthen resiliency in the health coverage is limited financing. Mada- face of power outages. In addition, there is gascar’s health system spends USD19.80 per ongoing work being supported by WHO to person per year — less than a quarter of the (a) make an inventory of greenhouse gases regional average of USD80.107 Since 1995, total (GHG) emitted by health establishments and health expenditure has remained at nearly (b) update the assessment on the vulnerability 4–5 percent of GDP, hitting 5.2 percent in and capacity of the health sector. 2019. Domestic government resources finance only about 30 percent of the health sector’s 78. Climate change impacts a wide range of budget, with the rest of the budget coming health programs that are important for service from private sources and OOP payments that delivery (including nutrition and food security, make up 35.5 percent of health expendi- maternal and child health, and communi- tures.108 Moreover, regular salary expenditures cable diseases such as malaria), making for health personnel accounted for 71 percent it vital to incorporate them into all health of the allocated domestic financing in 2022 activities. Malnutrition is a major challenge — significantly higher than those typically in the country, and food security is projected observed in low-income economies. This to worsen due to changes in precipitation allocation has resulted in limited resources patterns. However, there is a lack of research for operational activities at the community and into country- and context-specific, climate-re- primary levels, negatively impacting service silient agricultural methods, seeds, and crops. delivery for the most vulnerable population. Furthermore, responses to nutrition are highly 42 | Climate and Health Vulnerability Assessment: Madagascar 80. The PNASS estimates costs of USD3.7 million will be funded by a forthcoming World Bank for implementing key strategies for the health project for pandemic preparedness. sector in the face of climate change. From that budget, 38 percent would be directed to 82. Health services provision is mostly fee-for-ser- capacity building (USD1,421,798), followed by vice, thus curtailing access to health care. In the integrated monitoring of environmental addition, mechanisms to protect the poorest health at 23 percent (USD 850,000) and from health financial risks are limited, with emergency response (18 percent). The rest of no mechanisms in place to account for the budget would cover program coordination climate-related risks. Mechanisms instituted and management, monitoring and evaluation, — such as the community health insurance, research, and risk and capacity assessments.109 vouchers (for example, those for children This estimated budget is targeted solely for and pregnant women exist only in some the national level, leaving regional, commune, regions, and free services are provided only district, fokontany, and facility levels with no for specific programs), and the Equity Fund budgets for climate adaptation or mitigation (Fonds d’Equité) — suffer from fragmentation work, including emergency preparedness. and do not cover all regions or all population Moreover, although budgets have been groups. These mechanisms do not provide estimated, they are not being financed; thus, protocols or channels to protect climate-re- they depend on development partners or the lated vulnerable populations. Moreover, while private sector to be implemented. costs have increased for climate-sensitive diseases such as malaria, the malaria funding 81. The central MoH does not have a budget envelope has not increased concomitantly line for climate-related activities, including to meet these needs.110 emergency preparedness and other adaptation measures. Work on climate change appears to be limited to its Environmental Health Department. Despite generating cost estimates for the key strategies from the PNASS, MoH depends on external funders to allocate resources for implementing the activities. Development partners — such as GIZ, WHO, and USAID — are among the key stakeholders advancing climate and health strategies in Madagascar. However, most of the activities outlined in the PNASS have had a weak or low level of implementation due to the lack of resources being allocated, as the MoH’s resource allocations to climate change and health are limited. For example, the climate and health bulletin was developed in partnership with a private consulting firm — the main mobile company Airtel — and funding from GIZ. The other PNASS activities Adaptive Capacity of the Health System | 43 TABLE 4. Health system’s adaptive capacity gaps. ADAPTIVE CAPACITY GAPS OF MADAGASCAR’S HEALTH SYSTEM HEALTH SYSTEM BUILDING BLOCK SUMMARY OF GAPS IN ADAPTIVE CAPACITY Leadership and Governance • The NBCC does not have the enforcement capacity and budget lines to allocate resources for implementation. Nor does it have the systems in place to ensure the adoption of the NAP. • Implementation challenges are mostly due to limited budgets being allocated to the Action Plan and the lack of human resource capacities at the district and local levels. • Cross-sectoral coordination mechanisms lack clear definitions of roles, activities, and budgets to incentivize participation. Health Workforce • The health sector faces an imbalance in the number, skill mix, and deployment of the health workforce, including large urban-rural disparities. • Health personnel lack formal training as heads of PHC facilities, especially with regard to preparedness and response amid cli- mate-related hazards. • Further research is required to analyze the geographic distribu- tion of health personnel and their exposure to climate-related hazards. • Packages to incentivize the distribution of the health workforce to climate-vulnerable areas are non-existent. Health Information and Disease • Climate data produced by the Department of Meteorological Surveillance Systems Services are not well integrated into MoH’s decision-making and strategic planning, as well as at the facility level. • Both the climate and health bulletin and the 3-2-1 SMS service lack concrete recommended actions for climate-related health risks or climate-related hazards. Moreover, these systems do not use climate vulnerability as a criterion to direct messages. Essential Medical Products and • The distribution of essential medicines lacks contingency plans Technologies for climate-related hazards, which hinder adequate distribution. • The centralization of the SALAMA system poses a distribution challenge with regard to remote and distant communities. There is a lack of decentralized warehousing and storage to shorten times for the delivery of products amid extreme weather events. 