Climate and Health Vulnerability Assessment TANZANIA © 2023 International Bank for Reconstruction and Development/The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory, or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. 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TANZANIA Climate and Health Vulnerability Assessment CLIMATE INVESTMENT FUNDS CONTENTS ACKNOWLEDGMENTS................................................................................................................. vii LIST OF ABBREVIATIONS........................................................................................................... viii EXECUTIVE SUMMARY.................................................................................................................. 1 INTRODUCTION..............................................................................................................................5 Country Context.................................................................................................................................................... 5 Aims of this Assessment and Conceptual Framework ..................................................................................7 CLIMATE CHANGE: OBSERVED TRENDS AND PROJECTIONS..............................................11 Tanzania’s Geography .........................................................................................................................................11 Observed and Projected Climatology and Sea-Level Rise ........................................................................12 Temperature ...........................................................................................................................................................13 Precipitation ............................................................................................................................................................14 Climate Trends and Projections in Zanzibar ..................................................................................................15 Temperature............................................................................................................................................................15 Precipitation ............................................................................................................................................................16 Sea-Level Rises ..................................................................................................................................................... 17 Key Messages: Observed and Projected Climatology and Sea-Level Rises.......................................... 17 Climate-Related Hazards....................................................................................................................................18 Floods........................................................................................................................................................................18 Droughts...................................................................................................................................................................19 Key Messages: Climate-Related Hazards.......................................................................................................20 CLIMATE-RELATED HEALTH RISKS............................................................................................ 21 Food Security and Nutrition Risks...................................................................................................................22 Vector-Borne Disease Risks.............................................................................................................................24 Waterborne Disease Risks................................................................................................................................24 Heat-Related Morbidity and Mortality.............................................................................................................28 Air Quality Related Health Risks......................................................................................................................28 Direct Mortality and Injuries..............................................................................................................................30 Mental Health and Wellbeing Risks.................................................................................................................. 31 CLIMATE ADAPTIVE CAPACITY OF THE HEALTH SYSTEM................................................... 35 Health System Overview...................................................................................................................................35 Leadership and Governance............................................................................................................................ 37 Health Workforce................................................................................................................................................42 iv | Climate and Health Vulnerability Assessment: Tanzania Health Information Systems.............................................................................................................................. 43 Essential Medical Products and Technologies............................................................................................. 44 Health Service Delivery.....................................................................................................................................45 Health Financing.................................................................................................................................................48 RECOMMENDATIONS TO ENHANCE HEALTH SYSTEM RESILIENCE TO CLIMATE CHANGE......................................................................................................................................... 51 Component 1: Leadership and Governance..................................................................................................52 Component 2: Health Workforce.....................................................................................................................52 Component 3: Vulnerability, Capacity, and Adaptation Assessment.......................................................52 Component 4: Integrated Risk Monitoring and Early Warning..................................................................53 Component 5: Health and Climate Research................................................................................................53 Component 6: Climate-Resilient and Sustainable Technologies and Infrastructure............................ 53 Component 7: Management of Environmental Determinants of Health.................................................53 Component 8: Climate-informed Health Programs.....................................................................................54 Component 9: Emergency Preparedness and Management....................................................................54 Component 10: Climate and Health Financing.............................................................................................54 ANNEXES........................................................................................................................................57 Annex A. Methods for the Estimation of Mosquito Suitability Under Representative Concentration Pathway (RCP) 8.5 in Tanzania.............................................................................................. 