I © 2023 The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank 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. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. World Bank. 2023. Climate and Health Vulnerability Assessment for Ghana. © World Bank All 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 photo: © Resolution / World Bank II CLIMATE AND HEALTH VULNERABILITY ASSESSMENT FOR GHANA III ACKNOWLEDGMENTS This report was done by: Prof. Mawuli Dzodzomenyo (Lead), University of Ghana, Legon; Dr. Margaret Appiah, University of Environment and Sustainable Development, Somanya; Dr. Naomi Kumi, University of Energy and Natural Resources, Sunyani; Dr. Jeffrey Nii Armah Aryee, Kwame Nkrumah University of Science and Technology, Kumasi; Prof. Duah Dwomoh University of Ghana, Legon; and Prof. Benjamin Delali Dovie, University of Ghana, Legon. Contributions were provided by the World Bank Health, Nutrition and Population team in Ghana: Patrick Mullen, Human Development Program Leader; Enoch Oti Agyekum, Health Economist; Akriti Mehta, Consultant; Pearl Opoku Youngmann, Liaison Officer, Global Financing Facility; and Leila Fall, Human Development Analyst. The report reflects valuable inputs from: the ministries of Health, Agriculture, Science Technology and Environment, and Water and Sanitation; the Atomic Energy Commission; and representatives of civil society. The team acknowledges Mr. Kwakye Kontor, Ministry of Health, and Dr. Carl Osei, Ghana Health Service, for their technical support and advice. The team appreciates the Ghana Health Service, which provided data through the Centre for Health Information Management, and the Ministry of Fisheries and Aquaculture Development, which provided data on sea-level rise. Finally, the team expresses its thanks to all stakeholders who took the time to provide information and input. IV TABLE OF CONTENTS LIST OF FIGURES........................................................................................................................................ VII LIST OF TABLES...........................................................................................................................................IX LIST OF ACRONYMS..................................................................................................................................X 1. EXECUTIVE SUMMARY...................................................................................................1 2. INTRODUCTION AND BACKGROUND..........................................................................11 2.1. Objective and conceptual framework.......................................................................................13 2.2. Approach and methodology........................................................................................................13 3. OVERVIEW OF GHANA COUNTRY CONTEXT.............................................................15 3.1. Geography........................................................................................................................................15 3.2. Current climate and environment...............................................................................................15 3.3. Population and demographic trends.........................................................................................17 3.4. Economic development................................................................................................................19 3.5. Disease burden...............................................................................................................................22 3.6. Health system..................................................................................................................................24 4. CLIMATE EXPOSURES / HAZARDS...............................................................................27 4.1. Annual and monthly observed trends in climatology: temperature, precipitation, humidity/heat index..............................................................................................27 4.2. Annual and monthly projected trends in climatology: temperature, precipitation, humidity/heat index..............................................................................................29 4.3. Observed and projected changes in sea-level rise...............................................................31 4.4. Climate related extreme events..................................................................................................34 5. HEALTH RISKS..................................................................................................................38 5.1. Vulnerable population groups.....................................................................................................38 5.2 Health Risk........................................................................................................................................44 5.2.1. National and regional level analyses of climate-sensitive infectious diseases: An ecological study........................................................................................................................44 5.2.2. Direct and indirect health outcome risks of climate change................................................46 5.2.3. Health system risks..........................................................................................................................64 Climate and Health Vulnerability Assessment for Ghana V 6. ADAPTIVE CAPACITY AND IDENTIFICATION OF GAPS............................................66 6.1. Leadership and governance.......................................................................................................66 6.2. Health workforce............................................................................................................................73 6.3. Health information systems.........................................................................................................75 6.4. Essential medical products, technologies and infrastructure.............................................76 6.5. Service delivery...............................................................................................................................77 6.6. Health system financing................................................................................................................77 7. RECOMMENDATIONS TO REDUCE CLIMATE RELATED HEALTH VULNERABILITIES AND VULNERABILITIES OF THE HEALTH SYSTEM...................80 7.1. Leadership and governance.......................................................................................................80 7.2. Health workforce............................................................................................................................80 7.3. Vulnerability, capacity and adaptation assessment..............................................................80 7.4. Integrated risk monitoring and early warning........................................................................80 7.5. Health and climate research.......................................................................................................81 7.6. Climate resilient and sustainable technologies and infrastructure...................................81 7.7. Management of environmental determinants of health.......................................................81 7.8. Climate informed health programmes......................................................................................82 7.9. Emergency preparedness and management.........................................................................82 7.10. Climate and health financing.......................................................................................................82 8. APPENDICES.....................................................................................................................83 8.1. Appendix 1: National analysis of diarrhea cases: findings from an ecologic study.......83 8.2. Appendix 2: National analysis of malaria cases: findings from an ecologic study........84 8.3. Appendix 3: National analysis of meningitis cases: findings from an ecologic study..86 8.4. Appendix 4. National analysis of schistosomiasis cases: findings from an ecologic study.................................................................................................................................88 8.5. Appendix 5. Sub-national/ regional level analysis: findings from an ecologic study...89 VI Climate and Health Vulnerability Assessment for Ghana LIST OF FIGURES Figure 2-1. Pathways through which climate change affects human health....................................................................................13 Figure 2-2. WHO operational framework for building climate resilient health systems...............................................................13 Figure 3-1. Ghana's administrative regions and their capitals.............................................................................................................15 Figure 3-2. Ghana's population size and growth rate, 1960-2021......................................................................................................17 Figure 3-3. Distribution of population size by region............................................................................................................................18 Figure 3-4. Population pyramid by gender...............................................................................................................................................18 Figure 3-5. Population pyramid by location.............................................................................................................................................19 Figure 3-6. GDP trends, 2014-2022, with projections for 2023 (USD Billion)................................................................................20 Figure 3-7. Causes of deaths in Ghana.....................................................................................................................................................22 Figure 3-8. Causes of deaths and disability in Ghana..........................................................................................................................23 Figure 3-9. Risk factors causing deaths and disability in Ghana.......................................................................................................23 Figure 3-10. Organization of the health system in Ghana...................................................................................................................25 Figure 4-1. Observed annual climatology of (a) rainfall (b) mean- (c) maximum- (d) minimum-temperatures over Ghana, 1991-2020............................................................................................................................................................28 Figure 4-2. Observed monthly climatology of (a) rainfall (b) mean- (c) maximum-(d) minimum-temperature, averaged over the defined agro-ecological zones, 1991-2020...................................................................................28 Figure 4-3. Projected climatology of (a) rainfall (b) mean- (c) maximum- (d) minimum-temperatures over Ghana (2020-2039) and (e) rainfall (f) mean- (g) maximum- (h) minimum-temperatures over Ghana (2040-2059)....30 Figure 4-4. Projected monthly climatology of (a, b) rainfall (c, d) mean- (e, f) maximum-(g, h) minimum-temperature averaged over the defined agro-ecological zones, 2020-2039 and 2040-2059..................................................31 Figure 4-5. (a) Timeseries analysis of sea-level anomaly and (b) monthly climatology of sea level anomaly.......................32 Figure 4-6. Sea level change for (a) 2020-2039 and (b) 2040-2059 under 5 Shared Socio-economic Pathways (SSPs)........................................................................................................................................................................33 Figure 5-1. Region wise reported malaria cases, 2012-2021 (a) among females (b) among males and (c) as % of total OPD attendance (disease density).........................................................................................................................49 Figure 5-2. Total reported malaria cases by region, 2012-2021........................................................................................................50 Figure 5-3. (a) Annual region-wise reported malaria cases (b) trends.............................................................................................51 Figure 5-4. Region wise reported schistosomiasis cases, 2012-2021 (a) among females (b) among males and (c) as % of total OPD attendance (disease density)................................................................52 Figure 5-5. Total reported schistosomiasis cases by region, 2012-2021........................................................................................53 Figure 5-6. (a) Annual region-wise reported schistosomiasis cases and (b) trends.....................................................................54 Climate and Health Vulnerability Assessment for Ghana VII Figure 5-7. Region wise reported meningitis cases, 2012-2021 (a) among females, (b) among males, and (c) as % of total OPD attendance (disease severity)..............................................................................................................56 Figure 5-8. Total reported meningitis cases by region, 2012-2021...................................................................................................57 Figure 5-9. (a) Annual region-wise meningitis cases and (b) trends.................................................................................................57 Figure 5-10. Region wise reported diarrhea cases, 2012-2021 (a) among females, (b) among males and (c) as % of total OPD attendance (disease severity).......................................................................................................58 Figure 5-11. Total reported diarrhea cases by region, 2012-2021......................................................................................................59 Figure 5-12. (a) Annual region-wise diarrhea cases and (b) trends....................................................................................................60 Figure 6-1. Health system building blocks................................................................................................................................................66 Figure 8-1. Effect of temperature on diarrhea cases nationally (LQ: lower quartile UQ: upper quartile).................................84 Figure 8-2. Effect of temperature on malaria cases (LQ: lower quartile, UQ: upper quartile)....................................................85 Figure 8-3. Marginal effect of precipatation on malaria cases in Ghana.........................................................................................86 Figure 8-4. Effect of temperature on meningitis cases in Ghana. (LQ: lower quartile, UQ: upper quartile)...........................87 Figure 8-5. Distribution of schistosomiasis cases in Ghana (LQ: lower quartile, UQ: upper quartile)......................................89 Figure 8-6. Distribution of climate induced conditions by region......................................................................................................89 Figure 8-7. Effect of temperature on diarrhea in the North East region of Ghana........................................................................90 VIII Climate and Health Vulnerability Assessment for Ghana LIST OF TABLES Table 1-1. Summary of adaptive capacity gaps and recommendations..........................................................7 Table 2-1. Mediating processes and direct and indirect potential effects of changes in temperature and weather on health...............................................................................12 Table 3-1. Overview of Ghana’s climate context...................................................................................................16 Table 3-2. Ghana’s GDP contributions by sector..................................................................................................21 Table 4-1. List of extreme climate events and their impacts in Ghana between 1968 and 2017.............................................................................................................................................36 Table 6-1. National climate change policies and plans relevant for health....................................................68 Table 6-2. National health sector policies and plans relevant to cliamte change: The National Plan of Action for Building a Climate-Resilient Health Sector, 2015-2025 (draft).....................70 Table 6-3. Sub-national policies and plans relevant to climate change and health: The Medium-Term National Development Policy Framework.........................................................72 Table 6-4. Distribution of health workforce by cadre, 2015...............................................................................74 Table 6-5. Distrbution of health workforce by region, 2015...............................................................................75 Table 6-6. Summary of adaptive capacities and gaps by health system building blocks..........................78 Table 8-1. Distribution of monthly diarrhea cases in Ghana, 2012-2020........................................................83 Table 8-2. Effect of temperature and precipitation on diarrhea cases in Ghana..........................................83 Table 8-3. Distribution of monthly malaria cases in Ghana, 2012-2020.........................................................84 Table 8-4. Effect of temperature and precipitation on malaria cases in Ghana...........................................85 Table 8-5. Distribution of monthly meningitis cases in Ghana, 2012-2020...................................................86 Table 8-6. Effect of temperature and precipitation on meningitis cases in Ghana......................................87 Table 8-7. Distribution of monthly schistosomiasis cases in Ghana, 2012-2020..........................................88 Table 8-8. Effect of temperature and precipitation on schistosomiasis cases in Ghana............................88 Table 8-9. Effect of temperature and precipitation of diarrhea cases in the North East region...............90 Table 8-10. Effect of temperature and precipitation on malaria cases in Savannah region of Ghana....91 Table 8-11. Effect of temperature and precipitation on meningitis cases in Upper West region of Ghana...........................................................................................................................................................91 Table 8-12. Effect of temperature and precipitation on schistosomiasis cases in Upper East region of Ghana.....................................................................................................................................................92 Climate and Health Vulnerability Assessment for Ghana IX LIST OF ACRONYMS AFRO Africa Regional Office BRT Bus Rapid Transit CBEA Community Based Extension Agents CCKP Climate Change Knowledge Portal CFSVA Comprehensive Food Security and Vulnerability Analysis CHAG Christian Health Association of Ghana CHIM Center for Health Information Management CHPS Community Health Planning and Services CHVA Climate and Health Vulnerability Assessment CMIP6 Coupled Model Intercomparison Project Phase 6 COPD Chronic Obstructive Pulmonary Disease CSM Cerebro-Spinal Meningitis CSRPM Centre for Scientific Research into Plant Medicine DENV Dengue Virus DHMIS District Health Information Management System EPA Environmental Protection Agency EWS Early Warning Signs FEW Flood Early Warning GCF Green Climate Fund GDP Gross Domestic Product GHS Ghana Health Services GMet Ghana Meteorological Agency GoG Government of Ghana GSS Ghana Statistical Service HEW Health Early Warning HIV Human Immunodeficiency Virus HSS Heath System Strengthening IDSR Integrated Disease Surveillance and Response IgG Immunoglobulin-G IHD Ischemic Heart Disease IMF International Monetary Fund IPCC Intergovernmental Panel on Climate Change ITNs Insecticide Treated Nets LUSPA Land Use and Spatial Planning Authority M&E Monitoring and Evaluation MDAs Ministries Departments Agencies MMDAS Metropolitan Municipal District Assemblies MOFA Ministry of Food and Agriculture MOH Ministry of Health MRDPs Migrants Refugees and Internally Displaced Populations NADMO National Disaster Management Organisation NAP National Adaptation Plan NDCs Nationally Determined Contributions NGOs Non-Governmental Organizations X Climate and Health Vulnerability Assessment for Ghana NHIS National Health Insurance Scheme NMCP National Malaria Control Program OPD Out-Patient Department PHC Primary Health Care PM Particulate Matter QGDP Quarterly Gross Domestic Product RTI Road Traffic Injuries SSP Shared Socioeconomic Pathways UN United Nations UNFCCC United Nations Framework Convention on Climate Change USAID United States Agency for International Development USD United States Dollars WHO World Health Organization WHO-AIMS World Health Organization Assessment Instrument for Mental Health Systems WMO World Meteorological Organization Climate and Health Vulnerability Assessment for Ghana XI 1. EXECUTIVE SUMMARY Climate change impacts various aspects of life, including health. Its effects on human health can be direct and immediate or indirect and delayed. Direct effects result from increased frequency and severity of extreme weather events, such as heat, drought, and heavy rain. Indirect and delayed effects may be mediated through alterations in natural systems, such as air pollution and water insecurity, or mediated by human systems, such as malnutrition and mental health. Ghana is vulnerable to the effects of climate for strengthening each of the ten components of change. Climate change impacts the epidemiology health system climate resilience. of climate-sensitive infectious diseases such as malaria and diarrhea, which are estimated to be CLIMATE EXPOSURES/HAZARDS the 1st and 8th most common causes of death in Ghana. Additionally, malnutrition and air pollution, OBSERVED AND PROJECTED CLIMATOLOGY also sensitive to climate change, have been AND SEA LEVEL RISE identified as the top two risk factors contributing to death and disability in the country. An analysis of Ghana’s observed climatological trends indicates wide variability in temperature Climate and Health Vulnerability Assessments and precipitation across the country, with (CHVA) are country-level diagnostic tools used the Northern region receiving less rainfall to identify climate risks to health and health and experiencing higher mean and maximum systems, the adaptive capacities in place to deal temperatures. Rainfall patterns are unimodal with these risks, and recommendations to meet in the north and bimodal in the southern part identified gaps. This report presents the findings of the country, with maximum rainfall amounts from Ghana’s CHVA. Accounting for the burden recorded in the southwestern part. The average of climate-sensitive infectious diseases in Ghana, air temperature from 1991 to 2020 generally this report places greater focus on understanding increases with latitude. The mean temperature the impact of climate change on vector and over Ghana ranges between 26OC and 30OC, with water-borne diseases, particularly the impact at the highest in the country's north. Projections for the national and sub-national levels of malaria, 2020-2039 and 2040-2059 estimate that monthly diarrhea, meningitis, and schistosomiasis. It also rainfall patterns will be unimodal, peaking between presents an exploratory analysis of the direct June and September. Overall, a substantial health effects of climate change and its impact on decline in rainfall magnitude is expected over the mental health and air pollution-related diseases. country. Projected temperatures showed bimodal patterns and warmer periods for 2040-2059 The assessment used a multi-pronged compared to 2020-2039. Relative to historical methodological approach, including desk trends, monthly temperature peaks are expected review of documents and literature, quantitative to shift by a month to March-April. analysis of secondary data, and qualitative data collection and analysis. Using the World Health On average, an increase of 3.44 mm in sea Organization’s (WHO) Operational Framework levels per year was observed from 1993 to for Building Climate-Resilient Health Systems, it 2016, though recent years exhibit an estimated presents the assessment of capacities and gaps rise of 50 mm and above. An analysis of along the six Health System Strengthening (HSS) projected changes in sea levels under different building blocks and identifies recommendations emission scenarios using the new Shared 1 Executive Summary Socioeconomic Pathways (SSPs), an indication of HEALTH RISKS climate change projections and Socioeconomic scenarios for evaluating climate impact and VULNERABLE SUB-POPULATIONS adaptation measures, estimated an increasing trend in projected sea level rise. Four SSPs, with Dimensions of poverty, gender, age, urban- varying adaptation and mitigation pathways, rural residence, occupation, and disability can were assessed for the 2020-2039 and 2040- characterize population sub-groups that are 2059 periods. For extreme emission scenarios, most vulnerable to the impact of climate change. with no-to-limited complementing adaptation and The elderly, women, children, the chronically ill, mitigation strategies, the sea level will possibly the socially isolated (for example, disabled, ethnic rise by 6–7 mm/year within the 2020-2039 minorities, and migrants), and at-risk occupational period and 8.5–9.7 mm/year by the 2040-2059 groups are particularly vulnerable to climate period. If stringent measures are adopted to limit change impacts. Relative to other parts of the the emissions, the sea level is expected to rise country, the northern part of Ghana greatly relies by about 5.3 mm/year within 2020-2039, with an on subsistence farming. Thus, it is prone to food increase of about 5.5 mm/year in 2040-2059. insecurity due to the damaging effect of frequent exposure to extreme rainfall and flood events on crop yields. Additionally, poverty rates are higher CLIMATE-RELATED EXTREME EVENTS IN GHANA in the northern region, reducing the ability to adapt to climate change and exacerbating its impact. In the past 50 years, 22 major Women, particularly poor women, are more likely hydrometeorological events in Ghana have to be victims of direct impacts of extreme climate affected 16 million people, directly causing events and are disproportionately affected over 400 deaths. Six climate hazards associated by food and water insecurity in households. with extreme events can be identified in Ghana: Pregnant women are also particularly susceptible droughts, earthquakes, epidemics, floods, to malaria, resulting in maternal anemia. In Ghana, wildfires, and storms. There have been 19 the drivers of migration, particularly in rural areas, significant flood events in the past five decades; are linked to the impacts of climate change on the despite declining projected average rainfall, sustainability of agrarian livelihoods. The level of heavy rainfall events are expected to increase vulnerability is higher in rural areas compared in Ghana, resulting in flooding, flash floods, and to urban due to fewer resources and lower riverbank erosion. Additionally, sea-level rise in adaptive capacity. Women are disproportionately the country is resulting in sea erosion and flooding affected, particularly within rural communities. along the coastal stretch and is pervasive on the Heat stress and high levels of physical labor eastern coast along the Volta delta, affecting disproportionately impact farmers and miners. communities along the coast. Three drought events have occurred in Ghana in the past five decades with varying degrees of impact. Both DIRECT RISKS TO HEALTH OUTCOMES floods and droughts pose a significant threat to the agricultural sector, with the most immediate Extreme climate events like floods and droughts consequence being a decrease in the production have resulted in injuries and fatalities in Ghana. of staple crops and a negative impact on the It is also