44 | Climate and Health Vulnerability Assessment: Madagascar Health Service Delivery • Climate change and its associated impacts are not mainstreamed into the operations and decision-making of health programs at all levels. • Cross-sectoral coordination lacks clear roles and strategies. • Climate-resilient healthcare facility, health infrastructure, and WASH infrastructure assessments are lacking, which makes pri- oritizing the needs and enforcing the adoption of building codes challenging. • The PHC directorate lacks technical capacities on climate and health. Financing • PNASS lacks the budget for implementing its strategies and activ- ities, making it dependent on development partners for financing. • Protection mechanisms for the population are limited and do not target climate-vulnerable populations. • Budgets are centralized at the national level, thus limiting opera- bility capacities at the district and fokontany levels. Source: Elaborated by the World Bank Adaptive Capacity of the Health System | 45 SECTION IV. RECOMMENDATIONS 83. This section outlines a set of recommendations to enhance health system resil- ience and adaptation to climate change, including potential health interventions and strategies that can be put in place. These recommendations are intended to further the implementation of the National Action Plan for the Health Sector to Climate Change (PNASS). They are based on an assessment of both the magnitude of the current and projected climate-related health risks, the existing gaps in the adaptive capacity to manage and/or prevent these risks, and the feasibility of developing them in the short and medium terms. FIGURE 15. The WHO operational framework for climate-resilient health systems. LIMATE RESILIENCE C hip & Heal ders Workf th Lea vernance orce Go V uln pac ation t Fin alth & A Ca apt men He ate era ity & Leadership As g d ess Clim cin bil & Governance Health s ity, an Workforce Financing Preparedness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential C li o r m e h Re ima & I n f a lt s Medical ma d C l a lt h se te Products & h He ra m Pro te a rc Technologies He - g Ma nt na ili e Env ge m ent o Res le f C li m a t e ir o n in a b D et m ental & S u st a gies ri m e o lo n ts Tech n re of H ct u e a lt h s tr u & Infra Recommendations | 47 This section is organized by using the WHO HEALTH FINANCING framework for climate-resilient health systems c. Establish a budget line at MoH for the imple- (Figure 15) and drawing from the consultations mentation of the strategies and activities and the review of all relevant governmental identified in the PNASS and incorporate the policies, as well as the World Bank’s Health, objectives of the PNASS into the annual Nutrition, and Population (HNP) Climate and planning of departments throughout the Health Guidance Note. Further details on the MoH. A budget line and the integration of stakeholders’ involvement concerning the the PNASS activities into the annual planning recommendations are in Annex C. Recommen- would help to ensure that they are completed dations for integrating climate and health into while decentralizing activities currently covered the World Bank-financed health operations are by the Ministry. This would help with the in Annex B. These recommendations — based execution and institutionalization of climate on in-country interviews — were reviewed and adaptation activities more effectively. validated at a workshop held on May 31, 2023. It emphasized the importance of prioritizing d. Use climate and health vulnerability as a the PNASS and the associated strategies to criteria for implementing the PNASS and facilitate implementation, given the limited allocating resources. Specifically, climate available resources. vulnerability can be used to prioritize health workers and allocate resources and activities LEADERSHIP AND GOVERNANCE to the locations most vulnerable to climate-re- lated hazards so that efforts targeted at the a. Strengthen intersectoral coordination implementation of adaptation actions for through the implementation of the One reducing the population’s risks could advance. Health platform, including climate-related health risks, with a focus on tracking the progress of the PNASS and the efforts led HEALTH WORKFORCE by different stakeholders. Notably, programs addressing malnutrition and the high levels of e. Extend the existing training on climate to food insecurity in the south could benefit from all health workers, including those at the the improved coordination and monitoring of community level, as well as subnational-level activities and progress to ensure effectiveness, administrators such as those working at the avoid duplication, and improve collaboration. district and facility levels, along with local authorities such as the chief fokontany. Addi- b. Develop and implement a comprehensive tionally, the pre-service training curriculum communications strategy to increase the should be adapted to include climate-related awareness and visibility of the PNASS and health risks and climate emergency prepared- its prioritized strategies. Currently, these ness and response. documents are not widely known within MoH and other ministries, as well as among stakeholders engaged in climate and health HEALTH INFORMATION SYSTEMS initiatives. f. Prioritize the expansion of the 3-2-1 SMS information system to reach climate-vul- nerable areas and populations. Broadening 48 | Climate and Health Vulnerability Assessment: Madagascar the coverage of the system will enable the j. Develop formal standard operating effective dissemination of climate and health procedures that focus on preparedness emergency response and preparedness early for climate-related hazards. Preparedness warning messages to those most susceptible processes should include communication and to climate-related hazards and extreme coordination systems