57 Annex B. Vector-Borne Disease Suitability Per Region — Season 1: March–May ................................63 Annex C. Vector-Borne Disease Suitability Per Region — Season 2: October–December ...............64 Annex D: Key Recommendations and Relevant Line Ministries In Tanzania..........................................65 Annex E: Categorization of Recommendations ...........................................................................................66 Annex F: Menu of Adaptation Recommendations by Climate-Related Health Risks............................68 REFERENCES................................................................................................................................ 72 LIST OF TABLES Table 1. Development Indicators for Tanzania........................................................................................................6 Table 2. Seasonal Calendar of Temperature and Rainfall in Mainland Tanzania..........................................13 Table 3. CMIP6 Projections under SSP3-7.0 for Mainland Tanzania................................................................13 Table 4. Two-Week Prevalence of Diarrhea in Children under 5 years in Tanzania, 2015/2016 ........... 26 Table 5. Extreme Weather Events Injuries and Mortality for Tanzania from 2000 to 2022.......................31 Table 6. Summary of Climate Change Impacts on Health Outcomes............................................................33 Table 7. Public Sector Facilities in Tanzania, Including Faith-Based Organizations (FBOs) (2014)..........47 Table 8. Summary of Health System Adaptive Capacity Gaps for Tanzania ............................................... 49 Table A1. Model Parameterization and Data Sources for Habitat Characterization................................... 58 Table A2. Copernicus Global Land Cover Layers: CG:S-LC100 Collection 2 Global Landcover Map Classifications for Anopheles gambiae s.s. ............................................................................................... 59 Contents | v Table A3. Copernicus Global Land Cover Layers: CG:S-LC100 Collection 2 Global Landcover Map Classifications for Anopheles arabiensis ................................................................................................... 60 Table A4. Copernicus Global Land Cover Layers: CG:S-LC100 Collection 2 Global Landcover Map Classifications for An. funestus ...................................................................................................................... 61 Table B1. Vector-Borne Disease Suitability Per Region and Vulnerable Population in the Past, Present, and Future — Season 1: March–May .................................................................................................... 63 Table C1. Vector-Borne Disease Suitability Per Region and Vulnerable Population in the Past, Present, and Future — Season 2: October–December.................................................................................... 64 LIST OF FIGURES Figure 1. Key Climate Change-Related Health Risks............................................................................................. 8 Figure 2. WHO’s Operational Framework for Building Climate-Resilient Healthcare Systems................. 9 Figure 3. Map of Tanzania and its Administrative Regions.................................................................................10 Figure 4. Elevation Map of Tanzania and Major Cities ........................................................................................12 Figure 5. Projected Mean Temperature Increases for 2040–2059 throughout Tanzania under SSP3-7.0...........................................................................................................................................................................14 Figure 6. Projected Average Monthly Temperature and Precipitation Patterns in Mainland Tanzania under SSP3-7.0.............................................................................................................................................15 Figure 7. Projected Precipitation Anomalies for 2040–2059 (Annual) in Tanzania.....................................16 Figure 8. Riverine, Urban, and Coastal Flooding Risks in Tanzania.................................................................18 Figure 9. Projected Average Number of Consecutive Dry Days Per Month during Annual Dry Period (May–October).................................................................................................................................................20 Figure 10. Vector-Borne Diseases — Suitability for Season 1: March–May...................................................25 Figure 11. Vector-Borne Diseases — Suitability for Season 2: October–December...................................25 Figure 12. Map of Tanzania Showing Projected Water Stress (2040)............................................................. 27 Figure 13. Map of Tanzania Showing Projected Number of Days with Heat Index >35°C.........................29 Figure 14. Map of Tanzania Showing Tropospheric Nitrogen Dioxide (NO2).................................................30 Figure 15. WHO’s Health System Building Blocks............................................................................................... 37 Figure 16. Location of Hospitals and Population Distribution in Tanzania.....................................................46 Figure 17. Who’s Operational Framework for Building Climate-Resilient Health Systems.........................51 vi | Climate and Health Vulnerability Assessment: Tanzania ACKNOWLEDGMENTS The authors are thankful to the Africa Climate Resilient Investment Facility (AFRI-RES) Trust Fund and the Climate Investment Funds (CIF) for funding this work. This Climate and Health Vulnerability Assessment (CHVA) for Tanzania was produced by the Health, Climate, Environment and Disasters (HCED) program in the Health, Nutrition and Population (HNP) Global Practice of the World Bank, which is led by Tamer Rabie. It is authored by Judith Namanya, Mikhael Iglesias, Stephen Dorey, and Tamer Rabie. The authors sincerely appreciate the valuable contributions provided by Ana Lucrecia Rivera-Rivera, Muloongo Simuzingili, Maria Gracheva, April Frake, and Peter Okwero. This work also benefited from the administrative support of Fatima-Ezzahra Mansouri, and the editorial work of Kah Ying Choo, and the production of Sarah Jene Hollis. The authors are also highly grateful to the HNP management for their strong support of the HCED program and this product and would like to extend their thanks to Juan Pablo Uribe and David Wilson. Acknowledgments | vii LIST OF ABBREVIATIONS AR6 IPCC Assessment Report 6 CCKP Climate Change Knowledge Portal [World Bank] CHVA Climate and Health Vulnerability Assessment CHF Community Health Fund CHMT Council Health Management Team CHW Community Health Worker CMIP6 Coupled Model Inter-comparison Project Phase 6 COVID-19 Coronavirus disease 2019 CRU Climatic Research Unit [University of East Anglia, UK] DMO District Medical Officer DRM Disaster Risk Management EMA Environment Management Act EWS Early Warning Systems FBO Faith-Based Organization GCM General Circulation Model GDP Gross Domestic Product GHG