estimated that about 2 million Ghanaians livelihoods of smallholder farmers. are vulnerable to food insecurity and in the event of a natural disaster, food availability will be greatly affected, particularly in the Northern region and the country’s rural areas. There was little evidence of heat-related mortality and morbidity in Ghana’s context. However, the literature describes the health effects of Climate and Health Vulnerability Assessment for Ghana 2 heat waves. Heat strokes, common during heat damage, physical health effects, food and water waves, result in substantial mortality with a rapid shortages, conflict, and displacement from progression to death. In survivors, permanent acute, subacute, and chronic climactic changes. damage to organ systems can cause severe Regarding resource availability, Ghana’s health functional impairment and increase the risk of system lacks the infrastructure and human early mortality. Besides an increase in mortality, resources to address the burden of mental health evidence from other countries depicts an issues. association between heat waves and increased emergency room admissions, particularly in the INDIRECT RISKS TO HEALTH OUTCOMES: elderly and particularly for respiratory and renal ANALYSES OF CLIMATE-SENSITIVE INFECTIOUS disease outcomes. Additionally, heat waves are DISEASES associated with other health hazards, including air pollution, wildfires, and water and electricity The study analyzed national and sub-national supply failures that have health implications. data on climate-sensitive infectious disease cases. However, there was limited information on Available data suggest that air pollution-related the prevalence of dengue in Ghana, partly due diseases have a high mortality rate and high to challenges in diagnosing it as distinct from cost of treatment in Ghana. According to the malaria. The Ashanti and Eastern regions of the Global Burden of Disease, air pollution remained country reported the maximum absolute number the second greatest risk factor contributing to of malaria cases between 2012 and 2021, though the most deaths and disability in Ghana between cases show a declining trend. As a proportion of 2009 and 2019. A report on ambient air pollution total outpatient cases, the northern part of the and its health impact estimated that in Greater country had the highest malaria load and the least Accra, the 2015 levels of air pollution would be decline in absolute number of cases over time. responsible for about 70,000 years of life lost Between 2012 and 2021, the absolute number of in the adult (25+) population over 10 years. It schistosomiasis cases has been declining nation also estimates that implementing air pollution wide. The number of cases as a proportion of reduction strategies could prevent 1,790 deaths total outpatient cases was <1% across all regions. annually in Greater Accra. Additionally, the report Across the regions, the number of schistosomiasis identifies household air pollution as an issue cases recorded between 2012 and 2021 ranged resulting from the significant use of solid fuels. from less than 500 to over 10,000, with the highest in the Eastern and Upper East regions. Though evidence suggests the role of climate change in increasing stress, anxiety, The study also analyzed national and sub-national depression, and other mental health issues, incidence data for meningitis and diarrhea. there is limited information in the context of Between 2012 and 2021, the total number of Ghana. The literature reflects rapidly expanding meningitis cases reported across the regions of evidence on the link between climate change the country ranged from less than 100 to about and mental health. Extreme weather events such 900 cases. All regions reported <1% meningitis as heat events, humidity, and flooding have been cases as a proportion of total outpatient visits. associated with increased reports of mood and While the upper parts of the country showed a behavioral disorders, including schizophrenia, declining trend in reported cases, regions in the mania, and neurotic disorders. Post Traumatic middle belt, such as the Ahafo and Ashanti, and Stress Disorder (PTSD) is the most often reported the Central Region in the south, have recorded mental health impact of acute climate change- marginal increases. The Ashanti and Eastern related disasters, though there are increasing regions recorded the highest total number of reports of suicide and suicidal ideation. Climate diarrhea cases between 2012 and 2021. However, change can also result in indirect mental health as a proportion of total outpatient visits, the impacts due to physical and social infrastructure northern regions reported the maximum number 3 Executive Summary of cases. Across regions, the total number of HEALTH SYSTEM RISKS cases over the decade ranged from 400,000 to 1.75 million. While the Greater Accra, Eastern, An affordable and accessible primary health and Upper East Regions have seen the greatest care (PHC) system is integral for early decline in cases over time, cases in the Bono East recognition and management of a climate- region seem to be rising by an average of 2,000 induced health emergency. A 2018 report by cases per year. the University of Ghana indicates that Ghana has insufficient health facilities per population In addition, statistical models were constructed density to manage both communicable and to quantify the association of precipitation non-communicable diseases. Moreover, in 2010 and ambient temperature with monthly and 2013, the density of health posts per 100,000 reported diarrhea, malaria, schistosomiasis, people in Ghana declined marginally from 1.18 and meningitis cases at the national and sub- to 1.11, respectively, while the density of health national levels. An ecological study design was centers per 100,000 people fell slightly from 9.69 used in which the unit of observation was the to 9.13. national and administrative regions of Ghana using a monthly time series dataset compiled Despite the expansion of Community Health from the routine health management information Planning and Services (CHPS) Zones, various system and meteorologic estimates between population sub-groups still lack access to 2012 and 2020. PHC services, which may be exacerbated by climate-sensitive health risks. There are gaps Nationally, temperature was associated with in the supply of PHC through government health higher numbers of diarrhea, malaria, and services, while the National Health Insurance meningitis cases, while precipitation was Scheme (NHIS) benefits package largely does associated with higher numbers of malaria not include preventive services. Additionally, cases. At the national level, it was estimated strong referral systems across levels of care that temperature increases were associated with are lacking. The health infrastructure needs to immediate and delayed increases in diarrhea be strengthened to enhance service availability incidence, while the association between and readiness. About half of CHPS Zones meet precipitation and diarrhea was not statistically standards in terms of infrastructure and transport, significant. Both increases in temperature and in and only a third of CHPS Zones and less than precipitation were associated with immediate and half of Health Centers have the full complement delayed rises in malaria incidence. Temperature of equipment. Rural and remote districts often increases were associated with immediate report stock-outs of essential medicines. and delayed increases in meningitis incidence, while the association between precipitation Human resources for health have increased in and meningitis was not statistically significant. Ghana, though there are regional and urban- Neither increased temperature nor increased rural disparities. Over 60% of health facilities precipitation was associated with the incidence and human resources are found in 6 of the of schistosomiasis. In the regional analysis, higher 16 administrative regions of the country, with temperature and precipitation were associated Ashanti and Greater Accra accounting for 40% with both immediate and delayed effects on the of infrastructure and human resources. There incidence of diarrhea, malaria, and meningitis are shortages in some cadres of health workers, cases. However, temperature and precipitation inequities in the distribution and skill configuration were not associated with schistosomiasis, of workers, insufficient training, and deficiencies although the number of schistosomiasis cases in working conditions. This hampers access to increased with increasing temperature. services and achievement of national health objectives. Climate and Health Vulnerability Assessment for Ghana 4 ADAPTIVE CAPACITY AND IDENTIFICATION policy document is the Medium-Term National OF GAPS Development Policy Framework, 2018-2021. The Ministry of Health is establishing a steering Leadership and governance: Ghana has committee on climate change and health that will introduced policies addressing climate change harmonize existing policies and strategies that and its health risks across various sectors. For address the health impact of climate change. example, the government released the National Climate Change Policy Master Plan for 2015- Health workforce: Climate change influences 2020 and initiated the development of a National workforce capacity and may put a strain on overall Adaptation Plan (NAP) in 2020. The NAP aims to health system performance. Despite an increase adopt an integrated, coordinated, and sustainable in the magnitude of the health workforce in the approach to resilience building to reduce country, the country faces a shortfall. Additionally, vulnerability to the negative impact of climate the distribution of the health workforce in the change. Other notable multisectoral policy efforts country is unequal. Health workforce training include the development of a National Climate initiatives relevant to climate change and health Change Adaptation Strategy in 2012, spearheaded have largely focused on infectious diseases, by the National Climate Change Committee, and particularly malaria. the recently updated Nationally Determined Contributions under the Paris Agreement, led by Health information systems: Currently, the the Ministry of Environment, Science, Technology Ghana Health Service collects routine data for and Innovation. Notably, most national-level policy health services rendered, morbidity, mortality, documents have emerged from the non-health and disease burden, which are useful to health sectors, with a variable focus on the health impact managers and used for planning, budgeting, and of climate change. However, the health sector has decision-making. Such information is collected by developed a National Plan of Action for Building a facilities and districts and submitted through the Climate Resilient Health Sector in Ghana for 2015- District Health Information Management System 2025. This plan of action is anchored around the (DHIMS). DHIMS collects information on specific WHO’s ten components of climate-resilient health climate-sensitive infections, namely malaria, systems and includes sections devoted to health diarrhea, meningitis, and schistosomiasis. Outside leadership and governance, health workforce, the health system, the Ghana Meteorological vulnerability, capacity and adaptation assessment, Agency tracks temperature, rainfall, and humidity integrated risk monitoring and early warnings, levels across major cities and districts, the health and climate research, climate resilience National Disaster Management Organization and sustainable technology and infrastructure, (NADMO) captures data on the effect of extreme management of environmental determinants heat, and the Environmental Protection Agency of health, climate-informed health programs, (EPA) has a framework for assessing air quality in emergency preparedness and management and limited parts of the country. climate and health financing. The plan outlines activities under each health system building Essential medical products, technology, and block with measurable outputs and time horizons infrastructure: Floods and other extreme (ongoing, short, medium, and long-term). It also weather events damage healthcare facilities and outlines the lead institutions that can play a key supporting infrastructure. Various national policy role in the realization of the plans and collaborating documents mention the need to strengthen institutions such as Development Partners, health facilities and “climate-proof” existing Non-Governmental Organizations (NGOs), and health infrastructure, though concrete steps the private sector. However, there is limited need to be taken to further these strategies. information about the implementation of the There is an absence of agreed-upon standards Plan of Action or its integration into multisectoral and implementation plans. Additionally, no policies and strategies. The only sub-national assessments have been conducted to determine 5 Executive Summary the climate resilience of the country’s health services; in fact, the share of OOPS in health facilities. This will be particularly imperative for the facilities’ total revenues is increasing. The budget health infrastructure in the rural areas that may be statement of the 2022 financial year estimates the only source of health services in the region. that Ghana requires a total of US$9.3 billion Diagnostic tools, vaccines, and treatments at in investments to implement the 47 Nationally most health facilities do not yet target addressing Determined Contributions programs from 2021 to the health risks of climate change. However, 2030. To mobilize sufficient financial resources, there are examples of interventions utilizing Ghana is exploring more results-based climate medical products and technologies that target financing options, including carbon markets certain climate-sensitive infections, for example, and climate impact bonds. From 2015 to 2020, malaria. Ghana’s National Essential Medicines the Government of Ghana (GoG) reports having List, 2017, includes drugs for various climate- spent a total of GH¢14.5 billion on Climate sensitive infections, including malaria, diarrhea, Relevant Actions, which amounts to an average and schistosomiasis; the list also includes of 4% of the total government expenditure. The meningococcal vaccine. While drug stockouts total GoG expenditure between 2015 and 2020 have been reported at health facilities, there is was GH¢ 369 billion, of which GH¢ 14.5 billion limited information on the frequency of stockouts was earmarked for Climate Relevant Actions. The of drugs specifically used to prevent and manage recent increase in GoG expenditure is attributed to common climate-sensitive conditions. government interventions in non-health sectors. Among Ministries, Departments, and Agencies Service delivery: There are gaps in the (MDAs), agriculture and food security showed distribution of health facilities and the health the highest expenditure. In contrast, at the workforce, particularly in rural areas, which affect Metropolitan, Municipal, and District Assemblies access to and availability of care to address the (MMDAs) level, water and sanitation showed the burden of climate-related health risks. Moreover, highest expenditure. better coordination is needed for service delivery across a range of healthcare and public health Recommendations to reduce climate-related programs, including those important to reduce health vulnerabilities and vulnerabilities of the climate change risks. Vertical health programs health system and interventions, such as for malaria, are in place to address the burden of the climate-sensitive Based on the findings presented in this report, diseases. However, given the wide-reaching the gaps in adaptive capacity and corresponding impact of climate change on mental health, recommendations are summarized in Table 1-1. maternal health, respiratory health, and infectious This report is a first, largely exploratory, analysis of diseases, to name a few, system-wide integration the impacts of climate change on health in Ghana is needed. Additionally, multisectoral action, as so that recommendations are necessarily geared highlighted in the country’s health and climate towards further research, monitoring, dialogue, change policies, needs to be implemented. policy development, and building systems and capacities. Health system financing: The government’s health budget has increased in absolute terms in recent years, but health facilities are highly dependent on NHIS payments for services to cover non-salary recurrent costs. Thus, delays in NHIS payments to the facilities limit their ability to render services, particularly in a disaster response situation. Despite the expansion of NHIS, out-of-pocket payments (OOPS) represent the second highest source of financing health Climate and Health Vulnerability Assessment for Ghana 6 TABLE 1-1. Summary of adaptive capacity gaps and recommendations HEALTH SYSTEM GAPS IN ADAPTIVE RECOMMENDATIONS BUILDING BLOCKS CAPACITY Leadership and • Little focus on strategies Leadership and governance governance to minimize the health • Undertake dialogue, impact of climate change development, and on the most vulnerable sub- implementation of the populations. National Plan of Action • Presence of many national for Building a Climate climate change policies with Resilient Health Sector varying focus on its health in Ghana, 2015-2025. impact. Most policies have Integrate its objectives emerged from non-health and activities into sectors, except the National climate change policies Plan of Action for Building emerging from other a Climate Resilient Health sectors to allow Sector in Ghana, 2015- alignment. 2025. However, there is limited information about the implementation of the Plan of Action or its integration into multisectoral policies and strategies. Health workforce • Despite an increase in the Health workforce magnitude of the health • Integrate climate-related workforce in the country, the impacts into health country faces some gaps. workforce planning. The distribution of the health • Institutionalize climate- workforce is unequal, with related capacity building resources concentrated in of the health workforce urban areas. with buy-in from relevant • Health workforce training regulators. initiatives relevant to climate change and health have largely focused on infectious diseases, particularly malaria, with little emphasis on the wide- reaching health outcomes and systems implications of climate change. 7 Executive Summary HEALTH SYSTEM GAPS IN ADAPTIVE RECOMMENDATIONS BUILDING BLOCKS CAPACITY Health information • The routine health information Vulnerability, capacity, and systems and surveillance systems in adaptation assessment Ghana collect information • Periodically conduct on specific climate-sensitive national and sub-national infections, namely malaria, climate and health diarrhea, meningitis, and vulnerability assessments. schistosomiasis. • There are information systems Integrated risk monitoring outside the health sector that and early warning track changes in climate and • Enhance the coverage of weather, though they are not climate-sensitive health integrated with the health conditions in routine health information systems. information systems. • Routine integration of weather and disease forecasting. Health and climate research • Identify and prioritize knowledge gaps in health and climate research. • Understand the impact of climate change on individuals and communities through research. • Build capacity to use combined health and climate models • Timely analysis and dissemination of surveillance data. Climate and Health Vulnerability Assessment for Ghana 8 HEALTH SYSTEM GAPS IN ADAPTIVE RECOMMENDATIONS BUILDING BLOCKS CAPACITY Essential medical • Floods and other extreme Climate resilient and sustainable products, technologies weather events are known to technologies and infrastructure and infrastructure. damage hospitals and other • Undertake vulnerability health care facilities. assessments of health • Various national policy facilities to climate change. documents mention the need • Upgrade public health to strengthen health facilities infrastructure. and “climate-proof” existing • Introduce climate-smart health infrastructure, though health sector infrastructure concrete steps must be taken codes. to further these strategies. • Routinely evaluate the • No assessments have been availability of drugs conducted to determine the and equipment for climate resilience of health the prevention and facilities in the country. management of climate- • Availability of diagnostic sensitive infectious tools, vaccine, and treatment diseases such as malaria. available at most health facilities is not yet targeted at addressing health risks of climate change. • There is limited information on the frequency of stockouts of drugs used to prevent and manage common climate- sensitive conditions. Service delivery • There are gaps in health Management of environmental infrastructure and workforce, determinants of health particularly in rural areas, • Multisectoral action to which limit access to and improve determinants of availability of care to address health. the burden of climate-related health risks. Climate-informed health • There is an absence of programs institutional mechanisms • Continue implementation that integrate strategies for and strengthening of vector addressing the impact of and water-borne infectious climate change into all vertical disease control programs. health programs and non- • Adopt systems approach health sectors by utilizing a to strengthen all health systems approach. programs towards climate change. 9 Executive Summary HEALTH SYSTEM GAPS IN ADAPTIVE RECOMMENDATIONS BUILDING BLOCKS CAPACITY Emergency preparedness and management • Contingency planning. • Build an effective emergency communication system. • Active engagement of communities in emergency response. Health system financing • The government’s health Climate and health financing budget has increased in • Sustained and holistic health and absolute terms in recent years, climate change financing. but health facilities are highly • Monitor climate-related health dependent on NHIS payments expenditure in line with policy for services to cover non-salary commitments. recurrent costs. • Ensure smooth and timely claims • Despite the expansion of payments from NHIS to the NHIS, out-of-pocket payments health facilities. (OOPS) represent the second • Financial protection of vulnerable highest source of financing sub-populations. health services. • Between 2015 and 2020, the GoG reportedly spent an average of 4% of the total government expenditure on Climate Relevant Actions. There is a need to establish sustainable streams of funding to address climate change. • The recent increase in GoG expenditure is largely attributed to government interventions in non-health sectors. Source: Authors Climate and Health Vulnerability Assessment for Ghana 10 2. INTRODUCTION AND BACKGROUND Due to global warming, the climate in most regions, especially Africa, is predicted to become more variable, and extreme weather events are expected to be more frequent and severe. These include increasing risks of droughts, flooding, and inundation due to sea-level rise in the continent’s coastal areas, potentially reducing economic prospects and national development. It will be imperative for countries to mitigate and adapt to these changing climatic conditions. To succeed,, the potential impacts of climate change and variability must be identified along with the country’s capacity to adapt and the means to overcome barriers to successful adaptation. Climate change impacts various aspects of life, exacerbate existing patterns of ill health by acting including health. Its effects on health can be on the underlying vulnerabilities of environmental direct or indirect. The impacts of climate change and sociodemographic origin that led to ill health on health result from three essential pathways even in the absence of climate change. Studies (see Table 2-1): (i) direct and immediate health suggest that children, young people, and the impacts relating primarily to increased frequency elderly are at increased risk of climate-related and severity of extreme weather events, including illness with adverse effects of malaria, diarrhea, heat, drought, and heavy rain, (ii) indirect and and undernutrition concentrated among children5. delayed effects mediated through alterations in natural systems such as air pollution and water Ghana is vulnerable to the health impacts of insecurity that include allergic and infectious climate change. In Ghana, malaria and diarrhea diseases, and (iii) indirect and delayed effects – both climate-sensitive infectious diseases – are heavily mediated by human systems such as estimated to be the 1st and 8th most common malnutrition and mental health1,2,3. The pathways cause of death6. Additionally, malnutrition and and effects of climate change are summarized in air pollution, also sensitive to climate change, Figure 2-1. have been identified as the top two risk factors contributing to death and disability in the country. Climate change impacts the epidemiology of infectious diseases4. It could alter or disrupt Ghana is a signatory to the United Nations natural systems. This disruption could make it Framework Convention on Climate Change possible for diseases to emerge. It could also (UNFCCC) and is obligated to carry out national cause diseases to spread to areas where they assessments of the potential impacts of were initially limited or did not exist. In other climate change, including on the health sector. scenarios, some areas could become less Vulnerability assessments have typically focused hospitable to the vector or the pathogen, causing on identifying communities and regions exposed diseases to disappear. Climate change could also to environmental stressors; they are not designed to examine strategies. Merging vulnerability assessments with adaptation and resilience 1. Costello A. et al. (2009). Managing the health effects of Climate Change. The research provides an opportunity to explicitly link Lancet. 373(9676):1693–733 2. Jankowska, M. M., Lopez-Carr, D., Funk, C., Husak, G. J., & Chafe, Z. A. (2012). vulnerability assessments with the formulation Climate change and human health: Spatial modeling of water availability, malnutrition, and livelihoods in Mali, Africa.  Applied Geography,  33, 4-15. doi:10.1016/j.apgeog.2011.08.009 3. Intergovernmental Panel on Climate Change (IPCC). (2014). Climate Change 2014: Summary for policymakers. Contribution of Working Group II to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change. 5. Xu, Z., Huang, C., Turner, L. R., Su, H., Qiao, Z., & Tong, S. (2013). Is diurnal Cambridge, United Kingdom and New York, USA: Cambridge University Press. temperature range a risk factor for childhood diarrhea?.  