for decision-making, weather events. This includes tailoring the training for healthcare workers and first timing and frequency of messages to match responders, and the establishment of the climate-related hazards faced by different evacuation plans tailored for different climate populations. exposures. SERVICE DELIVERY g. Implement a climate adaptation and resilience certification system for the healthcare and WASH infrastructures. The certification system should include an assessment of facilities against existing climate-resilient infrastruc- ture codes and identify health facility needs, thus facilitating the prioritization of resource allocations and supporting the enforcement of these codes. Such a system may be integrated with existing health facility quality assessments. h. Develop training modules on climate and health risks for PHC personnel. These modules should be directed to the national, regional, district, and fokontany levels, including commune mayors and other local-level key stakeholders coordinating with primary health facilities (CSBs). i. Formulate detailed contingency plans on the procurement of essential medicines amid extreme weather events, such as storms or floods. These plans should include pre-po- sitioning protocols in climate-vulnerable communities; clear roles and coordination with fokontany, non-governmental organiza- tions (NGOs), and other key stakeholders; along with the regular testing and updating of contingency plans based on the feedback of previous events. Recommendations | 49 ANNEXES ANNEX A. METHODOLOGY assessment is, therefore, on climate adaptation and resilience measures. However, as the Assessment Report Six (AR6)111 of the Intergovernmental Panel AIMS OF ASSESSMENT AND CONCEPTUAL on Climate Change (IPCC) makes clear, “Global FRAMEWORK surface temperature will continue to increase The objective of this Climate and Health until at least the mid-century under all emissions Vulnerability Assessment (CHVA) is to assist scenarios considered.” Mitigation is no longer a decision-makers in planning effective adaptation sufficient strategy, regardless of the pace at which measures to address climate-related health risks. governments and communities around the world Where available, these measures are provided act. Adaptation is now as critical a part of climate at a subnational level to assist regional health action as mitigation. This report, therefore, focuses planners. The recommendations of this CHVA on adaptation measures, but where possible, it are primarily aimed at the health sector and the also includes recommendations to reduce GHGs related sectors dealing with climate change-related or facilitate the decoupling of emissions from health risks, such as disaster risk management. progress toward human development goals. Adaptation priorities need to run alongside The report utilizes WHO’s operational framework fundamental and urgent action to mitigate for building climate-resilient health systems climate change. It is important to stress how to analyze adaptive capacity for the purpose complex the climate challenge is and how hard of adequately addressing current and future it is to precisely predict the magnitude of how identified risks. Following this framework (see severe climate exposures facing populations Figure 16), the assessment is structured around will become. Many factors could slightly slow or the six Health System Strengthening (HSS) significantly speed up rates of change, including building blocks. These six categories structure positive feedback effects and, most worrying of the assessment of capacities and gaps — now all, cascading climatological tipping points. For and into the future. The framework then considers this reason, mitigating existing greenhouse gas the 10 components of a health system’s climate (GHG) emissions and developing and implementing resilience to develop the “Recommendations” measures to protect human development from the section. changing climate are, in addition to adaptation measures, of paramount importance. This assessment follows a step-wise linear approach. The first step characterizes the Investing in adaptation strategies to proactively climatology in Madagascar by highlighting the address the effects of climate change on health observed and future climate exposures relevant to outcomes is critical. This assessment is concerned health. The second step examines climate-related with climate risks to health and health systems, health risks, including identifying the vulnerable the adaptive capacities in place to deal with these populations most at risk. The final step assesses risks, and the provision of recommendations to the adaptive capacity of the health system by meet the identified gaps. The primary focus of this identifying gaps in managing current and future Annexes | 51 FIGURE 16. WHO’s operational framework for building climate-resilient healthcare systems comprising 10 components and their connections to the building blocks of health systems. ATE RESILIENCE CLIM hip & Heal eaders nce Workf th L verna orce Go V uln pac ation t Fin alth & A Ca apt men He ate era ity & Leadership As g d ess Clim cin bil & Governance Health s ity, an Workforce Financing Preparedness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential C li o r m e h Re ima & I n f a lt s Medical ma d C l a lt h se te Products & h He ra m Pro te a rc Technologies He - g Ma nt na ili e Env ge m ent o Res le ir o n f C li m a t e b in a D et m ental & S u st a gies ri m e o lo n ts n of H Te c h t ur e e a lt h a s tr u c & Infr Source: World Health Organization climate-related health risks. Together, these steps spatial resolution for 1901–2020. Model-based inform a series of recommendations to reduce climate projection data was derived from the climate-related health vulnerability in Madagascar. Coupled Model Inter-Comparison Project Phase 6 The assessment was based on a review of the (CMIP6), with the projections shown through the published literature, national statistics, and an five shared socioeconomic pathways (SSPs). This in-country mission to consult with the key coun- assessment explores the projected climate change terparts in the government. under SSP3-7.0 for the short (2030s: 2020–2039) and medium (2050s: 2040–2059) terms. The SSP3-7.0 scenario