Greenhouse Gas [emissions] GHO Global Health Observatory HCED Health Climate, Environment and Disaster Program HIS Health Information Systems HMIS Health Management Information System HNAP Health National Adaptation Plan HNP Health, Nutrition, and Population HPAP Health and Pollution Action Plan HRH Human Resources for Health HSS Health System Strengthening HSSP Health Sector Strategic Plan HTA Health Technology Assessment IDSR Integrated Disease Surveillance and Response INDC Intended Nationally Determined Contributions IPC Integrated Food Security Phase Classification IPCC Intergovernmental Panel on Climate Change ITZC Intertropical Convergence Zone JRC Joint Research Centre LULC Land Use and Land Cover MAT Medical Association of Tanzania MHEWS Multihazard Early Warning Service MSD Medical Stores Department MoHSW Ministry of Health and Social Welfare MoW Ministry of Water NAPA National Adaptation Programme of Action NASA The National Aeronautics and Space Administration NCCCS National Climate Change Communication Strategy NCCRS National Climate Change Response Strategy NCCS National Climate Change Strategy NCD Noncommunicable Disease viii | Climate and Health Vulnerability Assessment: Tanzania NDC Nationally Determined Contributions NEP National Environmental Policy NHIF National Health Insurance Fund NIMR Tanzania National Institute for Medical Research NGO Non-Governmental Organization PM2.5 Fine Particulate Matter PPP Public-Private Partnership RCP Representative Concentration Pathway SMS Short Message Service SSP Shared Socioeconomic Pathway TAMSA Tanzania Medical Student’s Association TBA Traditional Birth Attendant TDCS Tanzania Disaster Communication Strategy TEPRP Tanzania Emergency Preparedness and Response Plan TFNC Tanzania Food and Nutrition Center TH Traditional Healer TIKA Tiba Kwa Kadi TURP The Tanzania Urban Resilience Program UHC Universal Health Coverage UNDP-GEF United Nations Development Programme Global Environmental Finance UNFCCC United Nations Framework Convention on Climate Change VBD Vector-Borne Disease WASH Water Sanitation and Hygiene WBD Waterborne Disease WFP World Food Programme WHO World Health Organization WWF World Wildlife Fund List of Abbreviations | ix EXECUTIVE SUMMARY Tanzania is already experiencing the impact of climate change on health, the economy, and livelihoods. Climate-related hazards, such as extreme rainfall patterns, floods, and rising temperatures leading to the increased severity of droughts, are affecting food security and nutrition, as well as waterborne disease (WBD) transmission and spread, such as for dengue and malaria. The increasing burden of diseases puts pressure on an already precarious health system, while also deepening inequality in the country. Considering Tanzania’s high exposure and vulnerability to climate change, the World Bank, through the Health Climate, Environment and Disaster Program (HCED), is conducting a Climate and Health Vulnerability Assessment (CHVA). The objective of this CHVA is to assist decision-makers in planning effective adaptation measures to deal with climate-related health risks. Where available, these measures are also provided at a subnational level to assist regional health planners. The recom- mendations of this CHVA are primarily aimed at the health sector, as well as related sectors that have an influence on the health risks of climate changes, such as disaster risk management (DRM). The report provides information on both mainland Tanzania and Zanzibar (the main island off the coast). The CHVA begins with an analysis of observed and projected climatology data from the Climate Change Knowledge Portal (CCKP) and climate hazards to inform climate-related health risks:  → Mean annual temperatures have increased by 0.56°C over the past half century and are projected to increase by 0.68°C by the 2030s and 1.40°C by the 2050s. Warming has been most pronounced in January, June, and September. While mean annual temperatures in Zanzibar will continue to accelerate through the mid-century, they will do so at a lower rate in mainland Tanzania. → Precipitation across mainland Tanzania has decreased by nearly 50 mm since the 1960s , with the most substantial declines in the highlands of the Eastern Rift Valley. While future precipitation projections are less certain, rainfall is likely to increase slightly through the 2050s. → Sea-level rises pose a significant threat to coastal communities along the Tanzanian coastline and to Zanzibar. Land and infrastructure damage is expected to amount to approximately USD200 million annually by 2050, based on projected sea-level rises ranging from 16 to 42 cm1 and projected increases in storm surges of nearly 2 meters (m) by 2050. → The escalating intensity of heavy rainfall events during the 2030s and 2050s is likely to exacerbate flooding risks, especially within the southeastern and northwestern regions of the mainland. → While the rainy season will be more intense, there will be an overall increase in the occurrences of dry spells through the mid-century, especially in regions such as Mbeya, Tabora, Geita, Kigoma, Katavi, Rukwa, Shinyanga, Singida, and Ruvuma.  1 Tanzania faces significant health challenges from communicable diseases and noncommunicable diseases (NCDs), and climate change will worsen the severity of these health challenges. Climate-re- lated health risks are not evenly distributed within the population, with some groups at greater risk than others. Tanzania’s CHVA assesses seven climate-related health risk categories: Nutrition risks: Tanzania is challenged by acute food insecurity: the prevalence of severe food insecurity was 56.4 percent among the Tanzanian population in 2019 — an increase from 55 percent in 2018. Rural Tanzanians (84 percent) are more vulnerable to food insecurity than urban residents (64 percent). Projected increases in population growth, coupled with climate change impacts on the agricultural sector, will continue to worsen extreme hunger, food insecurity, and malnutrition. Vector-borne disease risks (VBDs): At 13.4 percent, Tanzania has one of the highest malaria prevalence rates in Eastern and Southern Africa. An estimated 93 percent of the population of mainland Tanzania is at risk of contracting malaria. Vector suitability ranges — in particular for mosquitoes — are highly sensitive to climate factors. Projected increases in rain-induced floods will likely lead to increased malaria transmission and cases in Tanzania Waterborne disease risks (WBDs): Waterborne diseases (WBDs) are one of the leading causes of ill health and deaths among Tanzanian children; they are responsible for 23,900 deaths per year among the under-fives. Projected increases in extreme rainfall and associated floods will likely increase drinking water contamination and WBD outbreaks. Heat-related morbidity and mortality risks: Populations in the Mara region and Dar es Salaam are more vulnerable to extreme heat-related injuries and mortalities. Extreme heat exposure will become more common throughout the mid-century, with populations in the Dar es Salaam region and the regions of Zanzibar at the greatest risk. Air quality health risks: In Tanzania, indoor air pollution remains the single largest driver of poor health. Domestic biomass combustion is the biggest contributor to indoor air pollution in households, with women and children disproportionately affected due to their prolonged exposure. Direct injuries and mortality risks: Heavy rains, which induce flash floods, mudslides, and landslides, threaten lives and livelihoods in Tanzania. Projected increases in flooding, associated with increasing temperatures and precipitation, will likely cause more deaths and direct injuries. Mental health & well-being risks: Mental health conditions are a growing concern in Tanzania, with the country’s neuropsychiatric disorders accounting for an estimated 5.3 percent of the global disease burden. Climate change, along with the resulting socioeco- nomic and livelihood insecurities, have affected the mental health of low-income Tanzanians immensely and created new vulnerabilities for those already experiencing mental health and substance use disorders. 