PLoS One,  8(5), 4. Watts, N., et al. (2018). The 2018 report of the Lancet Countdown on health e64713. and climate change: shaping the health of nations for centuries to come. The 6. IHME (2019). Global Burden of Diseases. Seattle. Available at: https://www. Lancet, 392(10163), 2479-2514. healthdata.org/ghana 11 Introduction and Background of policies. The Third Intergovernmental Panel tool can assist in understanding the direct and on Climate Change (IPCC) Assessment Report indirect impacts of climate change by analyzing suggests that vulnerability is a function of the mediating influences, serve as a pathway to exposure, sensitivity, and coping or adaptive improving evidence and understanding of the capacity, reporting significantly on the global linkages between climate change and health, health impacts of climate change. and providing a baseline analysis against which changes in disease risk and protective measures Climate and Health Vulnerability Assessments can be measured. Despite an increasing (CHVA) are a country-level diagnostic tool understanding of health risks associated with to identify climate risks to health and health climate change, public health policies and systems, the adaptive capacities that are in place practices globally do not account for climate to deal with these risks, and recommendations change-related health impacts. Additionally, to meet identified gaps. The tool can be used to existing indicators used to evaluate climate change assess which populations are most vulnerable to resilience in the health sector are inadequate the different climatic stresses and accompanying and primarily drawn from environmental health health effects, identify key weaknesses in human perspectives. The CHVA, therefore, is pivotal in systems that protect vulnerable populations, and differentiating climate change and environmental propose interventions for critical response. The health outcomes. TABLE 2-1. Mediating processes and direct and indirect potential effects of changes in temperature and weather on health. Mediating process Health outcome Direct effects Changed rates of illness and death related to heat Exposure to thermal extremes and cold Changed frequency or intensity of other extreme Deaths, injuries, psychological disorders; damage to weather events public health infrastructure Indirect effects Disturbances of ecological systems: Changes in geographical ranges and incidence of Effect on range and activity of vectors and infective vector borne disease parasites Changed local ecology of water borne and food Changed incidence of diarrhoeal and other borne infective agents infectious diseases Changed food productivity (especially crops) Malnutrition and hunger, and consequent impairment through changes in climate and associated pests of child growth and development and diseases Sea level rise with population displacement and Increased risk of infectious disease, psychological damage to infrastructure disorders Biological impact of air pollution changes (including Asthma and allergies; other acute and chronic pollens and spores) respiratory disorders and deaths Social, economic and demographic dislocation Wide range of public health consequences: mental through effects on economy, infrastructure, and health and nutritional impairment, infectious resource supply. diseases, civil strife Source: McMichael and Haines, 1997 Climate and Health Vulnerability Assessment for Ghana 12 FIGURE 2-1. climate resilience (outer ring), providing Pathways through which climate change affects recommendations for strengthening each of human health. them. Figure 2-2. WHO operational framework for building climate resilient health systems. Source: World Bank Group and WHO, 2018 2.1. OBJECTIVE AND CONCEPTUAL FRAMEWORK This CHVA aims to assist decision-makers in Ghana with planning effective adaptation measures to deal with climate-related Source: WHO, 2015 health risks. The report identifies the impact of climate risks on health and health systems, the adaptive capacities in place to deal with these risks, and the gaps in the adaptive 2.2. APPROACH AND METHODOLOGY capacities. It also provides recommendations to close the identified gaps. Accounting for the burden of climate- sensitive infectious diseases in Ghana, this The report adopts the World Health report focuses on understanding the impact Organization’s (WHO) Operational of climate change on vector and water- Framework for Building Climate-Resilient borne diseases. In particular, it presents a Health Systems to analyze Ghana’s adaptive deep dive into the climate change effects on capacity to adequately deal with current national and sub-national cases of malaria, and future identified health risks of climate diarrhea, meningitis, and schistosomiasis. change. Following this framework (see Due to a paucity of data, the report presents Figure 2-2), the report assessment is firstly a limited analysis of the direct health effects structured around the six Health System of climate change and the climate change Strengthening (HSS) building blocks (inner impact on mental health and air pollution- ring). These six categories encompass the related diseases. assessment of capacities and gaps, now and into the future. The framework then considers The assessment used a multi-pronged the ten components of health system methodological approach, including a 13 Introduction and Background desk review of documents and literature, routine health management information quantitative analysis of secondary data, systems and meteorologic estimates between and qualitative data collection and analysis. 2012 and 2020. We used a negative binomial A desk-based review of published and regression model with robust standard errors grey literature was conducted to identify that address issues of residual autocorrelation key climate exposures. To summarize to quantify the association of precipitation current and future climatic patterns, a and ambient temperature with monthly comprehensive climate-related database reported diarrhea, malaria, schistosomiasis, comprising temperature, precipitation, and and meningitis cases, from the years 2012 humidity, among others, was used to assess to 2020 in 16 administrative regions of the historical and projected climatologies, as Ghana. To assess adaptation options and the well as, spatiotemporal climate patterns and health sector’s adaptive capacity towards to assess trends across the country. Climatic mitigating the impact of climate change, Research Unit (CRU) time series data was a desk-based review of policy documents used for historical assessment, whereas and country-level action plans from Ghana’s the ensemble mean of Coupled Model Ministries, Departments, and Agencies (MDA) Intercomparison Project Phase 6 (CMIP6) were reviewed. Additionally, a stakeholder data with Shared Socioeconomic Pathways validation workshop was held with individuals (SSP5.85) were used for the projection from various sector ministries, wherein assessment. To assess the intersection the report’s findings were validated, and between climatology and selected health additional information on Ghana’s current and outcomes or risks, the analysis utilized planned adaptive capacities was obtained. an ecological study design in which the unit of observation was the national and administrative regions of Ghana using a monthly time series dataset compiled from Climate and Health Vulnerability Assessment for Ghana 14 3. OVERVIEW OF GHANA COUNTRY CONTEXT 3.1. GEOGRAPHY into 16 regions, each further divided into districts that represent a decentralized local FIGURE 3-1. governance system and further represented Ghana’s administrative regions and by zonal committees. their capitals 3.2. CURRENT CLIMATE AND ENVIRONMENT Air temperatures in Ghana have increased over the last few decades with a higher rate of increase in the north compared to the south. The country’s tropical climate is strongly influenced by the West Africa monsoon winds; it is generally warm with variable temperatures masked by seasons and elevation. The northern part of the country typically records one rainy season, which begins in May and lasts until September. Southern Ghana records two rainy seasons: the major season from April to July and the minor one from September to November. Several climate models have confirmed that air temperature has increased by 1.0OC between 1960 and 2003, at an average rate of 0.21OC per decade. The rate of increase has generally been more rapid in the northern Source: The Permanent Mission of Ghana to the UN (n.d) parts than in the southern parts. Rainfall is highly variable on inter-annual and inter- Ghana is located on West Africa's south- decadal timescales, suggesting that long- central coast, sharing borders with Togo to term trends and associated consequences the east, Cote d'Ivoire to the west, Burkina would be difficult to identify and manage, as Faso to the north, and the Gulf of Guinea and scientific evidence confirms changing climatic the Atlantic Ocean to the south. The country conditions over the last three decades, lies close to the equator between latitudes including evidence of deteriorated prevailing 4.50 N and 11.50 N and longitudes 3.50 W and climatic conditions. There are uncertainties 1.30 E. Ghana has a total land area of 239,460 in the rainfall patterns that vary across the km², and its marine territories reach about 200 different ecological zones in Ghana. An nautical miles offshore. Ghana is divided into overview of Ghana’s current climate context sixteen central administrative regions, with is provided in Table 3-1. its capital headed by a politically appointed Regional Minister. Figure 3-1 shows the regions and their capitals7. Ghana is divided 7. The Permanent Mission of Ghana to the UN. Available at: https://www. ghanamissionun.org/map-regions-in-ghana/ 15 Overview of Ghana Country Context TABLE 3-1. Overview of Ghana’s climate context TEMPERATURE RAINFALL The average number of ‘hot’ days per year has Rainfall variability is higher in the forest regions increased by 48, an additional 13.2% of days. than in the rest of the country. The number of hot nights per year increased by More than ever before, the high likelihood of 73, an extra 20% of nights. wet spells may lead to floods. The frequency of cold days per year has The likely increases in dry spells can exacerbate decreased by 12, 3.3% of days. drought conditions. The number of cold nights per year has reduced by 18.5, 5.1% of days. Source: Authors The water quality of Ghana’s surface water diameter, are known to clog human lungs resources has a Class II or “fairly good” water and constitute a health risk11. The WHO quality status, though there are spatial and recommends a PM2.5 yearly guideline of 5 seasonal differences. Ghana’s surface water micrograms per cubic meter (g/m3)12 against resources are primarily derived from the Ghana’s PM2.5 concentrations of 35 g/m3 Coastal, South-Western, and Volta, the latter in 201713. However, these data are recorded comprising the Red, Black, and White Volta, as at only a few locations in the Greater Accra well as the Oti River. The South-Western river Region and are not accessible to the general systems comprise the Bia Tano, Ankobra, and public. The airflow and circulation over Pra rivers. Coastal river systems include the Ghana are dry and dusty northeast trade Tordzie/Aka, Densu, Ayensu, Ochi-Nakwa, winds during the Harmattan seasons and and Ochi-Amissah. These river systems the moist and warm southwest monsoon account for approximately 70% (Volta), 22% winds during the Rainy Season. The Hadley (South-Western), and 8% (Coastal) of the total Circulation drives the general atmospheric surface water8,9. The finest and worst water air circulation, with its converging arm largely quality occurs within the Densu basin10. linked with cloudiness and associated rainfall bands that drench the region with As a measure of Ghana’s air quality, the seasonal rains. Low-level air quality is driven annual mean PM2.5 concentrations are by dangerous amounts of toxic air, primarily up to six times higher than the WHO from car emissions, trash fires, road dust, recommended limits. These ultra-fine and soot from biomass-fueled cookstoves particles, 2.5 micrometers or smaller in and pollutants and other aerosols, which are mixed, especially during peak sunshine hours. 8. Ministry of Water Resources, Works and Housing, Ghana. (2007). Ghana national water policy. 9. Yeleliere, E., Cobbina, S. J., & Duwiejuah, A. B. (2018). Review of Ghana’s water resources: the quality and management with particular focus on 11. Xing, Y. F., Xu, Y. H., Shi, M. H., & Lian, Y. X. (2016). The impact of PM2. 5 on the freshwater resources. Applied Water Science, 8(3), 1-12. human respiratory system. Journal of thoracic disease, 8(1), E69. 10. Darko, H. F., Ansa-Asare, O., & Paintsil, A. (2013). A number description of 12. WHO. (2021). Ambient (outdoor) air pollution. Available at: https://www.who. Ghanaian Water Quality-A case study of the Southwestern and coastal rivers int/news-room/fact-sheets/detail/ambient-(outdoor)-air-quality-and-health. systems of Ghana. Journal of Environmental Protection, 4(11), 1318. 13. The World Bank group. (2017). World Development Indicators. Climate and Health Vulnerability Assessment for Ghana 16 3.3. POPULATION AND DEMOGRAPHIC household size is 3.6 persons. The population TRENDS has increased by 6.1 million from the 24.7 million recorded in 2010, constituting an Ghana’s annual intercensal population annual intercensal growth rate of 2.1%. This growth rate was 2.1% between 2010 rate is less than observed in the previous and 2021, the lowest observed since intercensal period (2000 – 2010: 2.5%) and is independence. Ghana has a total population the lowest observed since independence. At of 30.8 million, of which 50.7% are females this rate, the country’s population will double and 49.3% are males. The national sex ratio within 33 years. And by 2050, the population is 97 males for every 100 females, and the of Ghana will be over 50 million14. Figure 3-2 national population density is 129 persons per shows Ghana’s population size and growth square kilometer as per the 2021 Population rate from 1960 to 2021, and figure 3-3 shows and Housing Census. The average national the population size distribution by region15. FIGURE 3-2. Ghana’s population size and growth rate, 1960-2021. Source: Ghana Statistical Services, 2021 14. Ghana Statistical Service (GSS). (2021). Population and Housing Census (PHC). Available at: www.census2021.statsghana.gov.gh/dissemination. 15. Ghana Statistical Service (GSS). (2021). Population and Housing Census (PHC). Available at: www.census2021.statsghana.gov.gh/dissemination. 17 Overview of Ghana Country Context Figure 3-3. Distribution of population size by region Source: Ghana Statistical Services, 2021 The country’s population pyramid is represents the age and sex composition of transitioning from one dominated by the population. The report indicates that the children aged 0-14 years to that dominated proportion of children declined from 41.3% by young people aged 15-35 years, which is in 2000 to 35.3% in 2021, while the young evident in all the regions of Ghana though population increased from 34.0% in 2000 to most pronounced in Greater Accra (see 38.2% in 2021. Figure 3-4; 3-5). The population pyramid FIGURE 3-4. Population pyramid by gender Source: Ghana Statistical Services, 2021 Climate and Health Vulnerability Assessment for Ghana 18 FIGURE 3-5. Population pyramid by location Source: Ghana Statistical Services, 2021 The life expectancy in Ghana in 2021 was 3.4. ECONOMIC DEVELOPMENT 62 years and 66 years among males and females, respectively16. Life expectancy at Ghana is a lower-middle-income country. birth is the average number of years a newborn Its economy grew at an average of 7% is expected to live if mortality patterns at the from 2017 to 2019 before contracting time of its birth remain constant in the future. sharply in the second and third quarters It reflects a population's overall mortality level of 202017. The country has made significant and summarizes the mortality pattern across progress towards democracy under a multi- all age groups in a given year. The higher life party system in the last two decades, with its expectancy among females was evident in independent judiciary gaining public trust. urban and rural areas. Ghana has routinely ranked among Africa’s top three countries for freedom of expression and press. Major economic drivers/sectors of Ghana’s economy have been classified under agriculture, industry, and service sectors. In 2022, the share of agriculture in Ghana’s Gross Domestic Product (GDP) was 19.57%; industry contributed approximately 31.99%, and the services sector contributed about 16. Ghana Statistical Service (GSS). (2010) Population and Housing Census 17. 17. The World Bank Group. (n.d). Ghana Overview. Available at:   https:// (PHC). Available at: https://statsghana.gov.gh/gssmain/fileUpload/ www.worldbank.org/en/country/ghana/overview pressrelease/2010_PHC_National_Analytical_Report.pdf 19 Overview of Ghana Country Context 42.03%18. The current and projected GDP deficit as a percentage of GDP was 5.1%20. trends (Billions, USD) are presented in Figure As the pandemic-induced food price shock 3-6. In 2022, Ghana experienced a decrease subsided, headline inflation stayed low at in its GDP, which stood at 73.77 billion USD, 7.8% in June 2021, prompting the Bank of down from the previous year's GDP of 79.52 Ghana to cut its policy rate by 100 basis points billion USD19. Crops, education, trade, auto to 13.5 % in May to aid the recovery. However, repair, household goods, manufacturing, and due to rising food and non-food inflation, information and communication were the inflation increased by 9.7% in August. Imports primary drivers of GDP growth in the third grew faster than exports in early 2021, fueled quarter of 2021 (see Table 3-2). by the domestic recovery, while commodity demand remained passive. As a result, the In 2020, the country’s overall fiscal deficit current account deficit increased in the increased to 15.2%, and public debt climbed second quarter of 2021, rising from 0.8% to to 81.1% of GDP, putting the country at 1.3% of GDP21. risk of debt distress. Despite a significant downturn in mining and the pandemic's second wave, growth accelerated in the first and second quarters of 2021. The fiscal FIGURE 3-6. GDP trends, 2014-2022, with projections for 2023 (USD Billion) Source: Trading Economics, the World Bank Group 20. Data available at: https://www.statista.com/statistics/447524/share-of- 18. Data available at: https://www.statista.com/statistics/447524/share-of- economic-sectors-in-the-gdp-in-ghana/ economic-sectors-in-the-gdp-in-ghana/   21. Ghana Statistical Service. (2021). Quarterly Gross Domestic Product (QGDP) 19. Data available at: https://tradingeconomics.com/ghana/gdp Third Quarter 2021 Quarter 2019. 1–11 Climate and Health Vulnerability Assessment for Ghana 20 TABLE 3-2. Ghana’s GDP contributions by sector Related Last Previous Unit Reference GDP 72.35 67.23 USD Billion Dec/20 GDP per capita 1940.68 1974.29 USD Dec/20 GDP per capita PPP 5304.98 5396.87 USD Dec/20 GDP From Utilities 228.56 195.80 GHS Million Jun/21 GDP From Transport 2386.96 2443.50 GHS Million Jun/21 GDP From Services 16083.96 18253.10 GHS Million Jun/21 GDP From Public Administration 1448.38 1486.30 GHS Million Jun/21 GDP From Mining 4873.71 5018.50 GHS Million Jun/21 GDP From Manufacturing 4612.31 6772.80 GHS Million Jun/21 GDP From Construction 3365.57 3558.70 GHS Million Jun/21 GDP From Agriculture 7548.71 9554.50 GHS Million Jun/21 Source: Trading Economics, the World Bank Group Due to rising commodity prices and robust 14% of GDP in 2021 and 9.5% in 2023, still domestic demand, Ghana’s economy is exceeding Ghana’s 5% cap22. expected to gradually recover over the medium term. Ghana recently received $1 The country’s economic slowdown has an billion in Special Drawing Rights (SDR) from impact on household poverty rates. It is the International Monetary Fund (IMF), a estimated that the poverty rate in the country portion of which will be used to aid economic will increase from 25% in 2019 to 25.5% in recovery. In 2021-23, annual growth is 202023. The country’s northernmost regions predicted to average 5.1%. Real per capita are expected to remain the poorest. GDP is expected to rebound to pre-COVID-19 levels in 2021, after dropping by 1.7% in 2020. The fiscal deficit is expected to remain high as the government implements its economic stimulus program. It is expected to fall to 22. International Trade Administration. (2022). Ghana - Country Commercial Guide. Available at: https://www.trade.gov/country-commercial-guides/ ghana-healthcare 23. The World Bank Group. (n.d). Ghana Overview. Available at:  https://www. worldbank.org/en/country/ghana/overview 21 Overview of Ghana Country Context 3.5. DISEASE BURDEN of similar countries with low-middle social- demographic indicators. Lower respiratory Malaria, a climate-sensitive vector-borne infections, HIV/AIDS, tuberculosis, and disease, is the leading cause of death in the diarrhea are the other major infectious country and is the second leading cause of diseases causing deaths and disability in death and disability combined24. Despite the country (see Figure 3-8). The proportion a nearly 34% decrease in its contributions of deaths and disability due to non- towards total deaths in the country between communicable diseases (NCD) like stroke, 2009 and 2019, it still causes the most deaths ischemic heart disease, and diabetes are on (see Figure 3-7). Estimates suggest that the the rise, while road injuries are increasingly country’s burden of deaths and disability due causing more disability. to malaria is much higher than the average FIGURE 3-7. Causes of deaths in Ghana Source: IHME, 2019 24. IHME. (2019). Global Burden of Diseases, Seattle. Available at: https://www.healthdata.org/ghana Climate and Health Vulnerability Assessment for Ghana 22 FIGURE 3-8. Causes of deaths and disability in Ghana Source: IHME, 2019 Malnutrition and air pollution are two leading waste disposal and inappropriate disposal of risk factors causing the most fatalities and plastic bottles and bags. Lifestyle-related risk disability combined, both climate-sensitive factors like high blood pressure, high body (see Figure 3-9). In Ghana, there are various mass index, and high fasting blood glucose environmental, health, and safety issues are increasingly contributing to more deaths arising from the burning of used lorry tires and disability. to extract copper wires for sale, improper land reclamation in the mining industry, open defecation, the dismantling and burning of used electronic gadgets to extract valuable metals for sale, inappropriate human liquid FIGURE 3-9. Risk factors causing deaths and disability in Ghana Source: IHME, 2019 23 Overview of Ghana Country Context 3.6. HEALTH SYSTEM These levels of care include Community- Based Health Planning and Services (CHPS) In Ghana, the Ministry of Health (MOH) compounds, community health centers, and and Ghana Health Services (GHS) oversee polyclinics; followed by district hospitals at the health care infrastructure and service district health center level that are the primary delivery. The Ghana Health Service and the referral facilities for health centers and clinics Teaching Hospitals Act (ACT 525), passed in at the sub-district level; regional hospitals; 1996, separated governance and policy from and finally, referral hospitals that are usually the operational and service aspects of health teaching hospitals. Private health facilities service delivery. The Ministry is mandated to include clinics and hospitals. Available data formulate policies and design appropriate show that as of May 2020, the total number measures for implementation, while the GHS of health facilities countrywide was 2,773, implements the policies and is in charge of of which 1,625 were government hospitals. providing health services. Private hospitals and health facilities from the Christian Health Association of Ghana The mission statement of the Ministry of (CHAG) were 928 and 220 respectively27. Health (MOH) is to promote "health and vitality for all individuals living in Ghana Public funding through the Ministry of Health via access to quality health care provided and Ghana's National Health Insurance by motivated employees”25. However, Scheme (NHIS) constitute the major source cultural and religious convictions, poor of financing health care, followed by out-of- physical infrastructure, and limited resources pocket expenditures (OOPS). The National collectively contribute to significant service Health Insurance Scheme (NHIS) was discrepancies between North and South, established in 2003 to eliminate imbalances affluent and poor. All these factors combine in service provision between rich and poor to make it difficult for planners and politicians people. It evolved rapidly by transitioning to provide universal access to healthcare its existing community health insurance services. Furthermore, the Ghana National schemes into a national health insurance Health Policy 2007, dubbed “Creating Wealth program supported by significant amounts through Health,” was developed to help of earmarked government revenues28. realize the country’s vision26. The strategy The NHIS is financed by a national health acknowledges that poor health is both a cause insurance fund. The fund has three main and a result of poverty and that environmental sources: first, tax revenue of a 2.5% Valued factors impact health. It provides a sector- Added Tax (VAT) on goods and services which wide strategy for improving population health contributes to about 70% of the fund; second, and reducing access disparities based on 2.5% of contributions of Social Security and preventative and curative treatment. National Insurance Trust (SSNIT) contributors who are largely formal sector workers and Ghana’s health service delivery system is which contributes to about 20% of the fund; plural and decentralized. Service providers and third, income adjusted premiums which include public, private, faith-based, and range from between GH7 to GH48 for non- traditional medicine sectors (see Figure 3-10). SSNIT contributors which contribute to about The public sector is organized into primary, 5% or less to the fund. Funding for health secondary, and tertiary levels of care. care services, administration of the NHIS, and 25. Ministry of Health, Government of Ghana. Available at: www.moh-ghana.org 27. Data available at: https://www.statista.com/statistics/1238760/number-of- 26. Ministry of Health (2007). National Health Policy 2007, Government health-facilities-in-ghana-by-ownership/ of Ghana. Available at: https://www.moh.gov.gh/wp-content/ 28. Schieber, G., Cashin, C., Saleh, K., & Lavado, R. (2012). Health financing in uploads/2016/02/NATIONAL-HEALTH-POLICY.pdf Ghana. The World Bank. doi:10.1596/978-0-8213-9566-0 Climate and Health Vulnerability Assessment for Ghana 24 premium exemptions for specific categories through the National Health Insurance Law of people, including people with low incomes, (Act 650 of Parliament) in 2003 and had a are financed by the National Health Insurance legal framework in 2004 through the National Fund (NHIF). The NHIS was established Health Insurance Regulations (L.I. 1809)29. FIGURE 3-10. Organization of the health system in Ghana Source: George Joseph Schieber, 2012 29. Government of Ghana, 2003; 2004. 25 Overview of Ghana Country Context Box 1. Summary of Ghana country context Ghana lies close to the equator and is listed among the 19 “climate hotspots” in Africa. Air temperatures in Ghana have increased over the last few decades with a higher rate of increase in the north compared to the south. There is pronounced temperature and climate variability across the country. Surface water resources are restricted. The water quality of Ghana’s surface water resources has a Class II or “fairly good” water quality status, though there are spatial and seasonal differences. As a measure of Ghana’s air quality, the annual mean PM2.5 concentrations are up to six times higher than the WHO recommended limits, which constitute a health risk. The total population of the country in 2021 stands at 30.8 million, though the annual inter-censal population growth rate was 2.1% between 2010 and 2021, which is the lowest since independence. Additionally, the country’s undergoing a demographic shift, transitioning from one dominated by children aged 0-14 years to that dominated by young people aged 15-35 years. It also faces rapid urbanization. Diseases and risk factors like malaria, diarrhea, malnutrition and air pollution are some of the leading causes of deaths and disability in the country. Photo: © Jonathan Ernst / World Bank Climate and Health Vulnerability Assessment for Ghana 26 4. CLIMATE EXPOSURES / HAZARDS This section describes observed, historical climatic changes (1991-2020) and projected climatic changes in rainfall and temperature (mean, minimum, maximum) across Ghana for 2020-2039 and 2040-2059. Climate data were retrieved from the World Bank Group’s Climate Change Knowledge Portal (CCKP). The Climatic Research Unit (CRU) time series data processed and archived by the University of East Anglia, was used for the historical assessment, whereas the ensemble mean of Coupled Model Intercomparison Project Phase 6 (CMIP6) data with Shared Socioeconomic Pathways (SSP5.85) was used for the projection assessment. The data were assessed temporally (on can be attributed to differences in rainfall different resolutions: monthly and annually) onset dates, moisture build-up and transport, and spatially for the spatiotemporal patterns and rainfall regimes (uni- and bi-modal), to and trends and the short to medium-term mention a few30,31,32,33. Observed data shows changes. Also presented are observed and that the annual range of mean temperatures projected changes in sea level rise between increases from the south to the north. The 2020-2039 and 2040-2059 using the new climatological mean temperature over Ghana Shared Socioeconomic Pathways (SSPs) shows that the average air temperature that are an indication of climate change increases with latitude, except for some areas projections and socioeconomic scenarios of the east coast (see Figure 4-1b), ranging for evaluating climate impact and adaptation from 260C to 300C, the highest in the north, measures. The five SSPs consist of SSP1 and characteristic of climatic conditions within (“Sustainability”; low challenges to mitigation the tropics. The climatological maximum and adaptation), SSP2 (“Middle of the temperature (see Figure 4-1c), which indicates Road”; middle challenges to mitigation and the mean daytime temperature recorded adaptation), SSP3 (“Regional Rivalry”; high during peak solar insolation, mimicked the challenges to mitigation and adaptation), mean temperature pattern (see Figure 4-1b) SSP4 (“Inequality”; low challenges to with magnitudes ranging from 31 to 350C. On mitigation, high challenges to adaptation), the other hand, a reverse pattern is observed and SSP5 (“Fossil-fueled Development”; high with the minimum temperature (usually an challenges to mitigation, low challenges to indication of mean night-time temperature), adaptation). where higher values are recorded along the coast and the Volta basin. 