is a high-GHG emissions CLIMATOLOGY scenario in which countries are increasingly This section describes observed climatic changes competitive and emissions continue to climb, and projected climate trends — prioritizing doubling from the current levels by 2100. climate-related hazards in relation to human health risks in Madagascar. Climate information was acquired from the World Bank Group’s Climate CLIMATE-RELATED HEALTH RISKS Change Knowledge Portal (CCKP). Observed This assessment focused on five climate-related climate data was presented in a 50km x 50km health risk categories: (1) nutrition, (2) waterborne 52 | Climate and Health Vulnerability Assessment: Madagascar disease risks, (3) vector-borne diseases, (4) air the adaptive capacity and resilience to the health quality health risks, and (5) zoonotic diseases. risks of climate change is also critical: adaptive The exclusion criteria for selecting the categories capacity is likely to be greater when access to are based on two principles: resources within a community, nation, or the world is more equitably distributed. 1. These risks represent the most pressing health risks to the population in Madagascar as reflected in the Demographic and Health Survey (DHS) and the PNASS, as well as during meetings held with the key stakeholders. 2. Scientific evidence are available for each climate-related health risk category. Other climate-related health risks have not been included in this assessment, such as but not limited to direct injuries and mortality associated with natural hazard events, heat-related morbidity and mortality, along with mental health and well-being. ADAPTIVE CAPACITY OF THE HEALTH SYSTEM The extent to which the health system in Madagascar is prepared for and has the capacity to manage changes in hazards, exposure, and susceptibility will determine their resilience in the coming decades. In this assessment, Madagas- car’s adaptive capacity112 to prevent and manage climate-related health risks is examined according to the WHO’s six health system building blocks, as shown in Figure 16. See also Annex C for the Adaptive Capacity Rapid Assessment and the summarized Adaptive Capacity and Climate Change-Related Health Risks Gap Analysis that informs this section. It should be noted that several factors outside the scope of the health sector can also drive reductions in Madagascar’s adaptive capacity to manage the health risks of climate change in its institutions and people. These include the country’s economic challenges, changing demographic patterns, and slowly improving social conditions. The promotion of equity as a cross-cutting theme for enhancing Annexes | 53 ANNEX B. RECOMMENDATIONS FOR I. PANDEMIC PREPAREDNESS AND BASIC HEALTH SERVICES DELIVERY PROJECT WORLD BANK-FINANCED PROJECTS  (P174903) As part of the CHVA, provisional recommendations The Pandemic Preparedness and Basic Health for climate actions that can be taken as part of Services Project includes core activities that the World Bank-financed Health, Nutrition, and strengthen surveillance, preparedness, and Population (HNP) projects in Madagascar have response to epidemic-prone diseases, inclusive been developed. They are expected to represent of climate-sensitive diseases. The PAD outlines a subset of the overall recommendations in the the core activities for strengthening preparedness final CHVA presented to the Government. and response to climate-sensitive diseases as part of the overall project. The CHVA has identified The CHVA has identified core gaps and recom- (1) specific actions to fill gaps through the imple- mendations for strengthening climate adaptation mentation of the climate activities outlined in in the country, as outlined above. The current the PAD and (2) additional ways whereby gaps World Bank-financed health projects — primarily identified through the CHVA can be addressed the Pandemic Preparedness and Basic Health through project implementation. Services Delivery Project (P174903) and Phase 2 of Improving Nutrition Outcomes Using the Multiphase Programmatic Approach (P175110) — COMPONENT 1: STRENGTHENING CAPACITIES offer opportunities for beginning to address some FOR PANDEMIC PREPAREDNESS AND RESPONSE of the challenges identified in the CHVA. Some climate-related actions have been identified in the project appraisal documents (PADs) and can be Subcomponent 1.2: Improve Cross-sectoral enforced through project implementation, while Coordination, Collaboration, and Capacity others can be integrated into the project imple- for Preparedness and Response (USD20.1 mentation, or through additional financing that is million equivalent, International Development tentatively planned for the Pandemic Prepared- Association [IDA]) ness Project. DECENTRALIZED DISTRICT- AND REGIONAL- The areas outlined below are those that both (1) LEVEL CLIMATE EMERGENCY PREPAREDNESS relate to gaps identified in the CHVA and (2) are AND RESPONSE CAPACITY in the PADs of the World Bank-financed health This subcomponent currently includes investments projects in Madagascar or climate-related areas to strengthen the emergency response capacity at included by the project implementation unit (PIU) the local levels, including developing emergency in their work plan. These recommendations, which preparedness and response capacities at the are complementary to the overall recommendations district and regional levels. Developing the within the CHVA, identify specific avenues for the emergency response capacity for the health implementation of the CHVA recommendations aspects of climate events is incorporated within through the World Bank projects. this activity, as outlined in the PAD. Along with the general development of emergency operations centers at the local level, specific areas to strengthen the decentralized capacity for climate emergencies at the district and regional 54 | Climate and Health Vulnerability Assessment: Madagascar levels can include addressing needs identified intersectoral coordination for climate emergency in the CHVA: preparedness and response and the lack of budgets, as well as clear roles and points of → Developing local-level emergency response engagement, which have contributed to gaps plans for the outbreaks and health aspects in intersectoral collaboration. While the coordi- of