2 | Climate and Health Vulnerability Assessment: Tanzania The extent to which the health system in Tanzania is prepared for and has the capacity to manage changes in hazards, exposure, and susceptibility will determine its resilience in the coming decades. In this CHVA, Tanzania’s adaptive capacity to prevent and manage climate-related health risks is examined according to the World Health Organization’s (WHO) six health system building blocks: → The government of Tanzania recognizes climate change and its impacts on the country’s development. As a result, the government has already been developing strategies and policies to guide climate change mitigation and adaptation action. However, there is a need for coordina- tion mechanisms that promote synergies between ministries in order to improve resilience and health outcomes. → There are limitations in the health workforce, both in professional expertise and distribution, as well as an overarching lack of information on the awareness of climate change and health risks among health workers. → Tanzania has integrated disease surveillance and response (IDSR) systems that are currently monitoring 34 priority diseases and conditions. Other programs are aimed at strengthening early warning systems (EWs) and responses to climate-related hazards. The Tanzania Urban Resilience Program (TURP), created in 2016, integrates weather and climate information for all decision-making levels in order to enable improved responses to climate-related emergencies in urban areas. It also collects data on vulnerable and at-risk households, as well as identifies their coping strategies. → The introduction and implementation of public-private partnerships (PPPs) in the health sector in Tanzania have improved the access and delivery of health services. However, the health facilities in the country are mostly concentrated in urban areas, which means that those living in rural areas have to travel greater distances to receive health care. → While there have been improvements in national investments on health, Tanzania is still highly dependent on foreign donors. In fact, it still lags behind the Abuja Declaration target for African states to allocate 15 percent of their total budgets to the health sector. The extent to which the health system in Tanzania is prepared for and has the capacity to manage changes in hazards, exposure, and susceptibility will determine its resilience in the coming decades. Executive Summary | 3 RECOMMENDATIONS Recommendations to reduce climate-related health risk and improve overall health service delivery are focused on establishing climate-smart health systems. → Climate change and health should be adequately integrated, in terms of policies, strategies, and programs. Climate change should be put into consideration when national health policies, strategies, and programs are developed. The integration of health and climate change should be strengthened from the national level to the local government level. → The Health Management Information System (HMIS) and monitoring / surveillance activities could account for climate-related health risks and indicators. This would require cross-sectoral work that will involve the Tanzania Meteorological Agency, along with the water & sanitation, disaster risk management (DRM), agriculture, and environment, responsible entities among others. Weather data could be incorporated into the assessment of health risks for better surveillance and early warning mechanisms. → Financing to cover climate-related health risks should be increasing. A proportion of national health funding should be earmarked for adaptation and mitigation policies and allocated to cover climate-related health risks; strategic purchasing that considers climate considerations should be adopted. 4 | Climate and Health Vulnerability Assessment: Tanzania SECTION I. INTRODUCTION COUNTRY CONTEXT 1. Climate change is already taking a toll on Tanzania’s economy, as well as its people’s health and livelihoods. The country is experiencing increasing geo- graphical socioeconomic inequality and vulnerability to climate change impacts,2 which will continue to exacerbate these inequalities. Extreme floods caused by climate change, unpredictable rainfall, and prolonged droughts affect food pro- duction and nutrition, especially for children and poor rural households. Heavy rain-induced flash floods have increased contaminants in drinking water sources and associated waterborne disease (WBD) outbreaks. High temperatures have led to the spread of vector-borne diseases (VBDs) to new areas of Tanzania’s Northern highlands.3 The growing disease burden is putting increased pressure on the country’s already struggling health system. 2. Tanzania is the largest country in East 3. Tanzania is among the poorest countries in the Africa; its country status rose from “low” world, with a GDP per capita of USD1,079.47 to “lower-middle” income in July 2020.4 in 2020, despite the country’s strong and This achievement is primarily attributed to stable economic growth.9 Although its GDP the country’s two decades of economic has increased steadily over the last decades, reforms and commitment to poverty alleviation. an estimated 29 million Tanzanians, out of a One such reform is Tanzania’s Development population of 59.15 million, lived in extreme Vision 2025 — first formulated in 1995 and poverty in 2021 (poverty line: USD1.90 per launched in 2000 to guide national-level day).10 While the 2019 Tanzania Mainland economic and social development efforts Poverty Assessment Report shows that extreme up to 2025.5 Tanzania, one of Africa’s fast- poverty declined from 11.7 percent in 2007 est-growing economies,6 has seen a steady to 8.0 percent in 2018,11 inequality remains increase in its gross domestic product (GDP) high (Gini: 40.5 in 2018), thereby highlighting from USD5.10 billion in 1988 to USD62.41 income inequality gaps. Furthermore, in 2018, billion in 2020.7 Agriculture, the backbone of most of the population living below the poverty Tanzania’s economic system, contributes to line resided in rural areas (31.3 percent of 50 percent of the national income. Additional the country’s population), compared with 15.8 contributors to the county’s economy are percent in urban areas12 (see Table 1 for a the energy, tourism, mining, and education summary of development indicators). sectors.8 5 TABLE 1. Development Indicators for Tanzania INDICATOR CATEGORY VALUE Population Population 59,734,213 Annual population growth (%) (2020) 2.9 Urban share of population (%) (2020) 35 Employment in agriculture (% of total employment) (2019) 65 GDP GDP (current USD, billions) (2020) 62.41 Annual GDP growth (%) (2020) 2.0 