4.1. ANNUAL AND MONTHLY OBSERVED TRENDS IN CLIMATOLOGY: TEMPERATURE, PRECIPITATION, HUMIDITY/HEAT INDEX 30. Kumi, N., & Abiodun, B. J. (2018). Potential impacts of 1.5 C and 2 C global warming on rainfall onset, cessation and length of rainy season in West Africa. Environmental Research Letters, 13(5), 055009 There is wide variability in the annual 31. Omotosho, J. B., & Abiodun, B. J. (2007). A numerical study of moisture temperature and precipitation across the build‐up and rainfall over West Africa. Meteorological Applications: A journal of forecasting, practical applications, training techniques and country, with the northern region receiving modelling, 14(3), 209-225. less rainfall and experiencing higher mean 32. Omotosho, J. B., Balogun, A. A., & Ogunjobi, K. (2000). Predicting monthly and seasonal rainfall, onset and cessation of the rainy season in West Africa and maximum temperatures. On an annual using only surface data. International Journal of Climatology: A Journal of basis, less rainfall is received in the northern the Royal Meteorological Society, 20(8), 865-880. 33. Sylla, M. B., Giorgi, F., Coppola, E., & Mariotti, L. (2013). Uncertainties in part and many areas in the southeast of the daily rainfall over Africa: assessment of gridded observation products and evaluation of a regional climate model simulation. International Journal of country (see Figure 4-1a). These differences Climatology, 33(7), 1805-1817. 27 Climate Exposures/Hazards FIGURE 4-1. Observed annual climatology of (a) rainfall (b) mean- (c) maximum- (d) minimum-temperatures over Ghana, 1991-2020 Source: Authors using Climatic Research Unit (CRU) data FIGURE 4-2. Observed monthly climatology of (a) rainfall (b) mean- (c) maximum- (d) minimum-temperature, averaged over the defined agroecological zones, 1991-2020 Source: Authors using Climatic Research Unit (CRU) data Climate and Health Vulnerability Assessment for Ghana 28 The monthly rainfall patterns vary by and minimum temperatures are expected region though monthly temperature trends to increase. Projected climatology of rainfall show a bi-modal pattern across all regions and temperature (mean, minimum, maximum) of the country. The observed monthly were undertaken across the country for climatological rainfall depicts the major and the periods 2020 - 2039 and 2040 - 2059 minor rainy seasons from March to June and informed by the CMIP6. Rainfall projections September to November, respectively, with were similar to the historical data (baseline), a “little dry season”34 in August (see Figure with reduced magnitude and patterns of 4-2a). The bi-modal rainfall patterns observed rainfall in the northern parts of the country, characterize the Forest, East- and West-Coast increasing south-westwards (see Figure 4-3a), zones, separated by the little dry season in projected in the order of 1000 - 1400 mm for August. Despite the transition zone showing both 2020 - 2039 and 2040 - 2059. However, a similar bi-modal pattern, rainfall peaks are marginal declines are expected in the 2040 recorded during the minor rainy season. - 2059 period, particularly in the middle belt On the contrary, a unimodal rainfall pattern of the country. On the contrary, rainfall along characterizes the savanna zone, with peak the Coast is projected to increase marginally rainfall recorded in August due to shifts in the within the 2040 - 2059 period, except for rain belt. The observed mean and maximum the Central Region (see Figure 4-3e). Mean temperatures show a bi-modal pattern with temperatures are projected to range from magnitudes ranging from 25 – 320C and 28 26 to 300C for the 2020 - 2039 period over – 380C, respectively (see Figures 4-2b, 4-2c) the entire country (see Figure 4-3b), with with their peaks recorded within February maximum and minimum temperatures from and March. Following the rainfall pattern 31 to 350C and 22 to 250C, respectively. The in Figure 4-2a, low-temperature values are peak values decreased gradually along a recorded in July – September, with August northern-southern gradient of the country, registering the minimum and November with projections for the 2040 - 2050 period the maximum towards the dry season. showing a substantial increase in the mean Meanwhile, night-time temperature (minimum >280C (see Figure 4-3f), maximum >310C (see temperature) peaks in February – April and Figure 4-3g), and minimum >230C (see Figure October, respectively, except for the coastal 4-3h). areas (see Figure 4-2d). The low values are recorded in June – August, with the lowest from November to January coinciding with the dry season. 4.2. ANNUAL AND MONTHLY PROJECTED TRENDS IN CLIMATOLOGY: TEMPERATURE, PRECIPITATION, HUMIDITY/HEAT INDEX While rainfall is predicted to decline in the middle belt of the country, it is likely to increase along the coast. Mean, maximum, 34. Omotosho, J. B., & Abiodun, B. J. (2007). A numerical study of moisture build‐ up and rainfall over West Africa. Meteorological Applications: A journal of forecasting, practical applications, training techniques and modelling, 14(3), 209-225. 29 Climate Exposures/Hazards FIGURE 4-3. Projected climatology of (a) rainfall (b) mean- (c) maximum- (d) minimum-temperatures over Ghana (2020- 2039) and (e) rainfall (f) mean- (g) maximum- (h) minimum-temperatures over Ghana (2040-2059) Source: Coupled Model Intercomparison Project Phase 6 The projected monthly rainfall will peak maximum and minimum temperatures are between June and September, yet with expected to be between 30 - 360C and 21 - substantial expected decline in magnitude, 260C respectively. The monthly temperature except for August, across most parts for patterns will deviate from the historical all periods (see Figure 4-4). Monthly rainfall observation within a month with the peaks patterns are expected to be unimodal over the expected in March and April. The lowest mean entire country. On average, rainfall amounts and maximum temperatures are projected are projected to remain approximately the to be in August, and the lowest minimum is same for 2020 - 2039 and 2040 - 2059. The expected in January. projected temperature shows similar bimodal patterns as the historical data over the entire country (see Figures 4-4c-h). For 2020 - 2039, the magnitudes of mean temperatures are expected to be between 27 and 310C; Climate and Health Vulnerability Assessment for Ghana 30 FIGURE 4-4. Projected monthly climatology of (a, b) rainfall (c, d) mean- (e, f) maximum- (g, h) minimum-temperature averaged over the defined agroecological zones, 2020-2039 and 2040-2059 Source: Coupled Model Intercomparison Project Phase 6 4.3. OBSERVED AND PROJECTED CHANGES Figure 4-5). There are monthly anomalies IN SEA-LEVEL RISE with heightened or reduced levels, with the highest in November, approximately 90 mm On average, there has been a 3.44 mm rise above mean sea level (see Figure 4-5b), as in sea levels per year from 1993 to 2016, yet opposed to August's shallowest observed current years exhibit an estimated rise of level at around 40 mm below mean sea level. 50 mm and above. This estimated increase in sea levels is a significant upward shift/ trend in the yearly and long-term anomaly signals in Ghana’s coastal waters (see 31 Climate Exposures/Hazards FIGURE 4-5. (a) Time series analysis of sea-level anomaly and (b) monthly climatology of sea-level anomaly Source: Authors using the World Bank Climate Change Knowledge Portal Data Stratification of sea level rise based on adaptation and mitigation strategies, the different emission scenarios indicates that sea level will possibly rise by 6 – 7 mm/ the influence of emissions on sea level year within the 2020-2039 period and 8.5 rise could be detrimental if appropriate – 9.7 mm/year by the 2040-2059 period. If mitigation and adaptation measures stringent measures are adopted to limit the are not implemented. The new Shared emissions, the sea level is expected to rise by Socioeconomic Pathways (SSPs) that about 5.3 mm/year within 2020-2039, with a indicate climate change projections and marginal increase to about 5.5 mm/year in socioeconomic scenarios for evaluating 2040-2059. Conclusively, the influence of climate impact and adaptation measures emissions on sea level rise is projected to were assessed with a keen consideration be detrimental if appropriate mitigation and of regional sea level change rate. Four adaptation measures are not put in place. SSPs, with varying adaptation and mitigation These could contribute to the development pathways, were assessed (see Figure 4-6) and spread of several water-related diseases for the 2020-2039 and 2040-2059 periods. and morbidities and could also lead to Under different emission scenarios, a the development of novel water-related coupled change in sea level is expected over diseases, coastal floods, submergence of the Gulf of Guinea. For extreme emission habitable lands, etc. scenarios, with no-to-limited complementing Climate and Health Vulnerability Assessment for Ghana 32 FIGURE 4-6. Sea level change for (a) 2020-2039 and (b) 2040-2059 under 5 Shared Socioeconomic Pathways (SSPs) Source: Authors using the World Bank Climate Change Knowledge Portal Data Box 2. Summary of historic observations and projected changes in temperature, precipitation, and sea level rise Rainfall patterns are unimodal in the north and bimodal in the southern part of the country, with maximum rainfall amounts recorded in the country's southwestern part. Climatological mean temperature shows that average air temperature from 1991 to 2020 generally increases with latitude. Mean temperature over Ghana ranges between 260C and 300C, with the highest in the country's north. Monthly rainfall patterns are projected to be unimodal, peaking between June and September for the periods 2020 - 2039 and 2040 – 2059. Overall, substantial decline in rainfall magnitude is expected over the country. At the countrywide level, rainfall amounts are not expected to be significantly altered between the periods 2020 -2039 and 2040 - 2059. Projected temperature revealed bimodal patterns, and warmer periods for 2040 - 2059 than for 2020 - 2039. There is an expected shift in the monthly temperature peaks by a month to March and April. On average, there has been a 3.44 mm change in sea level per year between 1993 and 2016. Sea level is expected to rise by 6 – 7 mm/year in 2020-2039 and 8.5 – 9.7 mm/year by 2040- 2059 under SSP 5.85 (high challenges to mitigation, low challenges to adaptation). Under SSP 1.19 (sustainable SSP with low challenges to mitigation and adaptation), sea level will rise by 5.3 mm/year in 2020-2039, with a marginal increase to about 5.5 mm/year in 2040-2059. 33 Climate Exposures/Hazards Photo: © Arne Hoel / World Bank 4.4. CLIMATE-RELATED EXTREME EVENTS Over 19 significant flood events have occurred in the past five decades (EPA In the past 50 years, 22 major 2020); despite declining trends, heavy hydrometeorological events in Ghana have rainfall events are expected to increase in affected 16 million people, resulting in over Ghana, resulting in flooding, flash floods, 400 deaths35. The World Bank identifies six and riverbank erosion. More erratic and different yet interrelated hazards associated intense rainfall patterns are anticipated with extreme events in Ghana. They are during the wet season, accompanied by droughts, earthquakes, epidemics, floods, overall lower precipitation levels. Floods wildfires, and storms36. This section focuses on are common, with at least 11 flood events the three extreme events that predominantly recorded in the past decade, which caused confront the country: heavy rainstorms/ widespread damage to infrastructure and floods, sea-level rise, and droughts. farmland, impacting the livelihoods of many Ghanaians. For example, a flood in the Greater Accra Region in 1991 affected an estimated two million people and caused over US$12 million worth of damage. Besides, floods have had significant impacts on Ghana’s agricultural sector, including, among other 35. EM-DAT(2016). Disaster List for Ghana. The International Disaster Database. things: i) the loss of crops – such as cassava, 36. Climate Risk Profile: Ghana (2021). The World Bank Group. Climate and Health Vulnerability Assessment for Ghana 34 rice, yams, and groundnuts – and livestock; ii) recede by about 202 m by the year 2100, the destruction of farmlands, houses, bridges, displacing the dense population (EPA 2020). schools, and health facilities; iii) damage to water supply infrastructure and irrigation Three drought events have occurred in facilities, and iv) damage to food storage and Ghana in the past five decades with varying post-harvest processing facilities37. Severe degrees of impact (EPA 2020). Drought floods that affected northern Ghana in 2007 exposes smallholder farmers to significant led to the Government pronouncing the then climate risk when seasonal changes and three northern regions and some parts of droughts occur. Given Ghana’s reliance the Afram Plains and Keta Area as a disaster on rain-fed agriculture, drought poses a zone. This event claimed 56 lives, damaged considerable threat to the agricultural sector, approximately 500 km of roads, destroyed with the most immediate consequence being 69 bridges and displaced around 332,000 a decrease in the production of staple crops people38. In 2010, floods in the White Volta – especially sorghum, millet, maize, and River Basin affected hundreds of thousands groundnuts, and a negative impact on the of people and destroyed many livelihoods. livelihoods of smallholder farmers, particularly Urban floods also regularly impacted key in the northern savanna zones. For example, cities, with the last major event occurring a severe drought in 1983 affected 12.5 in Accra in June 201539. The flood event million people across the country, resulting in experienced in Accra in June 2015 caused extreme hunger and the deaths of hundreds extensive harm to human life, infrastructure, of people, primarily children. The most and businesses40. affected regions of the 1983 drought were the Upper East, Upper West, and Northern Climate change is precipitating sea-level regions, southern Brong-Ahafo, and northern rise in the country, resulting in sea erosion Ashanti44. Table 4-1 presents the extreme and flooding along the coastal stretch41, climate events and their impact on the 42 , and is pervasive on the eastern coast country between 1968 and 2017. along the Volta Delta, affecting communities along the coast. The coastal Ramsar sites in the Muni-Pomadze lagoon experienced an average coastal retreat of 0.22 m/ year between 1972 and 201443, while the Dansoman coastline, which covers Panbros, Glefe, and Gbegbeyise communities, could 37. Armah, F. A., Yawson, D. O., Yengoh, G. T., Odoi, J. O., & Afrifa, E. K. (2010). Impact of floods on livelihoods and vulnerability of natural resource dependent communities in Northern Ghana. Water, 2(2), 120-139. 368. 38. Government of Ghana. (2007). Joint assessment report of flood disasters in the three northern regions of Ghana. Inter-ministerial Disaster Relief Committee and UN Country Team. 39. According to the Environmental Protection Agency (2020). 40. Amoako, C., & Inkoom, D. K. B. (2018). The production of flood vulnerability in Accra, Ghana: Re-thinking flooding and informal urbanisation. Urban Studies, 55(13), 2903-2922. 41. Boateng, I. (2012). An assessment of the physical impacts of sea-level rise and coastal adaptation: a case study of the eastern coast of Ghana. Climatic Change, 114(2), 273-293. 42. Evadzi, P. I. K. (2017). Regional sea-level at the retreating coast of Ghana under a changing climate (Doctoral dissertation, Staats-und Universitätsbibliothek Hamburg Carl von Ossietzky). 43. Davies-Vollum, K. S., & West, M. (2015). Shoreline change and sea level 44. Agency for International Development. (1984). Disaster Case Report: Ghana rise at the Muni-Pomadze coastal wetland (Ramsar site), Ghana. Journal of – Food Shortage. Office of U.S. Foreign Disaster Assistance. Washington D.C. coastal conservation, 19, 515-525. Available at: https://pdf.usaid.gov/pdf_docs/PBAAB318.pdf 35 Climate Exposures/Hazards TABLE 4-1. List of extreme climate events and their impacts in Ghana between 1968 and 2017 Year Disaster Regions affected Total Total description deaths people affected 1968 Flood Central - 25,000 1971 Drought Countrywide - 12,000 1977 Drought Northern, Upper East, Upper West - - 1983 Drought Countrywide - 12,500,000 1989 Flood Northern 7 2,800 1991 Flood Greater Accra 5 2,000,000 1995 Flood Greater Accra 145 700,000 1999 Flood Northern, Upper East, Upper West 52 324,602 2001 Flood Greater Accra 12 144,025 2002 Flood Greater Accra - 200 2002 Flood Greater Accra 4 2,000 2007 Flood Northern, Upper East, Upper West 56 332,600 2008 Flood Northern - 58,000 2009 Flood Greater Accra, Ashanti, Volta, 16 19,755 Western, Central Eastern 2009 Flood Northern 24 139,790 2010 Flood Greater Accra, Central, Volta 45 7,500 2010 Flood Brong Ahafo, Eastern, Western, 8 9,674 Upper East, Upper West, Northern 2011 Flood Eastern 6 12,571 2011 Flood 14 Greater Accra. Eastern, Volta 81,473 - 2013 Flood Northern, Volta 5 25,000 2015 Flood Greater Accra 25 5,000 2016 Flood Greater Accra 10 - Source: EM-DAT.be, 2016 Climate and Health Vulnerability Assessment for Ghana 36 Overall, Ghana faces four areas of demographic changes, including urbanization concern: rainfall variability leading to and densification of critical landscapes such extreme, unpredictable events, increased as coastal zones, increase exposure to temperatures, sea-level rise, and increasing extreme events. Fourth, there are limitations greenhouse gas emissions and loss placed on preparedness to respond to of carbon sinks. These broad areas of extreme events due to data paucity and concern can precipitate natural disasters, related uncertainties46. Fifth, the severe making the country vulnerable to extreme effects of land use and land cover changes, events such as floods, heat waves, drought/ including deforestation, loss of biodiversity, aridity. Projected increases in dry spells can soil erosion, and disruption of soil structure, exacerbate drought conditions, especially in play a pivotal role in land degradation. This the Savannah region. Second, the country degradation tends to modulate the impacts comprises mostly low plains to a low elevation of extreme events. Sixth, weak social and of between zero meters from the Atlantic environmental determinants of human well- Ocean, with coastal plains stretching across being, including extreme poverty in some the entire south interspersed with saltwater parts, predispose populations to the impacts lagoons, exposing it to fluctuating oceanic of extreme events. Finally, heat stress is a influences accompanied by water-related recently emerging phenomenon and can extreme events. An estimated 50% of the 540 exacerbate or magnify the impacts of other km shoreline of Ghana is vulnerable to sea- extreme events. level rise45. Third, the current development challenges of poor spatial planning and Box 3. Summary of climate related extreme events Rainfall variability will trigger frequent dry spells and potentially result in intensified drought conditions over the northern parts of the country, whilst wet spells may lead to more floods across the country. Ghana will continue to be warm with temperatures projected to rise by 2080, increasing the risk of droughts. The impact of droughts may be compounded by heat stress , resulting in detrimental effects on food systems. The impacts of climate risks are likely to magnify the uneven social and spatial distribution of risk in Ghana, and possibly amplify poverty in the Northern regions. The regions are likely to record more extreme weather events with projected increases in dry spells exacerbating drought conditions. 45. Boateng, I., Wiafe, G., & Jayson-Quashigah, P. N. (2017). Mapping vulnerability and risk of Ghana's coastline to sea level rise. Marine Geodesy, 40(1), 23-39. 46. Conway, G. (2009). The science of climate change in Africa: impacts and adaptation. Grantham Institute for Climate Change Discussion Paper, 1, 24. 37 Climate Exposures/Hazards 5. HEALTH RISKS This section assesses climate-related health risks that impact Ghana. It is divided into two sub-sections. It begins with identifying population sub-groups most impacted by the poverty dimensions and health impacts of climate change. The second sub-section assesses the intersection between climatology and selected health outcomes and health system risks. It presents the findings of an ecological study design in which the unit of observation was the national and administrative regions of Ghana using a monthly time series dataset compiled from routine health management information systems and meteorologic estimates between 2012 and 2020. In doing this, a negative binomial regression model with robust standard errors was constructed. The model addresses issues of residual the impacts of localized disasters resulting autocorrelation to quantify the association from climate change are likely to have a of precipitation and ambient temperature, compounded effect on rural livelihoods with monthly reported diarrhea, malaria, over time. Vulnerabilities to climatic impacts schistosomiasis, and meningitis cases, from on health are determined by physical 2012 to 2020 in the 16 administrative regions exposures and a range of socioeconomic, of Ghana. Three main considerations inform demographic, biological, and geographical the selection of these diseases: i) the disease factors47. Floods and droughts are among is a known climate-sensitive condition, ii) the Ghana's most devastating climate-induced burden of the disease is high in Ghana, and disasters, with far-reaching consequences iii) disease cases are reported so incidence on food security48,49. The elderly, children, data were readily available. We did not the chronically ill, the socially isolated, and assess other climate-related health risks, at-risk occupational groups are particularly such as air quality in relation to respiratory vulnerable. The following factors influence health, the crosscutting risks of ongoing a population’s vulnerability to the health climate change on mental health, and direct impacts of climate change. injuries and mortality associated with natural hazard events. The second sub-section also Poverty: The third IPCC assessment report presents findings from a desk review of the confirms that the poorest people are most direct and indirect health outcome and health vulnerable to climate change shocks and system risks of climate change in Ghana. identified several poverty-related climate change impacts, including decreased crop 5.1. VULNERABLE POPULATION yields due to decreased water availability, GROUPS food insecurity, unemployment, reduction in incomes and economic growth, population Besides the risk of infectious diseases, key displacement, and increased exposure to climate risks in Ghana include droughts, health risks50. Though poverty rates ($1.90 coastal erosion, floods, and landslides that are exacerbated by the current development dynamics and demographic changes in the 47. World Health Organization. (2021). Climate change and health: vulnerability and adaptation assessment. country. Many people are at risk from these 48. Asumadu-Sarkodie, S., Owusu, P. A., & Rufangura, P. (2015). Impact analysis disasters due to increasing rural poverty, rapid of flood in Accra, Ghana. Advances in Applied Science Research, 6(9):53-78 49. Atanga, R. A., & Tankpa, V. (2021). Climate change, flood disaster risk and urbanization, growth of informal settlements, food security nexus in Northern Ghana. Frontiers in Sustainable Food poor urban governance, and declining Systems, 5, 706721. 50. IPCC. (2001). Climate Change 2001: Summary for Policymakers, A ecosystem and land conditions. With a large Contribution of Working Groups I, II and III to the Third Assessment Report of the Intergovernmental Panel on Climate Change. Watson R.T. and the Core population depending directly on agriculture, Writing Team (eds). Cambridge University Press: Cambridge Health Risks 38 PPP) in Ghana have declined from 47.4% and capability to cope with climate change56, in 1991 to 13.3% in 2016, inequalities exist 57 . As the majority of the world’s poor, women across the country. Inequality in poverty has are the most vulnerable to the effects of widened with higher poverty levels observed climate change58. Poor women are more likely in the country’s three northern regions to become direct victims (mortalities and (Northern, Upper East, and Upper West injuries) of climate change disasters, such as Regions) and the Volta Region51, which has hurricanes and flooding59. Additionally, during the potential to exacerbate climate-related natural disasters, women die more often than health risks. Additionally, these regions men because they are not warned, cannot depend primarily on subsistence agriculture swim, or cannot leave the house alone. for livelihood, which is adversely affected by When poor women lose their livelihoods, perennial floods and droughts, limiting food they slip deeper into poverty, and the security, incomes, and access to health care inequality and marginalization due to gender 52 . Droughts and floods cause severe damage is exacerbated. Women and men also differ to farmlands, water supply, irrigation systems, in their vulnerabilities to food insecurity due food storage, and loss of livestock. The to their roles at home, access to information, Ministry of Food and Agriculture estimated control over resources, and influence in that floods affect about 70,500 hectares of household and community decision-making. land, resulting in the loss of 144,000 metric Men have a traditional role in managing tonnes of maize, sorghum, millet, groundnuts, agricultural production in Tariganga in yam, cassava, and rice53. Frequent exposure Northern Ghana. They have better adaptive to flood events caused by high-intensity capacity to climatic stressors than women rainfall, coupled with the opening of the since they usually control decision-making Bagre Dam in Burkina Faso, affected 100,000 around land use and agricultural assets such people in 2018. It destroyed 196 km2 of as livestock. Under varied climate scenarios, farmland in northern Ghana54. As a result, the cholera, diarrhea, malaria, malnutrition, and groups most vulnerable to food insecurity heat-related deaths are likely to increase. include farmers, children, and people with Pregnant women and children are particularly lower economic status. There are, however, susceptible to malaria, contributing to prenatal differential effects on diverse groups of mortality, low birth weight, and maternal farmers; in terms of gender, types of crops anemia60. Climate change can also affect the being cultivated, access to external support, availability of certain medicinal plants used by and alternative livelihood strategies55. most women, especially rural poor women, who rely on traditional medical plants for Gender: Climate change magnifies existing their health needs. According to a study on gender inequalities, reinforcing the disparity water needs and women’s health in Ghana, between women and men in their vulnerability women who maintain traditional norms are 56. UNDP. (2011).  