other emergencies. While the CHVA nation components of this subcomponent focus identified that local-level training on developing specifically on One Health and surveillance and emergency response plans, it is unclear do not necessarily include the broader aspects of whether these plans have been developed climate emergency and response coordination, and whether specific individuals/entities have there are core activities that the coordination been assigned the responsibility to ensure strengthening could include to address the gaps that they are developed. The project offers identified in the CHVA: an opportunity to develop these plans at the local level. → Development of regular platforms (meetings, → Budgeting for climate emergency prepared- analytics, etc.) for reviewing and using the ness and response can be incorporated into surveillance and One Health data to review decentralized capacity development. The surveillance planning and actions, including CHVA identified that there is currently a gap in climate-sensitive diseases and overlaying available budgets for emergency preparedness meteorologic data with surveillance data; and response at the local levels. Budgets can → Development of multisectoral preparedness be aligned with local emergency preparedness and response plans with specific roles for and response plans to climate-related hazards. each sector and responsible party within the → Incorporation of climate preparedness sector; and actions into local-level climate emergency → Budgeting / identification of resources for preparedness and response including the each sector to carry out their assigned function. preparedness of the following areas for climate shocks — health facilities (both the physical building and the emergency response), water Subcomponent 1.3: Strengthen Human and and sanitation systems, and referral systems — Animal Disease Surveillance (USD18.0 million should be done. Currently, the renovations of equivalent, IDA) some health centers and water and sanitation This subcomponent encompasses developing systems are included in the project. digital data systems linked to the DHIS2 system for the surveillance and notification of epidem- ic-prone diseases, including climate-sensitive SURVEILLANCE COORDINATION diseases. Based on mission discussions, this work This subcomponent also currently includes will include the establishment of early warning cross-sectoral coordination for preparedness and systems for epidemic-prone diseases — a need response, which is focused on the development identified during the mission. Key considerations of the One Health platform and the International for the development of this system to ensure Health Regulations (IHR) capacity to promote that it provides early warning for climate-related animal, human, and environmental health. The diseases include the following: CHVA identified the need for strengthening the Annexes | 55 → Multisectoral and decentralized early warning COMPONENT 2: STRENGTHENING THE notification: The early warning system will RESILIENCE AND PERFORMANCE OF BASIC need to notify agencies across relevant sectors HEALTH SERVICES (USD64.9 MILLION and at all levels from the national to the facility EQUIVALENT — USD32.9 MILLION FROM IDA levels. The sectors and levels that need to AND USD32 MILLION FROM GLOBAL FINANCING be notified corresponding to the diseases FACILITY [GFF])113 should be built into the system. Further, these levels will need to be coordinated in their Subcomponent 2.2. Strengthen PHC Financing by response and there will need to be mechanisms Increasing the Autonomy and Accountability of for using the data across the sectors and at CSBs and Providing Financial Protection for the different levels. Climate-sensitive diseases Poorest (USD22.9 million equivalent, including will also need to be integrated into the early USD12.9 million from IDA and USD10 million from warning systems. GFF, Portion B) → Response coordination and planning: The CHVA found that there is limited funding for Multi-sectoral and multi-level response action and attention to climate adaptation activities at the plans should be put into place, with consid- local and health facility levels. Several activities erations for different diseases when early could be incorporated within this subcomponent warning systems are activated. to strengthen climate adaptation at the local and → Data use: To further the use of early warning health facility levels: systems and plan for future outbreaks, mechanisms for data use at decentralized and → The inclusion of climate vulnerability in the national levels should be put in place. Currently, formula for allocating funds to PHC facilities there are climate and health bulletins. Utilizing (CSBs) to increase the amount of funds for the analysis generated in these bulletins, and climate-vulnerable health facilities will give training on data use at the national through them more resources to address climate vulner- district levels that include identified actions ability needs. Climate vulnerability could be and follow-ups on these actions could help identified using existent climate vulnerability ensure the substantive use of these data. maps, with the level of vulnerability potentially ranked on a scale. → The inclusion of climate adaptation actions in community-supported organizations’ (CSOs) monitoring of health facilities and fokontany or communes could help ensure that facilities are taking climate adaptation actions. In cases where they receive additional funds because of their level of climate vulnerability, CSOs can ensure that the funds are directed to climate adaptation activities while maintaining health facility autonomy. CSOs could potentially use climate adaptation criteria from a green health facility scorecard (described below) to monitor health facilities. 