GDP per capita (current USD) (2020) 1,076.5 Pover Poverty headcount ration at USD1.90 a day 49.4 (2011 PPP) (% of population) (2018) Climate and Disaster Risks Rank (2019) 147 ND-GAIN 13 Score (2019) 39.1 Sources: World Bank. Tanzania Mainland Poverty Assessment Report; https://www.statista.com/statistics/1230404/number- of-people-living-in-extreme-poverty-in-tanzania/; https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?locations=TZ; https:// worldpopulationreview.com/countries/tanzania-population 4. Tanzania’s population is quickly accelerating. public health, and livelihoods, by embarking The country has the fifth-highest growth rate on various mitigation efforts and adaptation across Africa (2.98 percent).14 In 2020, the measures. This includes developing policies population was 59.7 million — an exception- and measures to boost the country’s adaptive ally high increase from 25.2 million in 1990, capacity to climate impacts. Tanzania has and it is estimated to reach 129.4 million integrated climate into the country’s existing by 2050.15 The fertility rate is 4.8 births per policies and structures to support its climate woman and a birth rate of 36.2 live births per change response, including the development 1,000 people.16 As of 2022, 44.8 percent of of the National Climate Change Committee, Tanzania’s population is under 15 years and the National Adaptation Programme of Action 52 percent are between 15 and 64 years of (2007), the National Climate Change Strategy age.17 Most of the population resides in rural (2012), and the integration of climate change areas (64.77 percent in 2020) that are located into its Poverty Reduction Strategy Paper.18 In in the highlands of northeastern Tanzania July 2021, the country launched the 2021–2026 around Mt Kilimanjaro, Meru, and the Usambara National Climate Change Response Strategy mountains, along the shores of Lake Victoria, the coastal region, the southern highlands, (NCCRS) to boost its overall resilience to the and Zanzibar City. negative impacts of climate change and achieve sustainable development.19 In addition, 5. Tanzania has sought to address the impacts the Nationally Determined Contribution (NDC of climate change that threaten the country’s 2021) aimed for a greenhouse gas emissions socioeconomic and sustainable development, (GHG) reduction of 10–20 percent by 2030.20 6 | Climate and Health Vulnerability Assessment: Tanzania AIMS OF THIS ASSESSMENT AND Report Six (AR6)21 of the Intergovernmental Panel on Climate Change (IPCC) makes clear, CONCEPTUAL FRAMEWORK “Global surface temperature will continue to 6. The objective of this Climate and Health increase until at least the mid-century under Vulnerability Assessment (CHVA) is to all emissions scenarios considered.” Mitigation support decision-makers in planning effective is no longer a sufficient strategy, regardless adaptation measures to deal with climate-re- of the pace with which governments and lated health risks. Where available, these communities around the world act. Adaptation measures are also provided at a subnational is now as critical a part of climate action as level to assist regional health planners. The mitigation. This report therefore focuses on recommendations of this CHVA are primarily adaptation measures, but, where possible, also aimed at the health sector, as well as related includes recommendations for reducing GHGs sectors that affect climate-related health risks or facilitating the decoupling of emissions from such as disaster risk management (DRM) or progress toward human development goals. agriculture. 9. The Haines and Ebi (2019) framework is 7. Adaptation priorities need to be implemented adopted to guide the discussion on climate alongside fundamental and urgent action change-related health risks. The framework to mitigate climate change. It is important to (see Figure 1) shows the various exposure stress how complex the climate challenge is, pathways through which climate change-re- and how hard it is to predict the exact severity lated health hazards will affect human health. of the climate exposure facing populations in the future. There are many factors that could 10. The World Health Organization’s (WHO) slightly slow or significantly speed up rates of operational framework (see Figure 2) for change, including positive feedback effects, building climate-resilient health systems is and most worrying of all, cascading climatolog- adopted in this CHVA to analyze Tanzania’s ical tipping points. For this reason, though not adaptive capacity to adequately deal with a focus of this assessment, mitigating existing current and future identified risks. The greenhouse gas emissions (GHGs), as well as assessment is therefore structured around developing and implementing measures to the six-health system strengthening (HSS) protect human development from the changing building blocks that lie at the core of this climate, is of paramount importance. framework. These six categories are used to structure the assessment of the country’s 8. Investment in adaptation strategies to capacities and gaps — now and into the proactively address the effects of climate future. Subsequently, using the framework, change on health outcomes is critical. This the 10 components of health system climate assessment is concerned with climate risks resilience will be considered and presented to health and health systems, the adaptive in the Recommendations Section. capacities that are in place to deal with these risks, and recommendations to meet identified 11. This CHVA follows a stepwise linear gaps. The primary focus of this assessment is, approach (see CHVA Methodology for a therefore, on climate adaptation and resilience detailed approach). The first step presents measures. However, as the Assessment the pertinent characteristics of the climatology Introduction | 7 FIGURE 1. Key Climate Change-Related Health Risks Source: Andy Haines and Kristie Ebi, 2019, “The Imperative for Climate Action to Protect Health,” New England Journal of Medicine 380 (3): 267. 8 | Climate and Health Vulnerability Assessment: Tanzania FIGURE 2. WHO’s Operational Framework for Building Climate-Resilient Healthcare Systems LIMATE RESILIENCE C hip & Heal ders Workf th Lea vernance orce Go V uln pac ation t Fin alth & A Ca apt men He ate era ity & Leadership As g d ss Clim cin bil & Governance Health se ity, an Workforce Financing Preparedness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential C li o r m e h Re ima & I n f a lt s Medical ma d C l a lt h se te Products & h He ra m Pro te a rc He Technologies - g Ma nt na ili e Env ge m ent o m a t e Res le f C li ir o n in a b D et m ental & S u st a gies ri m e lo of H n ts Techno cture e a lt h s tr u & Infra Source: World Health Organization, 2015, Operational Framework for Building Climate Resilient Health Systems. in Tanzania, highlighting the observed and of the published literature, national statistics, future climate exposures relevant to health. and consultations with key government coun- Using the Haines and Ebi (2019) framework, terparts including the Ministry of (MoHSW). the second step examines climate-related health risks (present and projected), including 12. The CHVA incorporates subnational consid- identifying vulnerable populations most at risk erations for health-related climate action. to the climate change-related health risks. Tanzania is divided into 31 administrative Following