http://content-ext.undp.org/aplaws_publications/3253640/ 51. The World Bank Group. (n.d). Ghana Overview. AAP_Discussion_Paper1_English.pdf 52. Wood, A. L., Ansah, P., Rivers III, L., & Ligmann-Zielinska, A. (2021). 57. Mitchell, T., Tanner, T., & Lussier, K. (2007). ‘We know what we need’: South Examining climate change and food security in Ghana through an Asian women speak out on climate change adaptation. intersectional framework. The Journal of Peasant Studies, 48(2), 329-348. 58. Women’s Environment and Development Organization. (2008). Changing the 53. Armah, F. A., Yawson, D. O., Yengoh, G. T., Odoi, J. O., & Afrifa, E. K. (2010). Climate: Why Women’s Perspectives Matter. Impact of floods on livelihoods and vulnerability of natural resource 59. Neumayer, E., & Plümper, T. (2007). The gendered nature of natural dependent communities in Northern Ghana. Water, 2(2), 120-139. disasters: The impact of catastrophic events on the gender gap in 54. Atanga, R. A., & Tankpa, V. (2021). Climate change, flood disaster risk and life expectancy, 1981–2002. Annals of the association of American food security nexus in Northern Ghana. Frontiers in Sustainable Food Geographers, 97(3), 551-566. Systems, 5, 706721 60. Amegah, A. K., Damptey, O. K., Sarpong, G. A., Duah, E., Vervoorn, D. 55. Nti, F. K. (2012). Climate change vulnerability and coping mechanisms J., & Jaakkola, J. J. (2013). Malaria infection, poor nutrition and indoor among farming communities in Northern Ghana (Doctoral dissertation, air pollution mediate socioeconomic differences in adverse pregnancy Kansas State University). outcomes in Cape Coast, Ghana. PloS one, 8(7), e69181. 39 Climate and Health Vulnerability Assessment for Ghana particularly vulnerable during water scarcity, among women, as well as inadequate as they often prioritize their husbands, access to extension and old age/poor health ensuring that the man’s water needs are met among men. These studies recommend before theirs61. In addition, recent studies the integration of gender needs in climate on adaptation planning have revealed that change adaptation planning and intervention the major constraints to mitigating climate development to help build resilient farm change impacts in Ghana include the lack households in many communities62. of money and inadequate access to labor Photo: © Curt Carnemark /World Bank 61. Buor, D. (2004). Water needs and women's health in the Kumasi metropolitan area, Ghana. Health & Place, 10(1), 85-103. 62. Assan, E., Suvedi, M., Olabisi, L. S., & Bansah, K. J. (2020). Climate change perceptions and challenges to adaptation among smallholder farmers in semi-arid Ghana: A gender analysis. Journal of Arid Environments, 182, 104247. Health Risks 40 Age: Climate change, pollution, damaging face stigma, prejudice, and poor-quality commercial promotion, unhealthy lifestyles treatment67. Long-term health issues may and diets, injury and violence, conflict, induce disability, while impairment can migration, and inequality pose new hazards exacerbate health problems. The kind and to children (ages 0 to 18)63. Air pollution is severity of a person's handicap might also linked to poor respiratory health in children; impact their health. It might, for example, it damages the lungs and the brain and restrict their access to social and physical increases the risk of cardiovascular disease, activities and their involvement in them. obesity, type 2 diabetes, and metabolic Persons with impairments, on average, have syndrome throughout a child's life64. lower overall health and experience more Adolescent and young adult mortality rates psychological distress than people without are particularly alarming. The rising tendency disabilities. They also have greater rates of toward suicide, which is substantially higher various controllable health risk factors and in the 15-29 age range than in the following behaviors than those without impairments, age groups, is one source of worry. Injury- such as poor nutrition and tobacco use68. related mortality accounts for more than half Individuals with disabilities are at a greater of all deaths in the 15-24 age range, primarily risk of developing chronic diseases such as in motor vehicle accidents65. Generally, very obesity, hypertension, fall-related injuries, few age-related studies ascribe age as a key and mood disorders such as depression. factor to climate-related health risk. However, They are more likely to participate in risky a study on cerebrospinal meningitis (CSM), habits that endanger their health, such as a climate-sensitive disease in Ghana, shows smoking and insufficient physical exercise69. that although a majority of participants rightly Individuals with disabilities have greater linked CSM infections to very dry, hot, and levels of stress and depression than non- dusty conditions experienced during the dry disabled individuals. Children and people season, a few elderly participants ascribed with disabilities are more likely to be spiritual causes (disobedience to gods, overweight than children and adults without ancestors, and evil spirits) to CSM infections66. disabilities. Overweight and obesity can have detrimental effects on one's health. Disability: People with disabilities are a heterogeneous group who share living Migrants, refugees, and internally experiences with significant functional displaced populations: Migrants, refugees, restrictions and are often excluded from and internally displaced people (MRDPs) full community engagement. The number are among the world's most vulnerable of persons with a disability is growing populations, with several health and due to increased chronic health issues healthcare difficulties. People migrate for and population aging. When persons with various reasons, including violence, poverty, disabilities seek health care, they may catastrophes, urbanization, a lack of rights, discrimination, inequality, and globalization. The vast majority of the world's over 244 63. World Health Organization. (2020). Children: new threats to health https:// www.who.int/news-room/fact-sheets/detail/children-new-threats-to-health 64. Reiner, R. C., et al. (2019). Diseases, injuries, and risk factors in child and adolescent health, 1990 to 2017: findings from the Global Burden of 67. World Health Organisation. Disability and health. (2021). Disability and Diseases, Injuries, and Risk Factors 2017 Study. JAMA pediatrics, 173(6), health. Available at: https://www.who.int/news-room/fact-sheets/detail/ e190337-e190337. disability-and-health 65. Pecora, P. J., Whittaker, J. K., Barth, R. P., Borja, S., & Vesneski, W. 68. Australian Institute of Health and Welfare. (2022). Health of people with (2018). The child welfare challenge: Policy, practice, and research. disability. Available at: https://www.aihw.gov.au/reports/australias-health/ Routledge. health-of-people-with-disability 66. Codjoe, S. N. A., & Nabie, V. A. (2014). Climate change and cerebrospinal 69. According to the 2016 Annual Disability Statistics Compedium Available at: meningitis in the Ghanaian meningitis belt. International journal of https://disabilitycompendium.org/sites/default/files/user-uploads/2016_ environmental research and public health, 11(7), 6923-6939. AnnualReport.pdf 41 Climate and Health Vulnerability Assessment for Ghana million migrants do so freely and without characteristics, when other sociodemographic incident. However, about 65 million people and economic factors are controlled, a similar are displaced forcefully due to persecution, experience is less likely in communities with violence, food insecurity, or human rights forest characteristics. This paper concludes abuses70. Temporary migration is apparent that climate-related environmental events in many areas; however, the most vulnerable alone may not trigger migration if it is not to climate change are not necessarily the linked to other socioeconomic issues75. The most likely to migrate71. The risk of illness linkages between climate, migration, and and adverse health outcomes are not equal health outcomes have not been explored. across MRDP groups and are influenced by the multiple dimensions of migration. The Indigenous persons and ethnic minorities: number of people migrating because of the Indigenous peoples and members of many adverse impacts of climate change on their ethnic minorities are far more likely to live in livelihoods, daily lives, and health is expected poverty on average than the ethnic majority to rise72. The effects of climate change on and non-indigenous population in any water stress and agriculture are potential particular nation76. The word "ethnic minority" drivers of rural-urban migration. Population refers to ethnic or racial groups in a nation movement through rural-urban migration, subordinate to the main ethnic population77. due to crop failure and other climate-induced Indigenous peoples have distinct social, shocks, can cause health problems because economic, and political systems, languages, of overcrowding, psychological stress, and traditions, and beliefs and are adamant about the increased pressure on health and social preserving and developing their unique services in destination areas73. In Ghana, the identities78. Studies about indigenous peoples’ drivers of migration, particularly in rural areas health have shown that, to date, indigenous are linked to climatic impacts as climate peoples have a life expectancy at birth that change has threatened the sustainability of is more than five years shorter than the non- agrarian livelihoods. In the Northern semi- indigenous population79. Discrimination is arid regions and coastal areas, for example, a significant factor in the social isolation of migration is influenced by drought. Coastal indigenous peoples and ethnic minorities. communities face additional challenges of In many nations, ethnic minorities are less coastal sea erosion, flooding, soil salinization, adequately protected by health insurance and the destruction of critical habitats such than the ethnic majority. Similarly, linguistic as mangroves74. Other studies in Ghana, barriers between patients and doctors, along however, indicate that though flood and with a lack of awareness of indigenous culture drought are more likely to trigger migration and traditional healthcare institutions, has among people in communities with savanna resulted in a dearth of culturally appropriate health treatments. In Ghana, there is no known evidence of ethnic-related climate 70. United Nations High Commissioner for Refugees (2015). Global Trends 75. Abu, M. (2011, December). Migration as an Adaptation Strategy to Climate Forced Displacement in 2015. Available at: http://www.unhcr.org/statistics/ Change: evidence from Buoku and Bofie-Banda in the Wenchi and Tain unhcrstats/576408cd7/unhcr-global-trends-2015. Districts of Ghana. In Paper for the Sixth African Population Conference, held 71. International Organization for Migration. (2008). Migration and Climate in Ouagadougou, Burkina Faso (pp. 5-9). Change. Available at: https://publications.iom.int/system/files/pdf/mrs- 76. Hall, G. H., & Patrinos, H. A. (Eds.). (2012). Indigenous peoples, poverty, and 31_en.pdf development. Cambridge University Press. 72. International Organization for Migration. (2020). Health and Migration, 77. Ferrer, A., & Retis, J. (2019). Ethnic minority media: Between hegemony and Environment, Climate Change. Available at: https://environmentalmigration. resistance. Journal of Alternative & Community Media, 4(3), 1-13. iom.int/health-and-migration-environment-climate-change 78. Wiessner, S. (2011). The cultural rights of indigenous peoples: achievements 73. Toole, M. J., & Waldman, R. J. (1990). Prevention of excess mortality in and continuing challenges. European Journal of International Law, 22(1), refugee and displaced populations in developing countries. Jama, 263(24), 121-140. 3296-302. 79. Tjepkema, M., Bushnik, T., & Bougie, E. (2019). Life expectancy of First 74. Prosper, A., & Khan, A. (2018). Migration in climate change hotspots: Nations, Métis and Inuit household populations in Canada. Health opportunities and challenges for adaptation.CARIAA. Reports, 30(12), 3-10. Health Risks 42 change and health vulnerability, though slums and Ghanaian society in general84. A socioeconomic variability exists among the general observation is that Ghana’s rural diverse ethnic groups. and urban areas are vulnerable to changing climate and other exposures; however, the Urban/rural vulnerabilities: Both the rural level of vulnerability is higher in the rural and urban communities in Ghana are area due to the less adaptive capacity and vulnerable to changing climate exposures; lack of resources. Furthermore, women, however, the level of vulnerability is higher especially those in rural communities, are in the rural area due to lower adaptive disproportionately affected by this issue. This capacity and lack of resources. Despite the is often attributed to their limited access to global impact of climate change, its negative resources, lack of control over them, and consequences are projected to be felt more their limited involvement in decision-making strongly in developing countries, particularly related to crisis management and control, in communities that are reliant on natural both at the household, community, and resources and have little ability to adapt national levels. These challenges also hinder to climate unpredictability and extremes. rural communities from fully participating in Climate change makes impoverished people income-generating activities essential for more vulnerable by hurting their health poverty reduction and enhancing adaptive and livelihoods, limiting their possibilities capacities. Urban communities face for economic progress80,81,82. Africa is additional stresses and challenges stemming anticipated to warm faster than the rest of from populations migrating from rural to the world, with drier subtropical parts like urban areas 85, 86. Ghana expected to warm faster than the wetter tropics. Droughts in the Sahara, the Occupation-related vulnerabilities: Climate Sahel, and the Guinean Coast in the 1970s change adversely affects various working and 1980s indicate that more dry weather groups and occupations in the country. and reductions in rainfall are extremely Ghana’s socioeconomic growth and likely83. In a study by Owusu et al. (2019), the development primarily depend on the various authors demonstrate that by enhancing our formal and informal sectors. With the advent understanding of social differentiation and of the changing climate, climate-dependent vulnerability in poor urban communities in occupations have been vastly affected. For the Global South, it becomes obvious that instance, crop losses due to climate change the differential vulnerabilities faced by slum have adversely impacted the agricultural residents are closely linked to the interplay sector, including farmers, agricultural between gender and sociocultural norms extension officers, food sellers, and others. or institutional arrangements prevailing in Moreover, the heavy physical workload for long hours, and increasing workplace heat exposure due to rising temperatures stemming from climate change, especially in situations with inadequate prevention and 80. Hulme, M., Doherty, R., Ngara, T., New, M., & Lister, D. (2001). African climate change: 1900-2100. Climate research, 17(2), 145-168. 81. Davidson, D. J., Williamson, T., & Parkins, J. R. (2003). Understanding climate change risk and vulnerability in northern forest-based 84. Owusu, M., Nursey-Bray, M., & Rudd, D. (2019). Gendered perception communities. Canadian Journal of Forest Research, 33(11), 2252-2261. and vulnerability to climate change in urban slum communities in Accra, 82. Fields, S. (2005). Continental divide: why Africa’s climate change burden is Ghana. Regional environmental change, 19, 13-25. greater. Environmental Health Perspectives, 113(8), 534–537. 85. Twumasi-Ankrah, K. (1995). Rural-urban migration and socioeconomic 83. Christensen, J. H., Hewitson, B., Busuioc, A., Chen, A., Gao, X., Held, I., development in Ghana: some discussions. Journal of social development in Jones, R., Kolli, R. K., Kwon, W. T., Laprise, R., Magana Rueda, V., Mearns, L., Africa, 10, 13-22. Menendez, C. G., Raisanen, J., Rinke, A., Sarr, A, Whetton, P. (2007). Regional 86. Dumenu, W. K., & Obeng, E. A. (2016). Climate change and rural Climate Projections. Chapter 11. United Kingdom. Available at: http://www. communities in Ghana: Social vulnerability, impacts, adaptations and policy ipcc.ch/pdf/assessment-report/ar4/wg1/ar4-wg1-chapter11.pdf implications. Environmental Science & Policy, 55, 208-217. 43 Climate and Health Vulnerability Assessment for Ghana control policies, adversely affect workers' 5.2 HEALTH RISK health and safety, productive capacity, and social well-being. In a report on Climate 5.2.1. National and regional level analyses Change and Health of Vulnerable Farmers in of climate-sensitive infectious diseases: Ghana, increased heat exposure in Northern An ecological study Ghana was observed to significantly influence the health of the local population National analysis of diarrhea and agriculture, which is the people's main source of income. In a related study87 that Increase in temperature was linked to assessed perceptions of climate change and both immediate and delayed rises in occupational heat stress risks and adaptation diarrhea incidence, while the relationship strategies of mining workers in Ghana, it between precipitation and diarrhea was observed that the workers experienced was not statistically significant. At the heat-related morbidities. Still, the variation in country level, 13,091,680 cases of diarrhea heat-related morbidity experienced across were recorded from 2012 to 2020, with the type of mining activity was not significant, a monthly median value of 6,825. It was although the type of heat-related morbidities found that temperature had both immediate differed across the type of mining activity. and delayed effects on diarrhea, as a unit Box 4. Summary of vulnerable population groups Dimensions of poverty, gender, age, urban-rural residence, occupation and disability drive which population sub-groups are most vulnerable to the impact of climate change. The elderly, women, children, the chronically ill, the socially isolated (for example, disabled, ethnic minorities, and migrants) and at-risk occupational groups are particularly vulnerable to climate change impacts. Relative to other parts of the country, the northern part of Ghana relies on subsistence farming. Thus it is prone to food insecurity due to the damaging effect of frequent exposure to extreme rainfall and flood events on crop yields. Additionally, poverty rates are higher in the northern region, reducing the ability to adapt to climate change and exacerbating its impact. Women, particularly poor women, are more likely to be victims of direct impacts of extreme climate events and are disproportionately affected by food and water insecurity in households. Pregnant women are also particularly susceptible to malaria, resulting in maternal anemia. In Ghana, the drivers of migration, particularly in rural areas are linked to climatic impacts as climate change has threatened the sustainability of agrarian livelihoods. The level of vulnerability is higher in the rural areas compared to urban, due to less adaptive capacity and lack of resources. Women are disproportionately affected, particularly within the rural communities. Heat stress coupled with high levels of physical labor disproportionately impact farmers and miners. 87. Nunfam, V. F., Oosthuizen, J., Adusei-Asante, K., Van Etten, E. J., & Frimpong, K. (2019). Perceptions of climate change and occupational heat stress risks and adaptation strategies of mining workers in Ghana. Science of the total environment, 657, 365-378. Health Risks 44 increase in monthly ambient temperature in meningitis incidence; the association was associated with an 8.0% increase in the between precipitation and meningitis instantaneous incidence rate of diarrhea was not statistically significant. A total of cases reported at the health facilities. The 4,810 meningitis cases were recorded for individual temperature lags of one and two 2012-2020, with a monthly median value months were each also associated with of 30 cases. Nationally, a unit increase of a higher incidence rate of diarrhea (see three months' cumulative temperature Appendix 1). Nationally, an increase of 1 °C in had an associated incidence rate of 2.4 temperature across the three months before meningitis cases. Temperature exhibited diarrhea cases was associated with a 32% both instantaneous and delayed effects higher incidence rate of diarrhea reported, on the rise in cases. However, incidence corresponding to 2,459 direct cases. appeared to decline as the lag-temperature Nationally, the overall effect of precipitation effect decreased. Thus, instantaneous on diarrhea was not significant, despite an temperature and temperature at lag months observed instantaneous marginal effect. 1 and 2 were each associated with higher incidence rates (see Appendix 3). There National analysis of malaria was no association between precipitation and reported meningitis cases. An increase in temperature was associated with both immediate and National analysis of schistosomiasis delayed increases in malaria incidence; precipitation was associated with an Neither temperature nor precipitation increase in malaria incidence. A total was associated with the incidence of 65,828,883 malaria cases were recorded schistosomiasis. A total of 51,288 cases for 2012-2020, with a monthly median of schistosomiasis disease were recorded value of 32,730. A unit increase in monthly during the 2012-2020 period, with a monthly ambient temperature was associated median value of 373 cases. At the national with a 6.3% increase in the instantaneous level, temperature and precipitation do not incidence rate of malaria cases (see influence the number of schistosomiasis Appendix 2). The two-month temperature cases reported (see Appendix 4). lag was associated with a higher incidence rate of malaria, as an increase of 1 °C in Sub-national / regional level analysis temperature across the three months before malaria cases was associated with The association of temperature and a 14% higher incidence rate, corresponding precipitation with the incidence of diarrhea, to 5,509 direct cases. The precipitation for malaria, meningitis and schistosomiasis the index month and one and two-month was determined at a regional level. For lags were each associated with a higher each of the four outcome measures, the incidence rate of malaria (see Appendix region with the highest number of cases per 2). The overall effect of precipitation was 1,000 Out-Patient Department (OPD) visits associated with a 0.39% increase in the for malaria and diarrhea was selected, and malaria cases reported, corresponding to a per 100,000 OPD cases for meningitis and marginal increase of 165 cases per every 1 schistosomiasis was selected. The North – 3 month period. East region recorded the highest number of diarrhea cases for 2012-2020, and the National analysis of meningitis Savannah region recorded the highest number of malaria cases. The Upper West An increase in temperature was associated and the Upper East recorded the highest with both immediate and delayed increases number of meningitis and schistosomiasis, 45 Climate and Health Vulnerability Assessment for Ghana respectively (see Appendix 5). For diarrhea schistosomiasis cases reported in the Upper cases reported in the North East region, a East region. Precipitation at index month two-month lag effect of monthly ambient was associated with a minimal reduction temperature was associated with an 8.6% in the incidence of schistosomiasis but increase in the instantaneous incidence rate not with the overall three-month effect of of reported diarrhea cases (see Appendix precipitation. 5) corresponding to 239 direct cases of diarrhea. The overall effect of precipitation 5.2.2. Direct and indirect health outcome risks on diarrhea in the region was not observed. of climate change While there seems to be an increase in the incidence of malaria in the Savannah region Direct risk from extreme weather events associated with higher index temperatures and ambient temperatures after one Injuries and fatalities occur from the month, this effect did not reach statistical direct impact of extreme climate events, significance. The higher temperature at including floods, droughts, and heat the index month and temperature after one stress. Climate change is expected to month appeared to increase meningitis increase mean annual temperature, and the incidence by 21.7% in the Upper West intensity and frequency of heat waves are region, but the impact was not statistically putting more people at risk of heat-related significant. Precipitation at lag month two conditions. Several studies in Ghana have was associated with a marginal reduction of found both direct and indirect impacts 0.99% in the incidence of meningitis in the of climate variability and change on the region. Monthly ambient temperature was health of the population88. In recent times, not associated with the incidence rate of there has been exposure to temperature Box 5. Summary of national and regional analysis of infectious diseases: an ecological study Nationally, increase in temperature was associated with immediate and delayed increase in diarrhea incidence; the association between precipitation and diarrhea was not statistically significant. Nationally, increase in temperature was associated with immediate and delayed increase in malaria incidence; precipitation was associated with an increase in malaria incidence. Nationally, increase in temperature was associated with immediate and delayed increase in meningitis incidence; the association between precipitation and meningitis was not statistically significant. Nationally, neither temperature nor precipitation was associated with the incidence of schistosomiasis. In a regional analysis, higher temperature and precipitation were associated with both instantaneous and delayed effects on the incidence of , malaria, and meningitis cases. Temperature and precipitation were not associated with schistosomiasis, although the number of schistosomiasis cases increased with increasing temperature. 88. Adams, E. A., & Nyantakyi-Frimpong, H. (2021). Stressed, anxious, and sick from the floods: A photovoice study of climate extremes, differentiated vulnerabilities, and health in Old Fadama, Accra, Ghana. Health & Place, 67, 102500. Health Risks 46 extremes; there is also a higher frequency health hazards, including air pollution, of climatic hazards, an intensity of climatic wildfires, and water and electricity supply hazards, or both. Recent floods experienced failures that have health implications. in the country have been associated with Nunfam et al. (2019) found that perceptions fatalities, leaving many injured and others of climate change impact the health of with long-term psychological trauma. Accra mining workers in Ghana93. The mining experienced one of the worst flood events workers reported experiencing varying in June 2015, which resulted in the loss of heat–related morbidities. over 150 lives, with many others exposed to injuries89, 90. Victims of flood events and VECTOR-BORNE DISEASES their immediate families suffer from long- term mental health conditions91. Malaria Heat-related morbidity and mortality Evidence suggests a correlation between climate-related hazards such as rainfall, There is little evidence of the burden flooding, humidity, warmer temperatures, of heat-related morbidity and mortality and malaria in Ghana. Ghana has made in the context of Ghana. Biologically, significant strides in malaria control, yet high temperatures cause heat stroke, malaria remains a major health burden since heat exhaustion, heat syncope, and heat it affects many people, especially pregnant cramps92. Severe heat stroke occurs when women and children94. The suitability of the core body temperature exceeds 103°F, the climate for Anopheles mosquitoes leading to multiple organ dysfunction. Heat and Plasmodium parasite development stroke results in substantial mortality, with largely influences malaria transmission. rapid progression to death, as evidenced As climatic conditions continue to change, by documented global experiences. shifts in geographic locations suitable for The heat wave in France in August 2003 transmission and lengths of seasons of caused 14,802 deaths in 20 days, while suitability are expected to occur. Ankamah another in Athens in 1987 was associated et al. (2018) noted that climatic conditions with more than 2,000 deaths. In survivors, alone explain about 12.5% of the variability the permanent damage to organ systems in the trend of malaria in Ghana95. At the can cause severe functional impairment national level, the total number of rainy and increase the risk of early mortality. days and humidity have been found to Besides an increase in mortality, evidence predict malaria incidence96. Analyses from other countries depicts an association of the impact of climatic variability on between heat waves and increased malaria in Ghana revealed the highest emergency room admissions, particularly in positive effect of maximum temperature, the elderly and particularly for respiratory relative humidity, and rainfall on malaria and renal disease outcomes. Additionally, for September, March, and October, heat waves are associated with other 93. Nunfam, V. F., Oosthuizen, J., Adusei-Asante, K., Van Etten, E. J., & Frimpong, K. (2019). Perceptions of climate change and occupational heat stress risks 89. Asumadu-Sarkodie, S., Owusu, P. A., & Rufangura, P. (2017). Impact analysis and adaptation strategies of mining workers in Ghana. Science of the total of flood in Accra, Ghana. Advances in Applied Science Research, 6(9):53-78 environment, 657, 365-378. 