56 | Climate and Health Vulnerability Assessment: Madagascar → Incorporating budgeting for climate II. PHASE 2 OF IMPROVING NUTRITION adaptation in public financial management OUTCOMES USING THE MULTIPHASE (PFM) capacity development will help PROGRAMMATIC APPROACH (MPA2, communes and health facilities ensure that P175110) there are funds available for climate adaptation activities. Subcomponent 2.2: Strengthen the Availability and Utilization of Health and Nutrition Data (USD3.6 million) Subcomponent 2.3. Strengthen Human Resources Management (USD20 million equivalent, IDA) The use of climate and health data was identified in the CHVA as a gap. The project includes The CHVA found that the presence of health strengthening the availability and use of health and workers in rural areas, including climate-vulnerable nutrition data and incorporates overlaying mete- areas, is a challenge undermining the climate orologic data with nutrition data. The inclusion of adaptation of health facilities. This subcomponent improved analytics and platforms for climate-re- includes the development of a system for improving lated nutrition data use (such as meetings and the distribution, motivation, and rural retention of analytic outputs), including reviewing data and health workers. To strengthen the number and identifying actions based on data, could help quality of health workers in climate-vulnerable improve the use of climate-related nutrition data. areas, the suggestions are as follows: → Climate vulnerability could be included Subcomponent 2.3: Strengthen Supervision and as a criterion for the placement of health Management Capacities at Regional, District, and workers. This would entail more vulnerable Central Levels (USD10.9 million equivalent) areas being prioritized for health workers This subcomponent includes strengthened multi- — potentially increasing the speed at which sectoral planning and budgeting at the regional health workers are sent to these areas and level. As limited local-level planning and budgeting the number of health workers in these areas. for climate adaptation activities were identified → Climate vulnerability could also be included as gaps in the CHVA, the inclusion of climate in the formula for determining health worker adaptation in work planning and budgeting compensation. Compensation for health could be incorporated within the execution of workers sent to remote, rural areas should this subcomponent to strengthen the execution of be increased to improve their retention in climate adaptation activities. Food security activities these areas. should also incorporate seasonal planning to → The project also includes the pre-service training account for variable climatic conditions throughout of health workers, including training on climate the year. emergency preparedness and response. This may be expanded to include health facility Subcomponent 2.4: Results-based financing (RBF) climate adaptation training more broadly and to improve the quality of service delivery (USD4.4 linked with key activities — such as climate million equivalent) emergency response plans, health facility building measures, and water and sanitation This subcomponent includes a climate-related measures — to reinforce the execution of these quality indicator to be identified in the PAD. Based actions at the health facility level. Annexes | 57 on the CHVA’s identification of the implemen- measures in health facility buildings, and water tation of climate adaptation measures at the and sanitation measures. The RBF quality measure health facility level as a need, focusing on this could be aligned with or selected from adaptation results-based financing (RBF) quality measure measures in the green health facility scorecard, on climate adaptation could strengthen climate as described below. Facilities could integrate adaptation at health facilities. Options include climate adaptation measures into their structural the existence of climate emergency prepared- strengthening plans, using their performance-based ness and response plans, climate adaptation bonuses as a financing source. 58 | Climate and Health Vulnerability Assessment: Madagascar ANNEX C. KEY RECOMMENDATIONS AND RELEVANT LINE MINISTRIES IN MADAGASCAR WHO’S CLIMATE AND RECOMMENDATIONS RELEVANT LINE MINISTRIES HEALTH OPERATIONAL BUILDING BLOCK Strengthen intersectoral coordination Ministry of Health (MoH); National through the implementation of the One Bureau of Climate Change Health platform, which includes climate- Coordination (NBCC); Development related health risks, with a focus on Partners (World Health Organization tracking the progress of the National [WHO], World Bank, United Nations Adaptation Action Plan for the Health Children’s Fund [UNICEF], and Leadership and Sector to Climate Change (PNASS) and German Cooperation Office [GIZ]) Governance the efforts led by different stakeholders Develop and implement a comprehensive communications strategy to increase the MoH; NBCC awareness and visibility of the PNASS and its prioritized strategies Establish a budget line at MoH for the implementation of the strategies and activities identified in the PNASS and MoH; Ministry of Finance incorporate its objectives into the annual Climate and Health planning of departments throughout the Financing MoH Use climate and health vulnerability as MoH; NBCC; Department of criteria for implementing the PNASS and Meteorological Services allocating resources Extend the existing training on climate to all health workers, including at the community level, as well as subnational- MoH; Regional, District and Health Workforce level administrators at the district and Fokuntany focal points facility levels, along with local authorities like the chief fokontany Prioritize the expansion of the 3-2-1 SMS MoH; Department of Meteorological Health Information information system to reach climate- Services; Viamo; Air-Tel Systems vulnerable areas and populations Annexes | 59 Implement a climate adaptation and resilience certification system for health MoH; Department of Meteorological care and the water sanitation and Services; Viamo; Air-Tel hygiene (WASH) infrastructure Health Service Delivery Develop training modules on climate and MoH; Directorate of Primary Health health risks for primary health care (PHC) Care personnel Formulate detailed contingency plans for the procurement of essential medicines MoH; SALAMA; Department of amid extreme weather events, such as Meteorological Services; NBCC storms or floods Develop formal standard operating MoH; NBCC; Regional, District, and procedures that focus on preparedness Fokuntany focal points for climate-related hazards 60 | Climate and Health Vulnerability Assessment: Madagascar ANNEX D: BACK-TO-OFFICE REPORT OVERALL CHVA