WHO’s six HSS building blocks regions — 26 on the mainland and five in and the 10 components of health system Zanzibar (see Figure 3). The regions are climate resilience, the final step assesses further divided into 169 districts and then the adaptive capacity of the health system, into divisions and local wards. The capital, identifying gaps to manage current and future Dodoma, is located in the central area. Data climate-related health risks. Together, these for the analysis presented here reflect the steps inform a series of recommendations on administrative boundaries prior to the creation reducing climate-related health vulnerability of the Songwe Region in 2016. in Tanzania. The CHVA is based on a review Introduction | 9 FIGURE 3. Map of Tanzania and its Administrative Regions Source: World Bank Cartography Unit 10 | Climate and Health Vulnerability Assessment: Tanzania SECTION II. CLIMATE CHANGE: OBSERVED TRENDS AND PROJECTIONS 13. This section describes observed climatic changes and projected climate trends, highlighting the priority climate-related hazards in relation to human health risks in Tanzania. Climate information is taken from the World Bank Group’s Climate Change Knowledge Portal (CCKP), where historical and observed data are derived from the Climatic Research Unit, University of East Anglia (CRU). Observed changes in the mean annual temperatures, mean maximum temperatures, mean minimum temperatures, and precipitation, presented on CCKP, uses the CRU TS version 4.05 gridded dataset for the 1901–2020 period. Model-based, climate projection data is derived from the Coupled Model Inter-Comparison Project Phase 6 (CMIP6). CMIP6 is a standard framework for the analysis of coupled atmosphere-ocean general circulation models (GCMs): it provides estimates of future temperature and precipitation scenarios. CMIP6 projections are shown through the five shared socioeconomic pathway (SSP) scenarios, as defined by their total radiative forcing (the cumulative measure of GHGs from all sources) pathways and levels by 2100. These projections represent possible future GHG concentration trajectories adopted by IPCC. This assessment explores projected climate changes under SSP3-7.0 for the short term (2030s; 2020–2039) and the medium term (2050s; 2040–2059). TANZANIA’S GEOGRAPHY Victoria in the North, Lake Tanganyika in the West, Lake Nyasa in the Southwest, and the 14. Tanzania, a country in East Africa, is located Indian Ocean in the East. Elevation ranges within the African Great Lakes region and from 600 feet (ft) (coastal plains in the East) to situated south of the equator. Tanzania, 19,341 ft (Mount Kilimanjaro in the North), with comprising mainland Tanzania and Zanzibar much of the central mainland above 3,000 (the islands of Pemba, Unguja, and other small ft.23 Tanzania’s topography is highly diverse, islands), covers a total area of 939,699 square dividing the country into several physiographic kilometers (sq km). Mainland Tanzania is 740 regions, including the Northern Rift Zone, the miles long from North to South and 760 miles Eastern Plateau, the Coastal Zone, the Inland long, from East to West, with a coastline that Sedimentary Plateau, the Southern Highlands, stretches approximately 500 miles along the Central Plateau, and the Western Highlands the Indian Ocean.22 It is bordered by Lake (see Figure 4).24 11 FIGURE 4. Elevation Map of Tanzania and Major Cities Source: Natural Earth and Aster GDEM Version 3 OBSERVED AND PROJECTED arid, with approximately 500 mm of annual precipitation. The coastal belt experiences CLIMATOLOGY AND SEA-LEVEL RISE the country’s warmest temperatures that 15. Mainland Tanzania has four distinct climate average 27–30°C, coupled with 750–1250 zones due to the country’s highly diverse mm of annual precipitation.25 In general, the topography. The highlands of the northeast mainland experiences cooler temperatures and southwest are the coldest parts of the from May to August, with the highest tempera- country, with average temperatures ranging tures occurring in March and October (see from 20°C to 23°C. Annual precipitation is Table 2). greatest in the southwestern highlands and the Lake Tanganyika basin, where rainfall can 16. Precipitation is highly seasonal and strongly exceed 2,000 millimeters (mm) annually (see influenced by the Intertropical Convergence Figure 6). The northern and western high lakes Zone (ITCZ). The south, west, and central region experiences cooler, semi-temperate regions experience long rains from October conditions and approximately 750–1,250 mm to May. In the north and east, there are two of rainfall each year. The Central Plateau, rainy seasons: the primary season is from situated between the two north-south branches March through May and the secondary from of the East African Rift System, is hot and October to December.26 12 | Climate and Health Vulnerability Assessment: Tanzania TABLE 2. Seasonal Calendar of Temperature and Rainfall in Mainland Tanzania JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Temperature Warm Hot Cooler Months Hottest Warm Precipitation Long Rains Short Rains Long Dry Season Long Rains Source: World Bank Climate Change Knowledge Portal TABLE 3. CMIP6 Projections under SSP3-7.0 for Mainland Tanzania CMIP6 ENSEMBLE PROJECTION 2020–2039 2040–2059 Annual Mean Temperature Anomaly (°C) +0.68°C +1.40°C (0.36–0.96) (1.03–1.87) Annual Precipitation Anomaly (mm) +7.02 mm +3.6 mm (-427.07 - 488.56) (-434.79 - 537.54) Notes: Bold value is the median (or 50th percentile); values in parenthesis indicate 10th–90th percentile range in mm. Source: World Bank Climate Change Knowledge Portal TEMPERATURE 18. Mean annual temperatures across mainland 17. Mean annual temperatures, which have Tanzania are projected to increase by risen by 0.56°C over the past half century 0.68°C by the 2030s and 1.40°C by the throughout the mainland of Tanzania, have 2050s (see Table 3). As a result, monthly occurred alongside increases in minimum mean temperature increases are likely to (0.56°C) and maximum (0.55°C) tempera- range nationally from 21.4°C to 25.0°C in tures.27 Warming has occurred throughout the 2030s and from 22.2°C to 25.8°C in the the year since 1960, with the highest increase 2050s (see Figure 5). The largest increases in mean monthly temperature during August in temperatures are projected to occur in (+0.65°C). The shortening of the historical August and September, thus signaling a period for cooler temperatures, typically the continued lengthening of mainland Tanzania’s June–August period, means that the country is historic warmer period. Western Tanzania, experiencing warmer temperatures for longer including the regions of Shinyanga, Tabora, periods throughout the year. October has Mbeya, Rukwa, and Singida, is projected to historically had the highest average maximum experience larger temperature increases than temperatures: they range from 27.9°C in the eastern mainland. By the 2030s, extreme Njombe to 31.7°C in Pwani. In contrast, July heat exposure29 will threaten populations is typically the coolest month of the year, with residing in 10 regions across the mainland,30 minimum temperatures ranging from 9.9°C with most regions experiencing such tempera- to 19.6°C across the mainland. Annual mean tures from September to December. See the temperatures range from 19.5°C in Njombe to following section on extreme heat for further 26.4°C in Dar es Salaam. From 1912 to 