90. Amoako, C., & Inkoom, D. K. B. (2018). The production of flood vulnerability 94. IHME. (2019). Global Burden of Diseases. Seattle. Available at: https://www. in Accra, Ghana: Re-thinking flooding and informal urbanisation. Urban healthdata.org/ghana Studies, 55(13), 2903-2922. 95. Ankamah, S., Nokoe, K. S., & Iddrisu, W. A. (2018). Modelling trends of 91. Dziwornu, E., & Kugbey, N. (2015). Mental health problems and coping climatic variability and malaria in Ghana using vector autoregression. Malaria among flood victims in Ghana: A comparative study of victims and non- Research and Treatment, 2018. victims. Current Research in Psychology, 6(1), 15-21. 96. Akpalu, W., & Codjoe, S. N. A. (2013). Economic analysis of climate variability 92. Kovats, R. S., & Hajat, S. (2008). Heat stress and public health: a critical impact on malaria prevalence: the case of Ghana. Sustainability, 5(10), 4362- review. Annu. Rev. Public Health, 29, 41-55. 4378. 47 Climate and Health Vulnerability Assessment for Ghana respectively. Simulation of seasonal malaria July) by around 1-2 months between 2020 incidence shows that malaria transmission and 208098. In addition, projected changes follows rainfall peaks, with the intensity in climatic conditions are also expected to and duration of malaria transmission being lead to the reduction of malaria prevalence controlled predominantly by rainfall97. in these areas since temperatures above According to Amekudzi et al. (2014), the 350C degrees and reduced rainfall patterns prevailing shift in the peak rainfall patterns negatively influence malaria transmission. in the coastal cities in Ghana will lead to a shift in malaria transmission season (May- Photo: © Arne Hoel / World Bank 97. Asare, E. O., & Amekudzi, L. K. (2017). Assessing climate driven malaria variability in Ghana using a regional scale dynamical model. Climate, 5(1), 20. 98. Amekudzi, L., Codjoe, S. N. A., Sah, N. A., & Appiah, M. (2014). Impact of climate change on malaria in coastal Ghana. International Development Research Center. Health Risks 48 Between 2012 and 2021, the Ashanti and As a ratio of total OPD attendance, the Eastern regions of the country recorded most prevalent regions with reported the highest number of malaria cases. malaria cases were in the northern parts Figure 5-1 highlights the total reported of the country and the upper parts of malaria cases within the 2012 - 2021 period, the middle regions, with proportions grouped by gender across the region exceeding 30%. The Greater Accra region (Figure 5-1a – b) and also as a fraction recorded the lowest disease density, with of total attendance from the Out Patient malaria cases below 10%. The Ashanti Departments (OPDs) in each region (Figure Region also recorded less than 25% malaria 5-1c). The reported cases were over million disease density. each for males and females over the review decade. The Upper East, Bono, Western, and Central regions follow suit, with reported cases exceeding 2.5 million persons for the reviewed decade. The lowest reported malaria cases were recorded in the North East, Savannah, Ahafo, and Oti regions. FIGURE 5-1. Region-wise reported malaria cases, 2012-2021 (a) among females (b) among males and (c) as % of total OPD attendance (disease density) Source: Authors retrieved OPD data from Ghana Health Service 49 Climate and Health Vulnerability Assessment for Ghana The malaria cases recorded over the regions have the lowest numbers with decade are more than a million for each recorded cases on the order of a million. region across the country. Figure 5-2 highlights the accumulated number of The Greater Accra and Ashanti regions, individual malaria cases reported within over the years, have seen a reduction the 2012 - 2021 decade from all 16 regions of more than 60,000 reported malaria nationwide. By numbers, the Ashanti region cases, followed by the Eastern region has recorded over 10 million individual with an approximate reduction of 48,000 malaria cases, followed by the Eastern cases. On the other hand, relatively lower region with more than 8 million cases. declines (on the order of 10,000 to 20,000 The North East, Ahafo, Savannah, and Oti cases) have been observed in the upper FIGURE 5-2. Total reported malaria cases by region, 2012-2021 Source: Authors retrieved OPD data from Ghana Health Service Health Risks 50 parts of the country. Figure 5-3 provides a implemented to combat malaria, including time series analysis of the reported malaria the distribution of treated nets and cases per region (a) and the regional mosquito breeding ground clearance. trends in reported malaria cases for the review decade (b). The time series data offers insights into annual reported cases and observed changes over the years. Notably, there has been a nationwide decline in malaria cases, likely attributed to comprehensive education and interventions FIGURE 5-3. (a) Annual region-wise reported malaria cases (b) trends Source: Authors retrieved OPD data from Ghana Health Service 51 Climate and Health Vulnerability Assessment for Ghana Schistosomiasis combined. Schistosomiasis cases in other regions were generally below 1000 and Between 2012 and 2021, the Eastern the Volta and Western Region reported and Upper East regions recorded the between 1000 and 1500 cases, female and highest number of schistosomiasis cases. male respectively. Figure 5-4 provides information on the total reported schistosomiasis cases within As a ratio to total OPD attendance, the the 2012 - 2021 period, categorized by prevalence of schistosomiasis was low gender across the region (Figure 5-4a – b) (but more prevalent than meningitis), with and as a fraction of total OPD attendance disease densities below 1%. However, from in each region (Figure 5-4c). Reported the assessment, the most schistosomiasis- cases exceeded 3,000 for both males and prevalent regions are in the Upper East, females. The Bono East, Ashanti, Greater Bono East, and Eastern regions, with Accra, Upper East, and Central and Eastern proportions exceeding 0.035%. The least regions each had over 3000 reported prevalent regions are the Bono, North East, cases for the decade, female and male and Northern Regions. FIGURE 5-4. Region-wise reported schistosomiasis cases, 2012-2021 (a) among females (b) among males, and (c) as % of total OPD attendance (disease density) Source: Authors retrieved OPD data from Ghana Health Service Health Risks 52 Across the regions, the total by the Ashanti, Greater Accra, Central, schistosomiasis cases recorded between and Upper East regions with more than 2012 and 2021 ranged from less than 5,000 reported cases over the period. The 500 to over 10,000. Figure 5-5 presents Northern, North East, Ahafo, Bono, Western the accumulated number of individual North, Upper West, Savannah, and Oti schistosomiasis cases reported within the regions recorded the lowest numbers of 2012 - 2021 decade from all 16 regions schistosomiasis cases with less than 500 of the country. The highest cases have cases over the decade. been recorded in the Eastern region with magnitudes slightly above 10,000, followed FIGURE 5-5. Total reported schistosomiasis cases by region, 2012-2021 Source: Authors retrieved OPD data from Ghana Health Service 53 Climate and Health Vulnerability Assessment for Ghana A general decline in schistosomiasis reflecting the impact of interventions and cases is observed in most parts of the public education efforts. Figure 5-6b shows country between 2012 and 2021. Figure that the Upper East and Eastern regions 5-6 provides (a) a time series analysis of the have experienced the most significant reported schistosomiasis cases per region reduction, with more than 200 fewer and (b) the regional trends in reported reported schistosomiasis cases over the schistosomiasis cases for the review years. In contrast, other parts of the country decade. Generally, the time series data have seen relatively smaller declines, offers insights into annual reported cases typically below 100 cases. and observed changes over the years, FIGURE 5-6. (a) Annual region-wise reported schistosomiasis cases and (b) trends Source: Authors retrieved OPD data from Ghana Health Service Health Risks 54 Dengue Haemorrhagic Fever collectively105. Other Studies have shown 87.2% of dengue prevalence among Dengue is an important vector-borne viral 236 HIV-infected individuals106 and 3.6% disease impacted by climate change; dengue IgG seroprevalence among 360 studies have shown an association yellow fever suspect individuals across all between spatiotemporal patterns of regions in Ghana107. Pappoe-Ashong et al. dengue and climate99, 100, 101. In spite of (2020) have also found low to moderate the complexities in the linkages between levels of dengue virus infection in Ghana, climate and dengue, it has been established with infections occurring in all age groups that both rainfall and drought conditions and all regions in Ghana108. However, the affect dengue fever. It has been observed Upper East and the Volta regions had a that high rainfall and temperature can significantly higher seroprevalence than the lead to increasing disease transmission. overall seroprevalence in Ghana. In spite of At the same time, drought conditions the existing evidence of the prevalence of promote household water storage and dengue in Ghana, its linkage with climatic consequently increase the number of conditions is yet to be explored. suitable breeding sites for the vector102. The first dengue virus infection was reported WATER-BORNE AND WATER-RELATED in Ghana in 2008. Although cases of DISEASES dengue have been reported in Ghana over the years, there is the challenge of Meningitis distinguishing between the symptoms of dengue infection and other infections such Between 2012 and 2021, the Upper as malaria, measles, gastroenteritis, viral West and Upper East regions recorded hepatitis, and other bacterial infections103. the highest number of meningitis cases. This similarity has contributed immensely Figure 5-7 provides information on the to the over-diagnosis of malaria and the reported meningitis cases within the 2012 - under-recognition of dengue104. A study 2021 period, grouped by gender across the conducted among 218 febrile-ill children region (Figure 5-7a – b) and as a fraction clinically diagnosed with malaria from of total OPD attendance in each region Accra, Navrongo, and Kintampo showed (Figure 5-7c). Reported cases exceeded a DENV IgG seroprevalence of 21.6% 300 for both males and females. The Northern, Ashanti, Eastern, Greater Accra, and Central regions had reported cases exceeding 170 for the decade. Central region also had high reported cases in 99. Hales, S., De Wet, N., Maindonald, J., & Woodward, A. (2002). Potential females, exceeding 300 cases. In contrast, effect of population and climate changes on global distribution of dengue the Ahafo region had lower reported cases fever: an empirical model. The Lancet, 360(9336), 830-834. 100. Corwin, A. L., Larasati, R. P., Bangs, M. J., Wuryadi, S., Arjoso, S., Sukri, N., Listyaningsih, E., Hartati, S., Namursa, R., Anwar, Z., Chandra, S., Loho, B., Ahmad, H., Campbell, J.R. & Porter, K. R. (2001). Epidemic dengue transmission in southern Sumatra, Indonesia. Transactions of the Royal 105. Webster, J., Baiden, F., Bawah, J., Bruce, J., Tivura, M., Delmini, R., ... & Society of Tropical Medicine and Hygiene, 95(3), 257-265. Owusu-Agyei, S. (2014). Management of febrile children under five years in 101. Cazelles, B., Chavez, M., McMichael, A. J., & Hales, S. (2005). Nonstationary hospitals and health centres of rural Ghana. Malaria journal, 13(1), 1-13.106. influence of El Nino on the synchronous dengue epidemics in Thailand. PLoS 106. Sherman, K. E., Rouster, S. D., Kong, L. X., Shata, T. M., Archampong, T., medicine, 2(4), e106. Kwara, A. et al. (2018). Zika virus exposure in an HIV-infected Cohort in 102. Pontes, R. J., Freeman, J., Oliveira-Lima, J. W., Hodgson, J. C., & Spielman, Ghana. JAIDS Journal of Acquired Immune Deficiency Syndromes, 78(5), A. (2000). Vector densities that potentiate dengue outbreaks in a Brazilian e35-e38. city. The American journal of tropical medicine and hygiene, 62(3), 378-383. 107. Ofosu-Appiah, L., Kutame, R., Ayensu, B., Bonney, J., Boateng, G., Adade, R., 103. 103.  Stoler, J., Delimini, R. K., Bonney, J. K., Oduro, A. R., Owusu-Agyei, et al. (2018). Detection of Dengue Virus in samples from suspected yellow S., Fobil, J. N., & Awandare, G. A. (2015). Evidence of recent dengue fever cases in Ghana. Microbiology Research Journal International, 24(1), exposure among malaria parasite-positive children in three urban centers in 1-10. Ghana. The American journal of tropical medicine and hygiene, 92(3), 497 108. Pappoe-Ashong, P., Ofosu-Appiah, L., Mingle, J., & Jassoy, C. (2018). 104. Delimini, R. K. (2014). Investigation of dengue exposure and infection in Seroprevalence of dengue virus infections in Ghana. East African Medical Ghanaian children with malaria (Doctoral dissertation, University of Ghana). Journal, 95(11), 2132-2140. 55 Climate and Health Vulnerability Assessment for Ghana FIGURE 5-7. Region-wise reported meningitis cases, 2012-2021 (a) among females, (b) among males, and (c) as % of total OPD attendance (disease severity) Source: Authors retrieved OPD data from Ghana Health Service in females (less than 100 cases). The lowest absolute numbers, meningitis was the reported meningitis cases were in the Oti least prevalent compared to malaria, and Western North regions, with less than diarrhea, and schistosomiasis. Figure 100 cases each. 5-8 presents the accumulated number of individual meningitis cases reported As a ratio to total OPD attendance, within the 2012 - 2021 decade from all 16 meningitis was found to have low regions across the country. By numbers, prevalence with disease densities below the highest cases have been recorded in 1%. However, from the assessment, the the Upper East and Upper West regions, most meningitis-prevalent regions are in with magnitudes greater than 600 and 900, the north-western parts of the country respectively. The least reported meningitis (North West and Savannah regions), with cases are from the Western North and Oti proportions exceeding 0.008%. regions, with less than 100 cases over the decade. Meningitis cases recorded over the decade were less than 1,000 per region across the country, and, in terms of Health Risks 56 FIGURE 5-8. Total reported meningitis cases by region, 2012-2021 Source: Authors retrieved OPD data from Ghana Health Service FIGURE 5-9. (a) Annual region-wise meningitis cases and (b) trends Source: Authors retrieved OPD data from Ghana Health Service 57 Climate and Health Vulnerability Assessment for Ghana There was an observed decrease in being more than 1 million each for males meningitis cases over the upper parts and females. Studies in urban Accra show of the country. However, regions in the households linking the incidence of diarrhea middle belt such as Ahafo and Ashanti, to flood experience in their community109. along with the Central Region in the south, Figure 5-10 provides information on the have recorded marginal increases in total reported diarrhea cases within the reported cases. Figure 5-9 provides a time 2012 - 2021 period, grouped by gender series analysis of the reported meningitis across the region (Figure 5-10a – b) and cases per region (a) and the regional trends as a fraction of total OPD attendance in in reported diarrhea cases for the review each region (Figure 5-10c). The Upper East, decade (b). Northern, Bono, Western, Greater Accra, and Central regions followed with reported Diarrhea cases exceeding 500,000 for the decade. The lowest reported diarrhea cases were Between 2012 and 2021, the Ashanti and recorded in the North East, Savannah, Eastern regions recorded the highest Ahafo, and Oti regions with magnitudes diarrhea cases, with the reported cases below 300,000 cases. FIGURE 5-10. Region-wise reported diarrhea cases, 2012-2021 (a) among females, (b) among males and (c) as % of total OPD attendance (disease severity) Diarrhea Source: Authors retrieved OPD data from Ghana Health Service 109. Abu, M., & Codjoe, S. N. A. (2018). Experience and future perceived risk of floods and diarrheal disease in urban poor communities in Accra, Ghana. International Journal of Environmental Research and Public Health, 15(12), 2830. Health Risks 58 As a ratio to total OPD attendance, the accumulated number of individual diarrhea most diarrhea-prevalent regions were cases reported within the 2012 - 2021 predominantly in the northern parts of decade from all 16 regions nationwide. In the country, particularly the North East, terms of numbers, the Ashanti and Eastern Northern, Savannah, and Oti regions, with regions have reported more than 1.5 million proportions exceeding 8.5%. Meanwhile, individual diarrhea cases. Conversely, the the proportion in the Greater Accra and North East and Savannah regions have the Ashanti regions was the least, at less than lowest reported diarrhea cases, with less 4%. than 500,000 cases over the decade. Across the regions of the country, the diarrhea cases recorded over the decade ranged from about 400,000 to 1.75 million. Figure 5-11 highlights the Figure 5-11. Total reported diarrhea cases by region, 2012-2021 Diarrhea Source: Authors retrieved OPD data from Ghana Health Service 59 Climate and Health Vulnerability Assessment for Ghana In regions such as the Volta, Ashanti, and regional trends in reported diarrhea Greater Accra, Central, Western, Upper cases over the review decade (b). The East, Eastern, Oti, and Savannah, although most significant declines are observed in sporadic, there is an observable decline the Greater Accra, Eastern, and Upper East in diarrhea cases, whereas the remaining Regions, with reductions exceeding 40,000 regions show increasing trends. Figure cases. Conversely, Bono East shows an 5-12 presents a time series analysis of apparent increase, averaging around 2,000 reported diarrhea cases per region (a) cases per year. FIGURE 5-12. (a) Annual region-wise diarrhea cases and (b) trends Diarrhea Source: Authors retrieved OPD data from Ghana Health Service Health Risks 60 Food security and nutritional deficiencies Air quality and pollution-related illnesses Ghana faces food insecurity due to low Available data suggest that air pollution annual yield, attributable to adverse related diseases have a high mortality weather conditions. According to the United rate and high cost of treatment in Ghana. Nations, global food security demands The contamination of the indoor or outdoor that people have physical and economic environment by any chemical, physical, access to sufficient, safe, and nutritious or biological agent that alters the natural food that satisfies their food choices and characteristics of the atmosphere is termed dietary needs to live an active and healthy air pollution. The World Meteorological life. A review of general agricultural trends Organization (WMO) defines air quality as and challenges in Ghana110 highlights that ambient air with a particulate matter with a there are pockets of food insecurity in all diameter of 10 µm less than or equal to 50 regions of the country due to scarcity of µg m -3. Also, the Environmental Protection resources and inadequate alternatives for Agency (EPA, Ghana) defines air quality most people to achieve their nutritional as ambient air with particulate matter less demands. A 2009 World Food Programme than or equal to 70 µg m -3. The quality of report indicated that the total number air influences the health and well-being of of Ghanaians who are food insecure is humans. Air pollution is one of the causes about 453,000. The report projected that of climate change and is a major threat to about 2 million Ghanaians are vulnerable health and the environment. Agricultural to food insecurity and that should any activities, industrial activities, burning of natural disaster occur, food availability will fossil fuels, mining operations, indoor be greatly affected. The Northern regions pollution, etc., are some of the causes of air will be the most hit at about 25%, while pollution. Among the health effects of air the remaining 75% will be distributed pollution are respiratory and heart problems. across the other regions. The World Food A WHO report on ambient air pollution and Programme, in a Comprehensive Food its health impact estimated that in Greater Security and Vulnerability Analysis (CFSVA) Accra, the 2015 levels of air pollution will in Ghana in 2020, observed that about 3.6 be responsible for about 70,000 years of million people, representing about 11.7% life lost in the adult (25+) population over of Ghana’s population, are food insecure. a period of 10 years111. It also estimates Furthermore, 1.6 million out of the 3.6 that implementing air pollution reduction million are severely food insecure, and the strategies could prevent 1790 deaths remaining 2 million are moderately food annually in Greater Accra. Additionally, the insecure. Out of the 3.6 million people report identifies household air pollution as who are food insecure 2.8 million live in an issue in Accra due to the significant use rural areas, and 0.8 million in urban areas. of solid fuels. Household air pollution from Another report issued by the Ministry of solid fuel cooking was responsible for 4.3 Food and Agriculture, Ghana, indicated million deaths worldwide in 2012, according that approximately 1.2 million people are to the World Health Organization112. In terms food insecure representing about 5% of the of the economic costs of air pollution, a country’s population. 2020 report from Accra, Ghana, by the 111. Mudu, P.(2021). Ambient air pollution and health in Accra, Ghana. World 110. Darfour, B., & Rosentrater, K. A. (2020). Cost assessment of five different Health Organization. maize grain handling techniques to reduce postharvest losses from insect 112. WHO. (2004). Promoting mental health: Concepts, emerging evidence, contamination. Insects, 11(1), 50. practice: Summary report. World Health Organization. 61 Climate and Health Vulnerability Assessment for Ghana WHO Urban Health Initiative113 showed that Old-Fadama community in Accra117. Post Chronic Obstructive Pulmonary Disease Traumatic Stress Disorder (PTSD) is the (COPD) patients spent the most amount of most often reported mental health impact time in the hospital, an average of 29 days, of acute climate change-related disasters, followed by lung cancer patients, with 23 though there are increasing reports of days, Road Traffic Injuries (RTI) patients, suicide and suicidal ideation. The indirect with 21 day and pneumonia patients who mental health impact of climate change can stayed an average of 8.5 days in the be due to climate change-related damages hospital. The highest number of affected to physical and social infrastructure, people in terms of socioeconomic status physical health effects, food and water are the middle income (44.8%), followed by shortages, conflict, and displacement from the poor (31%) and the poorest (13.8%). The acute, subacute, and chronic climactic treatment of air pollution-related diseases changes. Mental illness is a primary cause was very costly, with patients who suffered of disability worldwide, with significant RTI paying on average US$885 for medical negative consequences, especially in low- care, patients who have lung cancer paying income nations. However, data on the as much as US$2135, stroke patients prevalence of mental health conditions paying US$351 and Ischemic heart disease and their linkages to climate change are (IHD) patients paying US$638, on average. limited in these settings, notably in Africa and specifically, Ghana. People with mental Mental health and well-being illnesses are frequently subjected to severe human rights breaches, discrimination, and A 2017 report by the American stigma. Even though many mental health Psychological Association found that illnesses can be adequately managed at climate change triggers stress, anxiety, a reasonable cost, the gap between those and depression and causes relationship needing care and those with access to strain114, 115. The literature reflects rapidly it remains significant. The percentage of expanding evidence on the link between people who receive effective treatment climate change and mental health. Mental is still deficient. Ghana has few resources health impacts may be direct or indirect. to manage the burden of mental health Extreme weather events such as heat illnesses. and humidity have been associated with increased hospital admissions for mood According to an article published by the and behavioral disorders, including Harvard Global Health Institute website, schizophrenia, mania, and neurotic there are approximately 38 psychiatrists to disorders116. There is some evidence serve Ghana’s entire population, resulting from Ghana on adverse physical and in a startling psychiatrist-to-population mental health impacts of flooding in the ratio of one psychiatrist for every 800,000 Ghanaians118. A report based on a survey conducted in 2012 on behalf of the Ministry of Health using the World Health 113. Essel, D., Spadaro, J. V., et al. (2020). Health and economic impacts of transport interventions in Accra, Ghana. World Health Organization 114. American Psychological Association. (2017). Stress in America: Coping with 117. Adams, E. A., & Nyantakyi-Frimpong, H. (2021). Stressed, anxious, and sick change. American Psychological Association. from the floods: A photovoice study of climate extremes, differentiated 115. World Health Organization. (2004). Promoting mental health: Concepts, vulnerabilities, and health in Old Fadama, Accra, Ghana. Health & Place, 67, emerging evidence, practice: Summary report. World Health Organization. 102500. 