RECOMMENDATIONS — MADAGASCAR’S CLIMATE AND The workshop discussed four main adjustments to strengthen the CHVA recommendations, which HEALTH VULNERABILITY ASSESSMENT will be incorporated into the document: (CHVA) WORKSHOP A workshop — held on May 30, 2023 — reviewed 1. The training recommendations should be and validated the results of the Climate and Health adjusted to reflect (a) the existence of a Vulnerability Assessment (CHVA), with a focus training manual on climate and health for on the CHVA recommendations. The workshop health workers; (b) the need to extend this had broad participation. training to subnational-level administra- tors and ensure that all health workers are The main workshop was structured into three trained in service in the curriculum; and (c) different sessions: (1) climate and climate-re- the need to adapt the training curriculum to lated health risks; (2) adaptive capacity; and (3) be incorporated into the pre-service training recommendations. In addition, a session on the of health workers. recommendations for the World Bank projects 2. Strengthened intersectoral coordination was held with the project implementation unit is also emphasized in the recommendation (PIU) of the Ministry of Health (MoH). concerning the monitoring of different actors Workshop discussions focused on the recom- engaged in climate and health. Specifically, mendations and highlighted the following: this recommendation should indicate the use of the One Health platform as the coordination platform for climate and health. The emphasis 1. The results of the CHVA’s assessment of should be placed on (a) tracking the imple- adaptive capacity and recommendations mentation of the PNASS and the associated were based on in-country interviews with a strategy; (b) using data to assess the progress sample that was largely representative of on the PNASS; and (c) instituting mechanisms the workshop participants. to ensure the substantive participation of all 2. The intent of the recommendations is to actors in climate and health. further the implementation of the National 3. There is a need to develop and implement Health Adaptation Plan to Climate Change a communications strategy to increase the (PNASS), not to duplicate it. awareness and visibility of the PNASS and 3. The recommendations are based on the current the associated strategy. The existence of the level of adaptive capacity in the country and documents is not widely known — at MoH do not touch on all areas of climate risks. as well as other ministries and stakeholders 4. In addition to the 2018 PNASS, there is a engaged in climate and health. 2021 Climate and Health Strategy that will be 4. The recommendations on the 3-2-1 informa- reviewed and incorporated into the CHVA. tion system should be adjusted to (a) ensure These points will be further articulated and that the messages currently propose specific incorporated into the CHVA. actions for the population based on the climate and health information; and (b) prioritize the expansion of the currently inadequate reach Annexes | 61 of the messages, particularly to climate-vul- 3. Operational support for climate change nerable populations. emergency preparedness and response, including climate emergency response In addition to these adjustments, the workshop planning, will be supported through assistance emphasized the importance of prioritizing the provided to the emergency response PNASS and the associated strategy to facilitate committees (COUSP) at the regional and implementation, given the limited available district levels. resources. The existing recommendation to 4. Support for pre-positioning pharmaceuticals prioritize the PNASS based on climate vulner- for climate-sensitive diseases and during ability and risks will be positioned as a central climate shocks will be given through the overall recommendation and extended to its strategy. support for pre-positioning medications for and during emergencies. Further, the workshop reviewed four recommen- dations in detail and developed specific actions to 5. Public financial management (PFM) capacity implement them, assessing what should be done building for budgeting and budget advocacy to achieve the recommendations, who should for climate adaptation and emergency be responsible for the actions, and when the preparedness and response will be provided actions should be completed. to the regional and district levels as part of the overall PFM capacity building. i. It was discussed that climate vulnerability RECOMMENDATIONS FOR THE WORLD BANK’S could be explored as a criterion in the PROJECTS formulas for the following. However, two On May 31, a discussion was held with the MoH’s aspects are still being considered: (a) first, PIU on options for incorporating the recommenda- whether climate-vulnerable areas differ from tions from the CHVA in the World Bank-financed areas meeting the existing criteria of being projects. The following aspects were accepted poor and / or remote should be explored; as options for incorporating the CHVA recom- and (b) second, the incorporation of climate mendations. vulnerability into the criteria may come at a later stage since decrees for these Pandemic Preparedness and Basic Health Service formulas are close to being finalized and Delivery Project (PPSB) released. Thos decrees include: (a) Distri- bution of funds to the basic health centers 1. Coordination of climate change and health at commune level (CSBs); (b) Deployment of will be supported through the One Health health workers to locations; and (c) Health platform at the national level and coordinated worker retention packages. at the subnational levels, including support 6. Climate emergency preparedness and for the multi-sectoral climate and health response training will be incorporated into response plans. the support of the overall HR training. 2. Early warning systems for climate 7. The PNASS and strategy will be launched emergencies and climate-sensitive disease as part of the launch of the Pandemic outbreaks will be incorporated into the overall Preparedness Plan to support advocacy for support for early warning systems. the documents. 