2009, discussions on population vulnerability to rising temperatures have contributed to the extreme temperatures. loss of 85 percent of the ice cover on Mount Kilimanjaro.28 Climate Change: Observed Trends and Projections | 13 FIGURE 5. Projected Mean Temperature Increases for 2040–2059 throughout Tanzania under SSP3-7.0 Source: Natural Earth and Aster GDEM Version 3 PRECIPITATION country has, in recent decades, experienced 19. Average annual precipitation across mainland heavy rainfall events in increasing frequency Tanzania has declined by nearly 50 mm over and intensity, which have led to widespread the last half century, with the most substantial flooding throughout the mainland (see the declines in the highlands of the Eastern Rift section below on flooding). Notably, changes in Valley. Average precipitation during the rainy the rainy season, including the unpredictability seasons across the mainland is 634 mm — of onset and considerable shortening, have more than two-thirds of the total annual rainfall. already led to shifts in the growing seasons,31 Generally, the southeastern mainland receives with important implications for the cultivation more precipitation than other areas of the of subsistence crops. country, except for the Kagera region in the northwest. Regions along the Eastern Rift 20. Projections for precipitation in Tanzania Valley have experienced the largest declines include significant uncertainty however, in overall precipitation, most notably Njombe median projections indicate that rainfall is (-101 mm) and Kilimanjaro (-90.6 mm). The Mara expected to be heterogeneous throughout the region is the only region that has experienced mainland with an albeit slight, but increasing, a net gain (+10 mm) since the 1960s. Despite trend through the mid-century. Mean annual an overall net decline in annual rainfall, the rainfall across the mainland is expected to 14 | Climate and Health Vulnerability Assessment: Tanzania increase by a mere 1 mm through the 2050s, TEMPERATURE with the largest increases in monthly mean 22. Since 1960, annual minimum temperatures precipitation occurring in January and March have increased more rapidly (+0.67°C) than (+12 mm in both months). Conversely, the the annual mean (+0.51°C) and maximum long dry season is expected to become more temperatures (0.36°C). Warming has been arid, with monthly precipitation declines the most pronounced in January, June, and expected from May to October. Projected September, with mean temperature increases changes in rainfall are expected to follow a of approximately 0.6°C. Mean monthly tempera- distinctly spatial pattern, with regions along tures now range from 25.4°C in July and the coastal belt experiencing declining mean August to 28.8°C in January and February, annual precipitation, while regions further while temperatures are fairly uniform across inland are likely to experience increases of the five regions of Zanzibar. Northern and more than 100 mm per year (see Figure 7). Southern Pemba typically experience lower Moreover, heavy rainfall events are projected temperatures than other regions. to intensify, with important implications for flooding across the mainland. 23. Mean annual temperatures in Zanzibar will continue to accelerate through the mid-century, but at a lower rate than those CLIMATE TRENDS AND PROJECTIONS projected for the mainland. During the 2030s, IN ZANZIBAR mean annual temperatures are likely to 21. Zanzibar has a tropical, hot climate year-round increase by 0.57°C, followed by a projected and two distinct rainy seasons — the more increase of 1.13°C by the 2050s. The most intense (“long rains”) occur from March to pronounced increases are projected to occur May, while the less intense (“short rains”) in Mjini Magharibi and Kusini Unguja in May takes place from mid-October to December. for both periods. Further, increases in mean FIGURE 6. Projected Average Monthly Temperature and Precipitation Patterns in Mainland Tanzania under SSP3-7.0 250 mm 27 ˚C 26 ˚C 200 mm 25 ˚C 150 mm 24 ˚C 23 ˚C 100 mm 22 ˚C 50 mm 21 ˚C 0 mm 20 ˚C Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Historical Reference Period 1986-2005 2020-2039 2040-2059 Historical Reference Period 1986-2005 2020-2039 2040-2059 Source: World Bank Climate Change Knowledge Portal Climate Change: Observed Trends and Projections | 15 FIGURE 7. Projected Precipitation Anomalies for 2040–2059 (Annual) in Tanzania Source: Natural Earth and Aster GDEM Version 3 maximum temperatures will push tempera- season in Zanzibar is getting drier. Likewise, tures to at, or above, 33°C in February and declines in monthly precipitation have also March. Residents of Pemba are likely to be the been observed from December (-1.5mm) to most at risk of extreme heat exposure during January (-19.7 mm) and in April (-15 mm), which these two months. This would be especially is historically the rainiest month of the year. the case in March, when the heat index will Nonetheless, despite monthly declines in exceed 35°C for approximately nine and 24 April, rainfall during the long rainy season days by the 2030s and 2050s, respectively, has increased by about 14 mm, due mainly to in both regions of the island. increases in precipitation (+26 mm) in March. Likewise, rainfall during the short rainy season has also increased slightly by 6 mm. PRECIPITATION 24. Since mid-century32, Zanzibar has experienced 25. Median projections of annual net precipi- distinct inter-seasonal changes in the island’s tation show an expected continued decline precipitation regime. Overall, annual precipi- through the 2030s in Zanzibar (-3.5 mm), tation has declined by approximately 40 mm, though it will increase by the 2050s (+52 with the most pronounced decline during the mm). In both periods, the dry season from dry season of June to September. The long dry June through September is likely to continue 16 | Climate and Health Vulnerability Assessment: Tanzania experiencing less overall rainfall, coupled with es Salaam.34 The coastal zone, rich in natural declines projected for mean monthly totals resources, is characterized by mangrove during the short rainy season, most notably forests and swamps, estuaries, coral reefs, in October (-7 mm: 2030s; -18 mm: 2050s). intertidal flats, as well as sandy and muddy Monthly increases in precipitation are likely beaches.35 These characteristics, along with to occur from December to April, with more other marine and coastal resources, contribute pronounced increases in January during the significantly to the overall social and economic 2030s (+10 mm) and December during the development of the coastal communities and 2050s (+15 mm). the country. 