116. Hayes, K., Blashki, G., Wiseman, J., Burke, S., & Reifels, L. (2018). Climate 118. MindIT Mental Health Service Story - Ghana. (2022). Harvard Global Health change and mental health: risks, impacts and priority actions. International Institute. Available at: https://globalhealth.harvard.edu/mindit-mental- journal of mental health systems, 12(1), 1-12. health-service-story-ghana Health Risks 62 Organization Assessment Instrument for mental health organizations to offer the Mental Health Systems (WHO-AIMS) by government guidance on mental health the Kintampo Project highlighted that, as policies and legislation. The total amount of 2011, there were no national or regional spent by the Government of Ghana on Box 6. Summary of change related health risks In the past, extreme climate events like floods and droughts have resulted in injuries and fatalities in Ghana. There is little evidence on heat-related mortality and morbidity. Vector borne diseases: The Ashanti and Eastern regions of the country reported the maximum absolute number of malaria cases between 2012 and 2021, though cases show a declining trend. As a proportion of total OPD cases, the northern part of the country had the highest malaria load and the least decline in absolute number of cases over time. Between 2012 and 2021, the absolute number of schistosomiasis cases has been declining across the country.The number of cases as a proportion of total OPD cases are <1% across all regions. Across the regions, the total schistosomiasis cases recorded between 2012 and 2021 ranged from less than 500 to over 10,000, with the highest in the Eastern and Upper East regions. There is limited information available on the prevalence of dengue in Ghana, partly due to challenges in diagnosing it as distinct from malaria. Water borne diseases: Between 2012 and 2021, the total number of meningitis cases reported across the regions of the country ranged from less than 100 to about 900 cases. All regions reported <1% meningitis cases as a proportion of total OPD visits. While the upper parts of the country showed a declining trend in reported cases, regions in the middle belt such as the Ahafo and Ashanti, as well as, Central Region in the south have recorded marginal increases. The Ashanti and Eastern regions recorded the highest number of total cases between 2012 and 2021, though as a proportion of total OPD visits the northern regions reported the maximum cases. Across regions, the total cases over the decade ranged from 400,000 to 1.75 million. While the Greater Accra, Eastern and Upper East Regions have seen the maximum decline in cases over time, cases in Bono East region seem to be rising by an average of 2000 cases per year. It is estimated that about 2 million Ghanaians are vulnerable to food insecurity and that should any natural disaster occur food availability will be greatly affected, particularly in the Northern region and the rural areas of the country. Available data suggest that air pollution diseases, like respiratory illness, stroke and heart disease, have a high mortality rate and high cost of treatment in Ghana. Though evidence suggests the role of climate change in triggering stress, anxiety, depression, and other mental health issues, there is limited information in the context of Ghana. In terms of resource availability, Ghana’s health system lacks the infrastructure and human resources to address the burden of mental health issues. 63 Climate and Health Vulnerability Assessment for Ghana health in 2011 was GH¢ 398,857,000, and people increased from 0.8 to 1.41 during the spending on mental health was 1.4% of that period. In the capital region, each sub- the total health budget119. Moreover, in 2011 metro is expected to have one polyclinic, the patient-to-bed ratio in inpatient mental but this is currently not the case. The health facilities was 5.5 beds per 100,000 recent subdivision of four districts into population, with three facilities offering ten new sub-metro regions makes it more 1,322 beds. In the same year, however, challenging to meet the infrastructure more patients were admitted than there requirements. were beds. Statistics show that about 77% of mental health patients spend at least three Despite the expansion of CHPS Zones, months in inpatient facilities for treatment, various population sub-groups still 11% spend about 12 to 48 months, and 13% lack access to primary health care spend 50 to 120 months120. All these metrics (PHC) services122, 123, which may be point to the fact that, should the causes exacerbated by climate-sensitive health of mental health be carefully researched risks. An affordable and accessible PHC and mitigated, its impact on the country’s system is integral for early recognition economy can be reduced. and management of a climate-induced health emergency. A key factor limiting 5.2.3. Health system risks access to PHCs is the exclusion of PHC services within the benefits package of Health infrastructure NHIS. Additionally, robust referral systems across levels of care are lacking. A report by the University of Ghana in 2018 on the state of the nation’s health The health infrastructure needs to suggests that Ghana has insufficient be strengthened to enhance service health facilities per population density availability and readiness. About half of to manage both communicable and non- CHPS Zones meet standards in terms of communicable diseases121. Moreover, the infrastructure and transport, and only a report observes that for 2010 and 2013, third of CHPS Zones and less than half of the density of health posts per 100,000 Health Centers have the full complement people in Ghana declined marginally of equipment. Rural and remote districts from 1.18 to 1.11, respectively, while the often report stockouts of essential density of health centers per 100,000 medicines124. people fell slightly from 9.69 to 9.13. However, between 2010 and 2013, the Health workforce density of provincial or regional hospitals per 100,000 people in Ghana remained The number of human resources for constant at 0.03. In addition, the density health has increased in Ghana, though of district and rural hospitals per 100,000 122. Braimah, J. A., Sano, Y., Atuoye, K. N., & Luginaah, I. (2019). Access to 119. Roberts, M., Mogan, C., & Asare, J. B. (2014). An overview of Ghana’s primary health care among women: the role of Ghana’s community-based mental health system: results from an assessment using the World Health health planning and services policy. Primary Health Care Research & Organization’s Assessment Instrument for Mental Health Systems (WHO- Development, 20, e82. AIMS). International journal of mental health systems, 8, 1-13. 123. Acquah-Hagan, G., Boateng, D., Appiah-Brempong, E., Twum, P., Atta, J. A., 120. Roberts, M., Asare, J. B., Mogan, C., Adjase, E. T., & Osei, A. (2013). The & Agyei-Baffour, P. (2021). Access Differentials in Primary Healthcare among mental health system in Ghana. Ghana: The Kintampo Project. WHO-AIMS. Vulnerable Populations in a Health Insurance Setting in Kumasi Metropolis, 121. University of Ghana, School of Public Health. (2018). Available at: https:// Ghana: A Cross-Sectional Study. Advances in Public Health, 2021, 1-14. publichealth.ug.edu.gh/sites/publichealth.ug.edu.gh/files/docs/state_of_ 124. Republic of Ghana. (2020). Ghana’s Roadmap for Attaining Universal Health the_nations_interior_final_compressed-compressed_2.pdf Coverage, 2020-2020. Ministry of Health. Health Risks 64 there are regional and urban-rural role at the sub-district level. A 2017 disparities. Over 60% of health facilities assessment found that three of 37 Health and human resources are found in 6 Centers had a doctor on staff, while nine of the 16 administrative regions of the had a medical assistant125. On average, the country, with Ashanti and Greater Accra rural areas are poorly served compared accounting for 40% of resources. A chronic to urban areas. The government has shortage of health workers, inequities in introduced various schemes to address their distribution and skill configuration, this challenge; these include the Deprived inadequate training, deficient working Area Incentive Scheme, which provides conditions, and suboptimal physician-to- an extra 20 – 35% of the basic salary patient relationships restrict access to as an allowance to motivate the even services and hinder the achievement of distribution and placement of health staff. national health objectives. Investments in Other such schemes include the Health the capacities of Health Centers, which can Staff Vehicle Hire Purchase Scheme and be characterized as the “missing middle,” various housing schemes, but none has are needed to strengthen their essential proved particularly successful. Photo: © Curt Carnemark / World Bank 125. World Bank. (2017). Baseline Report for the Impact Evaluation of the Ghana Community Performance Based Financing (CPBF) Pilot 65 Climate and Health Vulnerability Assessment for Ghana 6. ADAPTIVE CAPACITY AND IDENTIFICATION OF GAPS Ghana is highly vulnerable to adverse implications of climate change. Despite the government’s efforts to expand PHC services to cover most of the population, capacity is limited, leading to an overreliance on higher levels of care and the private sector, particularly in urban areas. The extent to which Ghana’s health system is prepared for and can respond to climate-related changes is a key modifier of climate-related health risks. This assessment examines Ghana’s adaptive capacity to prevent and manage climate-related health risks according to the WHO’s six health system building blocks, as outlined in Figure 6-1. These building blocks are further elaborated upon in the remainder of this section. FIGURE 6-1. To put policies in action and facilitate Health system building blocks climate change adaptation, the government released the National Climate Change Policy Master Plan for 2015-2020 and initiated the development of a National Adaptation Plan (NAP) in 2020. The NAP aims to adopt an integrated, coordinated, and sustainable approach to resilience building to reduce vulnerability to the negative impact of climate change. It is envisaged that developing future climate scenarios and conducting vulnerability assessments for the different sectors of the economy can generate evidence for planning126. Other notable multisectoral policy efforts include the development of a National Climate Change Adaptation Strategy in 2012, spearheaded by the National Climate Change Committee, and the recently updated Nationally Determined Source: WHO, 2010 Contributions under the Paris Agreement, led by the Ministry of Environment, Science, Technology and Innovation. 6.1. LEADERSHIP AND GOVERNANCE Notably, Ghana has developed a draft Across various sectors, Ghana has National Plan of Action for Building a introduced policies addressing climate Climate Resilient Health Sector in Ghana change with varying focus on its health for 2015-2025. However, there is limited impact. Ghana has released several national information about the implementation of climate change policy documents across the Plan of Action or its integration into various sectors that are relevant for health multisectoral policies and strategies. This (Table 6-1), national health sector-specific plan of action is anchored around the WHO’s policy documents (Table 6-2), and sub- national-level policy documents on climate change and health (Table 6-3). 126. United National Environment Programme. 2021. Adaptation Gap Report 2020. Available at: https://www.unep.org/resources/adaptation-gap-report- 2020#:~:text=The%20UNEP%20Adaptation%20Gap%20Report%202020%20 that%20finds%20while%20nations,floods%20and%20sea%2Dlevel%20rise. Adaptive Capacity and Identification of Gaps 66 ten components of climate-resilient health the plans, and collaborating institutions such systems and includes sections devoted as Development Partners, NGOs, and the to health leadership and governance, private sector. health workforce, vulnerability, capacity and adaptation assessment, integrated risk Ghana’s Ministry of Health is establishing a monitoring and early warnings, health and steering committee on climate change and climate research, climate resilience and health that will harmonize existing policies sustainable technology and infrastructure, and strategies that address the health management of environmental determinants impact of climate change. The steering of health, climate-informed health programs, committee is envisaged to be multisectoral, emergency preparedness and management involving various stakeholders, and will allow and climate and health financing. The plan the alignment of existing efforts in the country outlines activities under each health system pertaining to climate change and health. building block with measurable outputs and time horizons (ongoing, short, medium, and long-term). It also outlines the lead institutions that can play a key role in the realization of Photo: Weija floods. © Resolution / World Bank 67 Climate and Health Vulnerability Assessment for Ghana TABLE 6-1. National climate change policies and plans relevant for health POLICY / ACTION PRINCIPLES / GOALS / RELATED PUBLIC PLAN STRATEGIC AREAS SECTOR National Climate Policy Goal: To enhance Ghana’s GHS Change Adaptation current and future development MOH Strategy 2012 by strengthening its adaptive capacity concerning climate change impacts and building the resilience of the society and ecosystems 1. Reduce the incidence of water and airborne disease 2. Health worker capacity improvement 3. Increase and upgrade existing health facilities Ghana National Climate Focus Area 6: Addressing Ghana Health Change Policy 2013 Impacts of Climate Change Service, Teaching on Human Health hospitals 1. Identify and improve data recording, reporting, analysis, and storage of at all climate-sensitive diseases at levels of service delivery. 2. Enhance knowledge and sensitize the health sector on the impacts of climate change, including issues for vulnerable groups like the aged, women, and children. 3. Minimize the impacts of climate change on health in communities while strengthening public healthcare delivery and preventive care. Adaptive Capacity and Identification of Gaps 68 POLICY / ACTION PRINCIPLES / GOALS / RELATED PUBLIC PLAN STRATEGIC AREAS SECTOR Ghana National Climate Policy Focus Area 6: Impact MOH, GHS, Teaching Change Master Plan of Climate Change on Human hospitals, CHIM, Ghana 2015–2020 Health Public Records & Archives 1. Improvements in the capacity- Administration Dept, GMet, building of healthcare CSRPM, MoFA, providers and groups to All Research Institutions include strengthening disease surveillance and response systems. 2. Climate-related Health Research. 3. Strengthen Climate-sensitive Disease Surveillance and Response Systems. 4. Improved public health measures (immunization). 5. Partnerships with other agencies and NGOs. 6. Emergency Health Preparedness and Climate- proof Health Infrastructure. 7. Social Protection and Improved Access to Health Care. 8. Indigenous traditional knowledge and practices in health. Ghana’s Fourth National Policy Goal: Communicate to the GHS Communication, 2020 COP the status of Ghana’s effort MOH to implement the Convention MMDAS up to 2020 by highlighting the pertinent achievements and constraints. 1. Improved health care access 2. Surveillance and response system 3. Improve Collaboration and Partnership 69 Climate and Health Vulnerability Assessment for Ghana POLICY / ACTION PRINCIPLES / GOALS / RELATED PUBLIC PLAN STRATEGIC AREAS SECTOR Ghana’s Nationally Policy action: Managing GHS Determined Contribution climate-induced health risks MOH (NDC) 1. Strengthening disease 2021 surveillance 2. Improve health information systems 3. Traditional knowledge of health risk management. Source: Authors retrieved OPD data from Ghana Health Service TABLE 6-2. National health sector policies and plans relevant to climate change: The National Plan of Action for Building a Climate-Resilient Health Sector, 2015-2025 (draft) POLICY / ACTION PRINCIPLES / GOALS / RELATED PUBLIC PLAN STRATEGIC AREAS SECTOR National Plan of Action Human resource capacity MOH for building a climate- building for health sector GHS resilient health sector adaptation to climate change in Ghana (2015-2025— 1. Health workforce capacity Draft document) building 2. Climate leadership and governance 3. Organizational capacity development 4. Gender-sensitive climate change communication and awareness raising 5. Vulnerability and adaptation assessment of crucial climate change- related issues 6. Conduct M&E information sharing/exchange and validation workshops 7. Analysis of data from M&E surveillance systems and timely dissemination of outputs (risk maps, Adaptive Capacity and Identification of Gaps 70 POLICY / ACTION PRINCIPLES / GOALS / RELATED PUBLIC PLAN STRATEGIC AREAS SECTOR reports, EWS, etc to relevant stakeholders 8. Updating the DHIMS-2 to capture data for monitoring the health impact of CC 9. Design a multi-hazard EWS to predict infectious disease epidemics, with identified key focus areas 10. Improve and implement early detection tools (rapid diagnostic, syndromic surveillance) 11. Conduct periodic supplementary surveys to complement IDSR Develop and implement a national research agenda on climate change and health with stakeholder participation 1. Identify ongoing and past Health and climate-related research 2. Conduct studies to improve energy efficiency and access within the health sector Source: Authors retrieved OPD data from Ghana Health Service 71 Climate and Health Vulnerability Assessment for Ghana TABLE 6-3. Sub-national policies and plans relevant to climate change and health: The Medium-Term National Development Policy Framework POLICY / ACTION PRINCIPLES / GOALS / RELATED PUBLIC PLAN STRATEGIC AREAS SECTOR Medium-Term National 8.1 Promote proactive planning MDAs Development Policy for disaster prevention and GHS Framework: mitigation An Agenda For Jobs: 8.1.1 Educate public and private Creating Prosperity institutions on natural and And Equal Opportunity man-made hazards and For All, 2018-2021 disaster risk reduction 8.1.2 Strengthen early warning and response mechanisms for disasters 8.1.3 Implement gender sensitivity in disaster management 14.1 Address recurrent MDAs devastating floods GHS 14.1.3 Intensify public education NADMO on indiscriminate disposal of waste 14.1.4 Prepare and implement adequate drainage plans for all MMDAs 20.1 Improve quality of life in slums, LUSPA Zongos, and inner cities MDAs 20.1.4 Encourage the participation of slum dwellers in improving infrastructural facilities 20.1.6 Upgrade inner cities, Zongos, and slums and prevent the occurrence of new ones Source: Authors retrieved OPD data from Ghana Health Service Adaptive Capacity and Identification of Gaps 72 6.2. HEALTH WORKFORCE increased from 1.07 per 1,000 population in 2005 to 2.65 per 1,000 population in Climate change influences workforce 2017, which, however, is still well below capacity and may put a strain on overall the WHO recommendation of 4.45 skilled health system performance. Firstly, climate- health professionals per 1,000 population129. related changes in population health needs Estimates suggest a 42% gross deficit in the may increase health system demands, thus availability of the health workforce, which is altering the required staff. Similarly, climate- exacerbated among specialized groups of related health burdens may influence case health professionals130. mix, thus altering the skill requirements of the health workforce. Finally, climate-related The distribution of the health workforce in extreme events can impact both the health the country is unequal. In terms of absolute and productivity of those working in the numbers, across all cadres, the health sector127. workforce is largely concentrated in the Ashanti and Greater Accra regions of the Despite an increase in the magnitude of country, where most teaching hospitals are the health workforce in the country, the located, and specialist care is offered (see country faces a shortfall. The State of Table 6-5). However, these regions also have the Nation’s Health Report shows that the the maximum proportion of the country’s total health workforce in Ghana, across all population. The Upper West and Upper East cadres, increased from 28,662 in 1999 to regions have the fewest health workers. 94,696 in 2015.128 (see Table 6-4). The density of physicians, nurses, and midwives has 127. Salas, R. N. (2020). The climate crisis and clinical practice. New England 129. GHS. (2018). Human Resource Directorate Annual Report for 2017. Ghana Journal of Medicine, 382(7), 589-591. Health Service, Human Resource Directorate. 128. University of Ghana. (2018). State of the Nation’s Health Report. School 130. Asamani, J. A., Chebere, M. M., Barton, P. M., D’Almeida, S. A., Odame, E. A., of Public Health Available at: https://publichealth.ug.edu.gh/sites/ & Oppong, R. (2018). Forecast of healthcare facilities and health workforce publichealth.ug.edu.gh/files/docs/state_of_the_nations_interior_final_ requirements for the public sector in Ghana, 2016–2026. International compressed-compressed_2.pdf journal of health policy and management, 7(11), 1040. 73 Climate and Health Vulnerability Assessment for Ghana TABLE 6-4. Distribution of health workforce by cadre, 2015 Occupational categories/ cadres Number % HW HW/1000 population General Medical Practitioners** 2438 2.57 0.09 Specialist Medical Practitioners 726 0.77 0.03 Medical/Physician Assistants * 1729 1.83 0.06 Nursing Associate Professionals 32077 33.87 1.15 Nursing Professionals* 19093 20.16 0.68 Midwifery Professionals 5582 5.89 0.20 Dental Assistants and Therapists 533 0.56 0.02 Pharmacist* 666 0.70 0.02 Pharmaceutical Technicians and Assistants** 877 0.93 0.03 Environmental, Occupational and Hygiene Workers** 115 0.12 0.00 Physiotherapist and Physiotherapy Assistant 279 0.29 0.01 Optometrists and opticians 131 0.14 0.00 Medical Imaging &Therapeutic Equipment Operators 1439 1.52 0.05 Medical and Pathology Laboratory Technicians* 849 0.90 0.03 Medical and Dental Prosthetic Technicians 111 0.12 0.00 Community Health Workers** 3451 3.64 0.12 Health management Workers/Skilled administrative Staff* 215 0.23 0.01 Other Health Support Staff* 24385 25.75 0.87 Total 94696 100.00 3.37 ** Highly relevant to climate change and health *Relevant to climate change and health Source: IPPD, Dec, 2015 Adaptive Capacity and Identification of Gaps 74 TABLE 6-5. Distribution of health workforce by region, 2015 Region Medical Officer (%) Nurse (%) Midwife (%) Pharmacist (%) Ashanti 760 (24.0) 6200 (18.7) 1281 (22.9) 160 (24.0) Brong Ahafo 166 (5.2) 2513 (7.6) 483 (8.7) 45 (6.8) Central 136 (4.3) 3005 (9.1) 383 (6.9) 34 (5.1) Eastern 183 (5.8) 2580 (7.8) 600 (10.7) 64 (9.6) Greater Accra 1468 (46.4) 6524 (19.7) 973 (17.4) 204 (30.6) Northern 154 (4.9) 4222 (12.7) 408 (7.3) 45 (6.8) Upper East 46 (1.5) 1904 (5.7) 311 (5.6) 15 (2.3) Upper West 25 (0.8) 1331 (4.0) 219 (3.9) 11 (1.7) Volta 130 (4.1) 2086 (6.3) 465 (8.3) 41 (6.2) Western 96 (3.0) 2760 (8.3) 459 (8.2) 47 (7.1) Total 3164 (100) 33125 (100) 5582 (100) 666 (100) Source: IPPD, Dec, 2015 Health workforce training initiatives 6.3. HEALTH INFORMATION SYSTEMS relevant to climate change and health have focused mainly on infectious diseases, The routine health information and particularly malaria, with little emphasis surveillance systems in Ghana collect on the wide-reaching health outcomes and information on specific climate-sensitive systems implications of climate change. For infections, namely malaria, diarrhea, example, the GHS has conducted various meningitis, and schistosomiasis. Currently, training programs for health institutions on the Ghana Health Service collects routine malaria prevention and case management. health services, morbidity, mortality, and Workshops have been held to involve MoH disease, which are useful to health managers staff in developing a sustainability plan for the and used for planning, budgeting, and Neglected Tropical Diseases program in 2021. decision-making. The collection of such Additionally, MoH staff have participated in information is currently done by facilities internal capacity development programs and districts and submitted through the related to the National Malaria Control District Health Information Management Programme (NMCP), including partnerships System (DHIMS) structure. In this system, with the private sector on larval source data is organized from the facility level, management and indoor residual spraying, through subdistricts, districts, and regions, supported by USAID Ghana. However, it is eventually reaching the national level. The worth noting that climate-change related system does not separate the information training is not currently integrated into pre- gathered specifically for climate change service or in-service training and curricula. though it includes information about climate-sensitive diseases such as diarrhea, malaria, CSM. The WHO/AFRO Integrated Disease Surveillance and Response (ISDR) strategy was adopted as the guidelines for 75 Climate and Health Vulnerability Assessment for Ghana Ghana’s surveillance system. The system or a plan of implementation to achieve the covers 23 priority diseases across the same. Additionally, no assessments have country, of which four have been identified been conducted to specifically determine the as climate-sensitive diseases. They are climate resilience of health facilities in the Diarrheal diseases, Malaria, Meningococcal country. This will be particularly imperative meningitis, and Schistosomiasis. The country for the health infrastructure in the rural areas has three Demographic Surveillance Sites that may be the only source of health services (DSS) in Navrongo, Kintampo, and Dodowa in the region. that provide surveillance on vector-borne diseases, especially Malaria. The availability of diagnostic tools, vaccines, and treatment at most health facilities There are information systems outside is not yet targeted at addressing health the health sector that track changes in risks of climate change. However, there are climate and weather, though they are not examples of siloed interventions utilizing integrated with the health information medical products and technologies that systems. The Ghana Meteorological Agency target certain climate-sensitive infections. tracks temperature, rainfall, and humidity For example, the GHS implements a seasonal levels across major cities and the districts malaria chemoprevention exercise, mass drug assemblies, and the National Disaster administration to prevent yellow fever and Management Organization (NADMO) lymphatic filariasis-elephantiasis, mosquito captures data on the effect of extreme bed net distribution, and larviciding for larval heat. The Environmental Protection Agency source management. The percentage of (EPA) has a framework for assessing air children under five years of age sleeping quality at monitoring stations, on Bus Rapid under Insecticide Treated Nets (ITN) has Transit (BRT) routes, and in some residential, increased gradually from 28% in 2005 to commercial, and industrial areas in Accra. 