62 | Climate and Health Vulnerability Assessment: Madagascar PHASE 2 OF THE MULTIPHASE APPROACH (MPA2) FOR NUTRITION 1. A dashboard for the continual overlay of the climate and health data will be developed. (Climate and nutrition data are currently being analyzed periodically in the analytics produced by the Nutrition Cluster Technical Group.) 2. Climate adaptation needs will be incorporated into work planning and budgeting as well as the seasonal planning of activities, with the caveat that the project will not be able to finance the implementation of all these needs. 3. Climate emergency preparedness and response measures will be incorporated into results-based financing (RBF) measures, and climate adaptation / emergency preparedness and response activities may also be used as criteria for using a portion of the funds. 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Gibson, Jennifer Rozier, et al., 2020, “Mapping Malaria Seasonality in Madagascar Using Health Facility 98 This assessment focuses on the resiliency of the population and of the Data,” BMC Medicine 18 (1): 26, doi: 10.1186/s12916-019-1486-3. health system. According to UNFCCC, “resiliency” is defined as the ability of a system, community, or society — when exposed to hazards 84 Michele Nguyen, Rosalind E. Howes, Tim C. D. Lucas, Katherine E. — to resist, absorb, accommodate, adapt to, transform, and recover Battle, Ewan Cameron, Harry S. Gibson, Jennifer Rozier, et al., 2020, from the effects of climate-related hazards in a timely and efficient “Mapping Malaria Seasonality in Madagascar Using Health Facility manner. This includes preserving access to critical health services. Data,” BMC Medicine 18 (1): 26, doi: 10.1186/s12916-019-1486-3. In addition, it is also critical to ensure the resiliency of investments or 85 Cyril Caminade, Sari Kovats, Joaim Rocklov, Adrian M. Tompkins, infrastructure by ensuring that climate-proof structural features are Andrew P. Morse, Felipe J. Colón-González, Hans Stenlund, Pim incorporated into health facilities and that lifelines (that is, energy Marens, and Simon J. Lloyd, 2014, “Impact of Climate Change on Global and water) are guaranteed amid climate-related hazards. For more Malaria Distribution,” The Proceedings of the National Academy of information on resiliency at the facility levels, please refer to the GFDRR Sciences (PNAS) 111 (9): 3286–91, doi: 10.1073/pnas.1302089111. website: https://www.gfdrr.org/en/climate-disaster-resilient-health-sys- tems. 86 For Anopheles Gambiae, the optimal temperature for larvae development is between 18°C and 32°C; higher or lower temperatures 99 See the figure for 2018 (from WHO, 2023, “Global Health Workforce hinder their development and survival (extracted from April N. Frake, Statistics Database — Madagascar,” https://www.who.int/data/gho/data/ Brad G. Peter, Edward D. Walker, and Joseph P. Messina, 2020, themes/topics/health-workforce). “Leveraging Big Data for Public Health: Mapping Malaria Vector 100 WHO, 2016, Health Workforce Requirements for Universal Health Suitability in Malawi with Google Earth Engine,” PLOS ONE 15 (8): Coverage and the Sustainable Development Goals, Geneva, e0235697, doi: 10.1371/journal.pone.0235697. Switzerland: WHO, https://apps.who.int/iris/bitstream/handle/10665/25 87 Cyril Caminade, Sari Kovats, Joaim Rocklov, Adrian M. Tompkins, 0330/9789241511407-eng.pdf. Andrew P. Morse, Felipe J. Colón-González, Hans Stenlund, Pim 101 Government of Madagascar, 2015, National Health Human Resources Marens, and Simon J. Lloyd, 2014, “Impact of Climate Change on Development Plan — Plan National de Développement des Ressources Global Malaria Distribution,” PNAS 111 (9): 3286–91, doi: 10.1073/ Humaines en Santé (PNDRHS). pnas.1302089111. References | 67 102 Météo Madagascar, n.d., “Produits D’Information Bulletin Agrométéo,” https://www.meteomadagascar.mg/produits_prestations/bulletin-agro- meteo/. 103 USAID, 2015, “Supply Chain Network and Cost Analysis of Health Products in Madagascar,” https://publications.jsi.com/JSIInternet/Inc/ Common/_download_pub.cfm?id=17406&lid=3. 104 USAID, 2015, “Supply Chain Network and Cost Analysis of Health Products in Madagascar,” https://publications.jsi.com/JSIInternet/Inc/ Common/_download_pub.cfm?id=17406&lid=3. 105 USAID, 2015, “Supply Chain Network and Cost Analysis of Health Products in Madagascar,” https://publications.jsi.com/JSIInternet/Inc/ Common/_download_pub.cfm?id=17406&lid=3. 106 GFF (Global Financing Facility), 2022, GFF Partnership Annual Report 2021–2022, Washington, DC: World Bank Publications, https://www. globalfinancingfacility.org/sites/gff_new/files/gff-partnership-annual-re- port-2021-2022.pdf. 107 World Bank, 2023, “Country Data – Madagascar,” https://data. worldbank.org/indicator/SH.XPD.OOPC.CH.ZS?locations=MG. 108 World Bank, 2023, “Country Data – Madagascar,” https://data. worldbank.org/indicator/SH.XPD.OOPC.CH.ZS?locations=MG. 109 Government of Madagascar, 2016, Plan D’Action National D’Adaptation du Secteur Sante au Changement Climatique à Madagascar, https:// climhealthafrica.org/wp-content/uploads/2021/10/PNASS-VERSION-FI- NALE-3-1.pdf. 110 INSTAT (Institut National de la Statistique) and the DHS Program, ICF, 2022, Enquête Démographique et de Santé à Madagascar (EDSMD-V) 2021, Antananarivo, Madagascar et Rockville, Maryland, USA : INSTAT et ICF, https://dhsprogram.com/pubs/pdf/FR376/FR376.pdf. 111 IPCC, 2023, Sixth Assessment Report, https://www.ipcc.ch/assess- ment-report/ar6/. 112 “Adaptive capacity” is defined by IPCC as “the ability of a system to adjust to climate change, moderate potential damages, take advantage of opportunities, and cope with the consequences” (extracted from IPCC’s AR5). The related term, “resilience,” is the ability to prepare and plan for, absorb, recover from, and more successfully adapt to adverse events. People and communities with strong adaptive capacity have greater resilience compared to others. This assessment makes use of the terms — “adaptation” and “adaptive capacity”— to encompass both terms. 113 Although this component also includes the minor rehabilitation of health facilities, this is limited to developing adolescent-friendly health services, so the inclusion of adaptation measures at health facilities — identified as a need in the CHVA — is not easily incorporated within it. 68 | Climate and Health Vulnerability Assessment: Madagascar MARCH 2024 70 | Climate and Health Vulnerability Assessment: Madagascar