53% in 2013131. In 2012, to increase household access and use of ITNs, a nationwide door- 6.4 ESSENTIAL MEDICAL PRODUCTS, to-door campaign distributed more than 12.4 TECHNOLOGIES, AND million long-lasting ITNs to protect against INFRASTRUCTURE mosquito bites. Floods and other extreme weather events While drug stockouts have been reported at are known to damage hospitals and other health facilities, there is limited information health care facilities. These events may also on the frequency of stockouts on drugs damage critical non-health infrastructure, specifically used to prevent and manage including transportation, energy, and water common climate-sensitive conditions. supplies, which can adversely affect health Ghana’s National Essential Medicines List, service delivery. Remote healthcare facilities 2017, includes drugs for climate-sensitive often lack access to safe running water and infections such as malaria, diarrhea, sanitation, and extreme heat events can schistosomiasis, and the meningococcal significantly disrupt hospital and healthcare vaccine. facility power supply, leading to overheating. Various national policy documents mention the need to strengthen health facilities and “climate-proof” existing health infrastructure, though concrete steps must be taken to further these strategies. There is an absence of agreed-upon standards 131. According to the National Malaria Control Programme of Ghana (2018). Adaptive Capacity and Identification of Gaps 76 6.5. SERVICE DELIVERY on external financing from Development Partners (which has averaged about 10% of The density of health facilities and the total health spending over the past decade). health workforce is low, particularly in Especially crucial are payments for services rural areas, which limits access to and by the NHIS, which represent 80% of financial availability of care to address the burden resources managed at the level of front-line of climate-related health risks. Moreover, service providers133. Any delays in NHIS adequate coordination for service delivery payments to the facilities would limit their across a range of healthcare and public ability to render services, particularly in a health programs, including those important disaster response situation. to reduce climate change risks, are lacking in Ghana. Despite the expansion of NHIS, out-of- pocket payments (OOPS) represent the There is an absence of institutional second highest source of financing health mechanisms that integrate strategies for services134; in fact, the share of OOPS in addressing the impact of climate change health facilities’ total revenues is increasing. into all vertical health programs and other Data analysis of health facilities’ revenues non-health sectors by utilizing a systems from the Ghana Health Service shows that the approach. Siloed health programs and OOP share in total health facilities’ revenues interventions, such as for malaria, are in has consistently been above 40% and place to address the burden of the climate- increased by 11 percentage points between sensitive disease. However, given the 2017 and 2021. A year before the COVID-19 wide-reaching impact of climate change on pandemic in 2019, the share of OOPS on total mental health, maternal health, respiratory health facilities’ revenues reached its highest health, and infectious diseases, to name level at 53%135. a few, a health system-wide integration is needed. Additionally, multisectoral action, as The budget statement of the 2022 financial highlighted in the country’s health and climate year estimates that Ghana requires a total of change policies, needs to be implemented to US$9.3 billion in investments to implement maximize efficiency and effectiveness. the 47 NDC programs from 2021 to 2030. Out of this amount, US$3.9 billion will be 6.6. HEALTH SYSTEM FINANCING required to implement the 16 unconditional programs over the next ten years. The The government’s health budget has remaining US$5.4 billion for the 31 conditional increased in absolute terms in recent years, NDC programs will be mobilized from public, but health facilities are highly dependent international, and private sector sources on NHIS payments for services to cover and climate markets. To mobilize sufficient non-salary costs. Between 2014 and 2018, financial resources, Ghana is exploring more Domestic General Government Health results-based climate financing options, Expenditures per capita doubled from $32 including carbon markets and climate impact to $65132. Likewise, the share of government bonds. For example, Ghana has submitted spending on Current Health Expenditure 18 proposals to seek funding from the Green increased from 35.1% to 38.9%. The national Climate Fund (GCF) and co-financiers. Nine budget covers health worker remuneration, proposals were approved, totaling US$106.9 while meeting non-salary costs of primary million. health care service delivery depends largely 133. According to the Ministry of Health, 2015-2020 expenditure and 2021-2022 budget data. 134. World Health Organization. (2018). Global Health Expenditure Database. 132. World Health Organization. (2018). Global Health Expenditure Database. 135. Ghana Health Services (2021).   77 Climate and Health Vulnerability Assessment for Ghana From 2015 to 2020, the Government of The recent increase in GoG expenditure Ghana (GoG) spent GH¢14.5 billion on is largely attributed to government Climate Relevant Actions, which amounts interventions in non-health sectors. At to an average of 4% of the total government the level of Ministries, Departments and expenditure. There is a need to establish Agencies (MDAs), agriculture and food sustainable streams of funding for climate security showed the highest expenditure. In change. The total GoG expenditure between contrast, water and sanitation showed the 2015 and 2020 was GHS 369 billion, of which highest expenditure among the Metropolitan, GHS 14.5 billion was earmarked for Climate Municipal and District Assemblies (MMDAs). Relevance Actions. Percentage variations have been noticed over these years, starting with 5.6%, reducing to 2.29% in 2018 and 7. RECOMMENDATIONS TO rising marginally to 3.8 % in 2020136. TABLE 6-6. Summary of adaptive capacities and gaps by health system building blocks HEALTH SYSTEM BUILDING BLOCK GAPS IN ADAPTIVE CAPACITY Leadership and • Little focus on strategies to minimize the health impact of climate governance change on the most vulnerable sub-populations. • Presence of many national climate change policies with varying focus on its health impact. Most policies have emerged from non- health sectors, except the National Plan of Action for Building a Climate Resilient Health Sector in Ghana, 2015-2025. However, there is limited information about the implementation of the Plan of Action or its integration into multisectoral policies and strategies. Health workforce • Despite an increase in the magnitude of the health workforce in the country, the country faces a shortfall. • The distribution of the health workforce is unequal, with resources concentrated in the urban areas of the country. • Health workforce training initiatives relevant to climate change and health have largely focused on infectious diseases, particularly malaria, with little emphasis on the wide-reaching health outcomes and systems implications of climate change. ber-14-Session-1- 136. Mensah, L. (2021). Climate Public Expenditure and Institutional Review. Available at: https://www.cabri-sbo.org/uploads/files/Documents/Septem­ Ghana.pdf Adaptive Capacity and Identification of Gaps 78 HEALTH SYSTEM BUILDING BLOCK GAPS IN ADAPTIVE CAPACITY Health information • The routine health information and surveillance systems in Ghana systems collect information on specific climate-sensitive infections, namely malaria, diarrhea, meningitis, and schistosomiasis. • There are information systems outside the health sector that track changes in climate and weather, though they are not integrated with the health information systems. Essential medical • Floods and other extreme weather events are known to damage products, technologies hospitals and other health care facilities. and infrastructure • Various national policy documents mention the need to strengthen health facilities and “climate-proof” existing health infrastructure, though concrete steps need to be taken to further these strategies. • No assessments have been conducted to determine the climate resilience of health facilities in the country. • Availability of diagnostic tools, vaccine, and treatment available at most health facilities is not yet targeted at addressing health risks of climate change. • There is limited information on the frequency of stockouts of drugs used to prevent and manage common climate-sensitive conditions. Service delivery • The density of health facilities and the health workforce is low, particularly in rural areas, which limits access to and availability of care to address the burden of climate-related health risks. • There is an absence of institutional mechanisms that integrate strategies for addressing the impact of climate change into all vertical health programs and non-health sectors by utilizing a systems approach. Health system financing • The government’s health budget has increased in absolute terms in recent years, but health facilities are highly dependent on NHIS payments for services to cover non-salary costs. • Despite the expansion of NHIS, out-of-pocket payments (OOPS) represent the second highest source of financing for health services; in fact, the share of OOPS in health facilities’ total revenues is increasing. • Between 2015 and 2020, the GoG reportedly spent an average of 4% of the total government expenditure on Climate Relevant Actions. There is a need to establish sustainable streams of funding for climate change. • The recent increase in GoG expenditure is largely attributed to government interventions in non-health sectors. Source: Authors 79 Climate and Health Vulnerability Assessment for Ghana 7. RECOMMENDATIONS TO REDUCE CLIMATE-RELATED HEALTH VULNERABILITIES AND VULNERABILITIES OF THE HEALTH SYSTEM 7.1. LEADERSHIP AND GOVERNANCE and competencies post-training. Obtain buy-in from health professionals training • Undertake dialogue, development, and and regulatory institutions to institutionalize implementation of the National Plan of issues related to climate health vulnerability Action for Building a Climate Resilient Health in pre-service or in-service training. Sector in Ghana, 2015-2025: Integrate its objectives and activities into climate change 7.3. VULNERABILITY, CAPACITY, AND policies emerging from other sectors to allow ADAPTATION ASSESSMENT alignment. • Conduct national and sub-national climate 7.2. HEALTH WORKFORCE and health vulnerability assessments: Identify interventions and their impact over • Integrate climate-related impacts into health time, share findings with stakeholders, and workforce planning: Includes planning for obtain stakeholder buy-in for interventions. the size of the health workforce, the skill Assess the vulnerabilities and capacities mixes, and the geographical distribution, of the health system to respond to climate particularly urban-rural disparities, to meet change in different regions of the country. expected health needs. The Community Additionally, analyze local climate-related risk Based Extension Agents (CBEA) is a rural factors for infectious disease outbreaks and agricultural extension model based on the the capacity to manage epidemics. idea of providing specialized and intensive technical training to identified people in rural 7.4. INTEGRATED RISK MONITORING AND communities to promote various technologies EARLY WARNING and offer technical services with support and review from an extension organization. • Enhance the coverage of climate- The community-based extension model sensitive health conditions in routine can be explored to determine the potential health information systems: Besides the to contribute to climate change adaptation four climate-sensitive infectious diseases, through training service providers in climate namely malaria, diarrhea, meningitis, and data collection, analysis, and dissemination schistosomiasis, expand coverage of within their areas of operation to enable other high-priority climate-sensitive health communities to select appropriate response conditions in routine health information strategies. systems to enable estimation of disease burden and allow evidence-based decision- • Institutionalize climate-related capacity making to manage the same. building of the health workforce with buy-in from relevant regulators: Develop • Mainstreaming weather and disease guidelines for roles and responsibilities of forecasting: To mitigate the impact of extreme various health cadres to respond to the health weather events like floods on health, it is impact of climate change, identify associated necessary to integrate platforms supporting competencies, develop pre-service or in- various early warning systems, including flood service training to meet competency gaps, early warning (FEW) and health early warning and develop tools to assess knowledge (HEW). Recommendation to Reduce Climate-Related Heath Vulnerabilities and Vulnerabilities of The Health System 80 7.5. HEALTH AND CLIMATE RESEARCH 7.6. CLIMATE RESILIENT AND SUSTAINABLE TECHNOLOGIES • Identify and prioritize knowledge gaps AND INFRASTRUCTURE in health and climate research: Conduct stakeholder consultations to identify and • Undertake vulnerability assessments of prioritize data and knowledge gaps that health facilities to climate change: This will hinder evidence-based decision-making form the basis of planning and implementation regarding climate change and its health of facility upgrades that can withstand the impacts. This will also facilitate prioritization impact of climate change. for resource allocation. • Upgrade public health infrastructure: Based • Understand the impact of climate change on findings from vulnerability assessments, on individuals and communities through strengthen health facilities and infrastructure, research: Conduct regional and district-level including laboratory facilities, to help identify research to identify sub-populations most and assess climate-related health risks and vulnerable to the various effects of climate the effectiveness of mitigating actions. This change. The findings can inform sub-national includes evaluation of “sick” health facility adaptation of climate change policies to best buildings and retro-fitting them to make them protect the most vulnerable. “climate-proof”. It will be critical to engage with regulators of facilities, drugs, and • Build capacity to use combined health services as well as Quality Management Units and climate models: Once the knowledge for successful implementation. gaps have been identified, build research capacity in methods and models that link • Introduce climate-smart health sector climatic variables with climate-sensitive infrastructure codes: There is a need to diseases. This will allow in-depth analyses establish climate-smart infrastructure codes of country-level and sub-national-level data for the health sector to complement the to inform decisions and policy formulations. existing national codes, especially in the Access to data for climate change and health management of buildings and energy facilities assessment is challenging since the two data for lighting, refrigeration, and incineration. systems are not linked at all levels but are generated separately and would require some • Routinely evaluate the availability of drugs integration. Combining this with research and equipment for the prevention and partnerships would produce evidence for management of climate-sensitive infectious health decision-making. diseases such as malaria. • Timely analysis and dissemination of 7.7. MANAGEMENT OF ENVIRONMENTAL surveillance data: Enhance capacities for data DETERMINANTS OF HEALTH analysis from surveillance systems and timely dissemination of outputs (risk maps, reports, • Multisectoral action to improve EWS, etc.) to relevant stakeholders. This can determinants of health: Improve public contribute to establishing a multi-hazard Early health and environmental measures, including Warning System (EWS) to predict and detect immunization, improved drainage, sanitation infectious disease epidemics in identified/ and hygiene, food and water security, and air targeted hotspot areas, building upon pollution in climate-vulnerable communities disease surveillance systems strengthened in through multisectoral action plans that have a response to the COVID19 pandemic. foundation in policy documents. 81 Climate and Health Vulnerability Assessment for Ghana 7.8. CLIMATE-INFORMED HEALTH agency changes, depending on the type and PROGRAMS magnitude of the event. • Continue roll-out and strengthening 7.10. CLIMATE AND HEALTH FINANCING of vector and water-borne infectious disease control programs: Continue health • Sustained and holistic health and climate workforce capacity-building for implementing change financing: The health sector malaria and other infectious disease control adaptation strategy must be gazetted to programs, particularly in regions with high enable it to obtain the relevant financial disease burdens. Strengthen both supply investment required to implement the and demand side program components and programs. Besides non-health (though processes to enable access to care for these health-related) sectors such as agriculture diseases. and water and sanitation, financing the health sector must also be a priority to ensure early • Adopt a systems approach to strengthen all identification and management of climate- health programs towards climate change: related health emergencies. With buy-in from health system stakeholders, incorporate climate change considerations in • Monitor climate-related health expenditure the planning and implementation of all health in line with policy commitments: Establish programs. monitoring mechanisms to enable tracking of climate-related health expenditure in line 7.9. EMERGENCY PREPAREDNESS AND with policies and action plans (such as the MANAGEMENT Nationally Determined Contributions). • Contingency Planning: This is a forward- • Ensure smooth and timely claims payments planning process in a state of uncertainty from NHIS to the health facilities: Ensure and revolves around scenario-building and uninterrupted functioning of the health objectives that are agreed upon, and the facilities, particularly during climate and managerial and technical aspects defined, health emergencies. Enhance the capacity of with actions in place to prevent or better facilities to utilize Internally Generated Funds respond to an emergency. Key components of (IGF) for climate change-related needs based any contingency plan are a well-established on each facility’s vulnerability assessment. inventory of resources that can be accessed and action plans with agency/sector-wise • Financial protection of vulnerable sub- responsibilities of stakeholders. populations: Expand the NHIS to provide financial protection for the most vulnerable • Building strong and effective emergency sub-populations affected by the health communication apparatus: Strong and impacts of climate. reliable communication linkages to storm warning and forecast centers so that the emergency response actions taken are appropriate to the magnitude of the probable event. • Active engagement of communities in emergency response: There is a need for emergency response that must include input from the community and political levels, having clear lines of authority, even if the lead Recommendation to Reduce Climate-Related Heath Vulnerabilities and Vulnerabilities of The Health System 82 8. APPENDICES 8.1. APPENDIX 1: NATIONAL ANALYSIS OF DIARRHEA CASES: FINDINGS FROM AN ECOLOGIC STUDY TABLE 8-1. Distribution of monthly diarrhea cases in Ghana, 2012-2020 Distribution of monthly diarrhea cases (2012-2020) Month Total Mean Minimum Maximum Median 25th 75th percentile percentile Jan 1108510 7697.986 1868 20883 6937.5 4559 10020 Feb 1105485 7676.979 1766 17805 7053.5 4266 10155 Mar 1085332 7537.028 1814 20816 6394 4218.5 9668.5 April 1065467 7399.076 1514 37549 6450 4092.5 9033 May 1070291 7432.576 1963 19063 6672 4349 9760 Jun 1149674 7983.847 2162 19723 6962 4295.5 10593.5 Jul 1129473 7843.563 2372 20837 6980 4543 10468.5 Aug 1079108 7493.806 2253 18020 6722.5 4293 10258 Sep 1024721 7116.118 1510 15783 6441.5 4356 9390 Oct 1197380 8315.139 2289 53134 7509.5 4510.5 10540.5 Nov 1089820 7568.194 2154 17132 7212 4220 9741 Dec 986419 6850.132 1953 16268 6411.5 4001.5 9321 Total 13091680 7576.204 1510 53134 6824.5 4313 9931.5 Source: Authors based on OPD data from Ghana Health Service TABLE 8-2. Effect of temperature and precipitation on diarrhea cases in Ghana Diarrhea cases aIRR [95% CI] Predictive ME [95% CI] Overall effect of temperature 1.3241 [1.1046, 1.5873]** 2459 [760, 4157]** Temperature at lag 0 1.0805 [1.0055, 1.1611]* 678 [48, 1308]* Temperature at lag 1 1.0737 [1.0247, 1.1250]** 623 [202, 1043]** Temperature at lag 2 1.1414 [1.0619, 1.2269]*** 1158 [510, 1806]*** Overall effect of precipitation 1.0008 [0.9991, 1.0026] 7 [-12, 26] Precipitation at lag 0 1.0001 [1.0003, 1.0016]** 8 [3, 14]** Precipitation at lag 1 1.0002 [0.9998, 1.0006] 2 [-2, 5] Precipitation at lag 2 0.9997 [0.9985, 1.0008] -3 [-13, 7] Source: Authors based on OPD data from Ghana Health Service Abbreviation: aIRR: adjusted incidence rate ratio, ME: Marginal effect. P-value notation:*p<0.05, **p<0.01, ***p<0.05. 83 Appendices FIGURE 8-1. Effect of temperature on diarrhea cases nationally (LQ: lower quartile UQ: upper quartile) Source: Authors based on OPD data from Ghana Health Service 8.2. APPENDIX 2: NATIONAL ANALYSIS OF MALARIA CASES: FINDINGS FROM AN ECOLOGIC STUDY TABLE 8-3. Distribution of monthly malaria cases in Ghana, 2012-2020 Distribution of monthly malaria cases (2012-2020) Month Total Mean Minimum Maximum Median 25th 75th percentile percentile Jan 4970002 34513.90 5862 130906 28081.5 16753.5 46533.5 Feb 4466561 31017.78 4968 117786 25447 15304 42951.5 Mar 4382164 30431.69 3176 118609 25043.5 13884 42548 April 4490459 31183.74 2792 123708 23418 12917.5 44584 May 5223782 36276.26 3060 134157 30769.5 15447 50314 Jun 6035349 41912.15 3691 143083 35739 20332.5 57432 Jul 6439675 44719.97 6698 145160 38854 23567 58274 Aug 6194762 43019.18 7833 133420 38327.5 22800 55113.5 Sep 5685050 39479.51 9786 128554 36505.5 21358 48254 Oct 6584530 45725.9 14841 132915 41421.5 24002 56867 Nov 6237025 43312.67 6837 131412 38329 23031 58336 Dec 5119524 35552.25 4164 127784 30612 18804 48742.5 Total 65828883 38095.42 2792 145160 32730 18640 50198 Source: Authors based on OPD data from Ghana Health Service Climate and Health Vulnerability Assessment for Ghana 84 TABLE 8-4. Effect of temperature and precipitation on malaria cases in Ghana Malaria cases aIRR [95% CI] Predictive ME [95% CI] Overall effect of temperature 1.1405 [1.0074, 1.2912]* 5509 [495, 10527]* Temperature at lag 0 1.0626 [1.0159, 1.1113]** 2542 [823, 4260]** Temperature at lag 1 1.0145 [0.9793, 1.0511] 605 [-834, 2049] Temperature at lag 2 1.0580 [1.0076, 1.1109]* 2362 [506, 4218]* Overall effect of precipitation 1.0039 [1.0026, 1.0053]*** 165 [113, 216]*** Precipitation at lag 0 1.0012 [1.0007, 1.0018]*** 52 [32, 71]*** Precipitation at lag 1 1.0011 [1.0007, 1.0015]*** 46 [31, 61]*** Precipitation at lag 2 1.0016 [1.0011, 1.0021]*** 67 [50, 84]*** Source: Authors based on OPD data from Ghana Health Service Abbreviation: aIRR: adjusted incidence rate ratio, ME: Marginal effect. P-value notation:*p<0.05, **p<0.01, ***p<0.05. FIGURE 8-2. Effect of temperature on malaria cases (LQ: lower quartile, UQ: upper quartile) Source: Authors based on OPD data from Ghana Health Service 85 Appendices FIGURE 8-3. Marginal effect of precipitation on malaria cases in Ghana Source: Authors based on OPD data from Ghana Health Service 8.3. APPENDIX 3: NATIONAL ANALYSIS OF MENINGITIS CASES: FINDINGS FROM AN ECOLOGIC STUDY TABLE 8-5. Distribution of monthly meningitis cases in Ghana, 2012-2020 Distribution of monthly meningitis cases (2012-2020) Month Total Mean Minimum Maximum Median 25th 75th percentile percentile Jan 565 62.78 25 154 53 48 60 Feb 938 104.22 30 274 83 45 108 Mar 807 89.67 31 215 73 58 107 April 352 39.11 15 123 30 21 41 May 296 32.89 16 48 31 25 44 Jun 242 26.89 7 59 23 22 30 Jul 451 50.11 16 157 30 18 51 Aug 229 25.44 11 70 22 13 27 Sep 194 21.56 9 38 20 18 22 Oct 174 19.33 10 29 18 15 24 Nov 193 21.44 7 37 18 16 29 Dec 369 41.00 10 143 25 20 43 Total 4810 44.54 7 274 29.5 18 49.5 Source: Authors based on OPD data from Ghana Health Service Climate and Health Vulnerability Assessment for Ghana 86 TABLE 8-6. Effect of temperature and precipitation on meningitis cases in Ghana Meningitis cases aIRR [95% CI] Predictive ME [95% CI] Overall effect of temperature 2.3658 [1.7542, 3.1907]*** 6.0 [2.3, 9.7]*** Temperature at lag 0 1.5426 [1.2553, 1.8955]*** 3.0 [1.0, 5.0]** Temperature at lag 1 1.3311 [1.1913, 1.4874]*** 2.0 [1.0, 3.0]*** Temperature at lag 2 1.1522 [1.0269, 1.2928]* 1.0 [0.1, 1.7]* Overall effect of precipitation 0.9984 [0.9926, 1.0044] -0.009 [-0.062, 0.043] Precipitation at lag 0 1.0003 [0.9962, 1.0044] 0.002 [-0.024, 0.028] Precipitation at lag 1 0.9946 [0.9982, 1.0007] -0.003 [-0.011, 0.004] Precipitation at lag 2 0.9987 [0.9959, 1.0015] -0.008 [-0.026, 0.010] Source: Authors based on OPD data from Ghana Health Service Abbreviation: aIRR: adjusted incidence rate ratio, ME: Marginal effect. P-value notation:*p<0.05, **p<0.01, ***p<0.05. FIGURE 8-4. Effect of temperature on meningitis cases in Ghana. (LQ: lower quartile, UQ: upper quartile) Source: Authors based on OPD data from Ghana Health Service 87 Appendices 8.4. APPENDIX 4. NATIONAL ANALYSIS OF SCHISTOSOMIASIS CASES: FINDINGS FROM AN ECOLOGIC STUDY TABLE 8-7. Distribution of monthly schistosomiasis cases in Ghana, 2012-2020 Distribution of monthly schistosomiasis cases (2012-2020) Month Total Mean Minimum Maximum Median 25th 75th percentile percentile Jan 4296 477.33 222 859 417 271 692 Feb 4204 467.11 185 1036 397 250 594 Mar 5106 567.33 218 1523 456 267 566 April 4096 455.11 181 951 464 255 635 May 4576 508.44 173 957 424 288 856 Jun 4194 466.00 216 1130 369 267 608 Jul 4138 459.78 154 882 311 232 862 Aug 5113 568.11 181 1268 542 288 781 Sep 4163 462.56 194 815 376 238 798 Oct 4215 468.33 219 1047 349 288 601 Nov 3842 426.89 240 881 346 265 521 Dec 3345 371.67 188 694 257 232 503 Total 51288 474.89 154 1523 372.5 249.5 673 Source: Authors based on OPD data from Ghana Health Service TABLE 8-8. Effect of temperature and precipitation on schistosomiasis cases in Ghana Schistosomiasis cases aIRR [95% CI] Overall effect of temperature 1.0835 [0.7497, 1.5660] Temperature at lag 0 0.9867 [0.8747, 1.1131] Temperature at lag 1 1.0425 [0.9141, 1.1889] Temperature at lag 2 1.0534 [0.9002, 1.2327] Overall effect of precipitation 1.0005 [0.9970, 1.0041] Precipitation at lag 0 1.0006 [0.9987, 1.0025] Precipitation at lag 1 0.9987 [0.9977, 0.9965]* Precipitation at lag 2 1.0013 [0.9999, 1.0027] Source: Authors based on OPD data from Ghana Health Service Abbreviation: aIRR: adjusted incidence rate ratio. P-value notation:*p<0.05, **p<0.01, ***p<0.05. Climate and Health Vulnerability Assessment for Ghana 88 FIGURE 8-5. Distribution of schistosomiasis cases in Ghana (LQ: lower quartile, UQ: upper quartile) Source: Authors based on OPD data from Ghana Health Service 8.5. APPENDIX 5. SUB-NATIONAL/REGIONAL LEVEL ANALYSIS: FINDINGS FROM AN ECOLOGIC STUDY. FIGURE 8-6. Distribution of climate-induced conditions by region Source: Authors based on OPD data from Ghana Health Service 89 Appendices TABLE 8-9. Effect of temperature on diarrhea in the North East region of Ghana Diarrhea cases aIRR [95% CI] Predictive ME [95% CI] Overall effect of temperature 1.1074 [0.9916, 1.2368] 362.00 [-260.00, 984.00] Temperature at lag 0 1.0115 [0.9550, 1.0715] 41.00 [-164.00, 245.00] Temperature at lag 1 1.0079 [0.9520, 1.0672] 28.00 [-175.00, 231.00] Temperature at lag 2 1.0861 [1.0227, 1.1536]** 293.00 [79.00, 508.00]** Overall effect of precipitation 0.9997 [0.9977, 1.0017] -1.03 [-12.10, 10.04] Precipitation at lag 0 1.0006 [0.9996, 1.0017] 2.00 [-2.00, 6.00] Precipitation at lag 1 0.9999 [0.9989, 1.0008] -0.49 [-3.82, 2.84] Precipitation at lag 2 0.9992 [0.9981, 1.0003] -2.81 [-6.80, 1.19] Source: Authors based on OPD data from Ghana Health Service Abbreviation: aIRR: adjusted incidence rate ratio. P-value notation:*p<0.05, **p<0.01, ***p<0.05. FIGURE 8-7. Effect of temperature on diarrhea in the North East region of Ghana Source: Authors based on OPD data from Ghana Health Service Climate and Health Vulnerability Assessment for Ghana 90 TABLE 8-10. Effect of temperature and precipitation on malaria cases in Savannah region of Ghana Malaria aIRR [95% CI] Overall effect of temperature 1.0003 [0.9187, 1.0891] Temperature at lag 0 1.0217 [0.9711, 1.0750] Temperature at lag 1 1.0175 [0.9667, 1.0709] Temperature at lag 2 0.9622 [0.9125, 1.0145] Overall effect of precipitation 0.9998 [0.9986, 1.0011] Precipitation at lag 0 1.0002 [0.9995, 1.0009] Precipitation at lag 1 1.0002 [0.9993, 1.0011] Precipitation at lag 2 0.9994 [0.9986, 1.0002] Source: Authors based on OPD data from Ghana Health Service Abbreviation: aIRR: adjusted incidence rate ratio. P-value notation:*p<0.05, **p<0.01, ***p<0.05. TABLE 8-11. Effect of temperature and precipitation on meningitis cases in Upper West region of Ghana Malaria aIRR [95% CI] Overall effect of temperature 1.3955 [0.6879, 2.8310] Temperature at lag 0 1.2170 [0.8904, 1.6635] Temperature at lag 1 1.2619 [0.8467, 1.8807] Temperature at lag 2 0.9086 [0.6315, 1.3074] Overall effect of precipitation 0.9814 [0.9638, 0.9993]* Precipitation at lag 0 0.9929 [0.9843, 1.0016] Precipitation at lag 1 0.9983 [0.8995, 1.0073] Precipitation at lag 2 0.9901 [0.9821, 0.9981]* Source: Authors based on OPD data from Ghana Health Service Abbreviation: aIRR: adjusted incidence rate ratio. P-value notation:*p<0.05, **p<0.01, ***p<0.05. 91 Appendices TABLE 8-12. Effect of temperature and precipitation on schistosomiasis cases in Upper East region of Ghana Schistosomiasis aIRR [95% CI] Overall effect of temperature 0.9793 [0.7189, 1.3341] Temperature at lag 0 0.8913 [0.7575, 1.0486] Temperature at lag 1 1.0433 [0.8941, 1.2174] Temperature at lag 2 1.0532 [0.9083, 1.2211] Overall effect of precipitation 0.9962 [0.9899, 1.0024] Precipitation at lag 0 0.9959 [0.9923, 0.9995]* Precipitation at lag 1 0.9988 [0.9954, 1.0022] Precipitation at lag 2 1.0015 [0.9980, 1.0050] Source: Authors based on OPD data from Ghana Health Service Abbreviation: aIRR: adjusted incidence rate ratio. P-value notation:*p<0.05, **p<0.01, ***p<0.05. Climate and Health Vulnerability Assessment for Ghana 92 93 94