27. Historical sea-level data for coastal Tanzania SEA-LEVEL RISES show an overall increasing trend, with an 26. Sea-level rises pose a significant threat to average annual anomaly of 115.78 mm in coastal communities along the Tanzanian 2015.36 Potential impacts of ongoing sea-level coastline and to Zanzibar, including the five rises, coupled with anthropogenic pressures million residents of Tanzania’s largest city (for example, the overexploitation of coastal — Dar es Salaam.33 Tanzania’s mainland, with resources and destructive fishing), include approximately 800 km of coastline, comprises coastal erosion and damages to infrastruc- five administrative regions and several major ture, high storm surges, the destruction of coastal cities that house approximately 25 coastal and marine habitats and resources, the percent of the total population, including the inundation of low-lying areas, tourism-related commercial and government center — Dar economic losses, and population displacement. KEY MESSAGES: OBSERVED AND PROJECTED CLIMATOLOGY AND SEA-LEVEL RISES • Mean annual temperatures have increased by 0.56°C over the past half century and are projected to increase by 0.68°C by the 2030s and 1.40°C by the 2050s. • Average annual precipitation across mainland Tanzania has declined by nearly 50 mm since the 1960s, with the most substantial declines in the highlands of the Eastern Rift Valley. While future precipitation projections are less certain, rainfall is likely to slightly increase through the 2050s. • Ongoing sea-level rises pose a significant threat to coastal communities along Tanzania’s coastline. Land and infrastructure damage associated with sea-level rises is expected to be approximately USD200 million annually by 2050, as a result of the projected rise of sea levels from 16 to 42 cm and projected increases in storm surges of nearly 2 m by 2050.a,b • The escalating intensity of heavy rainfall events during the 2030s and 2050s is likely to exacerbate flooding risk, especially within the southeastern and northwestern regions of mainland Tanzania. • Projected declines in overall precipitation are likely to increase the occurrences of dry spells through the mid-century, especially in regions such as Mbeya, Tabora, Geita, Kigoma, Katavi, Rukwa, Shinyanga, Singida, and Ruvuma. a https://www.climatelinks.org/sites/default/files/asset/document/20180629_USAID-ATLAS_Climate-Risk-Profile-Tanzania.pdf. b https://documents1.worldbank.org/curated/en/891701634533267413/pdf/Groundswell-Africa-A-Deep-Dive-on-Internal-Climate-Migration-in-Tanzania.pdf. Climate Change: Observed Trends and Projections | 17 Land and infrastructure damage associated rapid population growth, and inadequate with sea-level rises is expected to be around housing. USD200 million annually by 2050,37 based on the projected rise of sea levels from 16 to 42 cm38 and projected increases in storm surges FLOODS of nearly 2 m by 2050.39 In the nearer term, 29. Floods are among the most significant 0.3 to 1.6 million people are expected to be climate-related hazards in Tanzania. Heavy at risk of flooding associated with sea-level rainfall and sea- level rises contribute to regular rises by 2030.40 riverine, urban, and coastal flooding across the country (see Figure 8), with the greatest risk of flooding occurring annually in March CLIMATE-RELATED HAZARDS and April. Since 2000, 33 major floods have 28. Tanzania is vulnerable to several climate-re- been recorded with nearly 400 deaths.42 lated hazards associated with ongoing climate Riverine flooding poses the greatest risk, change that can impact population health in terms of geographic extent, with most of considerably. More than 70 percent of the Tanzania considered at medium to high risk natural disasters in the country are related (see Figure 8). However, urban and coastal to climate.41 The most pressing ones are flooding also pose a significant population floods and droughts. Additional climate-re- risk: 35 percent of the total population reside lated hazards include landslides, cyclones, in urban areas,43 often in informal settlements heatwaves, and wildfires. The overall impacts that are ill-equipped to offer adequate safety of such events in Tanzania cannot merely during flooding events.44 In 2018, heavy rains be attributed to changing environmental led to severe flooding in Dar es Salaam, conditions including changes to the climatology affecting 1.7 million people, which resulted described in the previous section; they are also in economic losses equivalent to 4 percent are compounded by anthropogenic causes of the city’s GDP.45 including rapid deforestation, urbanization, FIGURE 8. Riverine, Urban, and Coastal Flooding Risks in Tanzania Source: World Bank, Think Hazard website. 18 | Climate and Health Vulnerability Assessment: Tanzania 30. Extreme precipitation is projected to increase poverty alleviation, food security, and during the 2030s and 2050s, exacerbating improved health outcomes. The conse- flooding risks, especially within the south- quences of drought are far-reaching, with eastern and northwestern regions of the direct impacts on human health due to the mainland. While projected annual mean effects on food availability and access, loss of precipitation across the mainland shows little biodiversity, and changes to migration patterns. change in rainfall totals, measurements of Current estimates of agricultural productivity 5-day cumulative rainfall and 1-day intense losses, primarily from droughts, are estimated precipitation signal an increasing likelihood at USD200 million.46 Pastoralist communities of flooding events through the mid-century. in Tanzania have reported trekking three Heavy cumulative rainfall over several days is times the average distance to water sources associated with a higher likelihood of runoff during drought conditions,47 placing additional entering river channels and subsequent pressure on community members and herds. flooding as soils reach their saturation point. Over the past three decades, Tanzania has Intense single-day events of heavy rainfall can experienced six major droughts.48 The central have the same effect but in a shorter period regions of Shinyanga, Dodoma, and Singida and may result in flash flooding events and/or have historically been the most vulnerable trigger landslide events. to drought conditions.49 During October to December 2021, prolonged periods of dry 31. Projected figures for five-day cumulative spells have led to areas of the country experi- rainfall show an average annual increase of encing the driest or second-driest conditions approximately 9 mm in the 2030s and 17 mm since 1981.50 Herder communities in the in the 2050s, with the largest increases likely northwest Manyara region, in particular, have to occur in January. The regions projected experienced devastating losses (starvation to see the greatest increases in cumulative of more than 62,000 livestock animals) due 5-day rainfall totals are Mtwara (+21 mm) and to drought conditions.51 Shinyanga (+21 mm) in the 2030s, and Tabora (+21 mm) and Singida (+ 21mm) in the 2050s. 34. Drought projections for Tanzania are uncertain52 however, though projected 32. Nationally, there are expected increases in declines in precipitation are likely to increase intense 1-day precipitation totals in the 2030s the occurrences of dry spells through the (+4 mm) and 2050s (+9 mm), which are more mid-century. By the 2050s, the lack of rainfall likely to occur in December in the 2030s during the driest period of the year (May– and January in the 2050s. Mtwara and Dar October) will lead to 23 consecutive dry days es Salaam are most likely to be vulnerable each month, on average, during the 2030s to flooding events triggered by heavy 1-day and 2050s (see Figure 9). By the 2050s, rainfall events during the 2030s, with Mtwara Mbeya, Tabora, Geita, Kigoma, Katavi, Rukwa, increasing in vulnerability through the 2050s. Shinyanga, Singida, and Ruvuma are expected to be consecutively dry throughout July and August. Individuals whose livelihoods depend DROUGHTS directly on climate-related sectors, such as 33. Droughts and dry spells are frequent pastoralists and farmers with rainfed crops, occurrences in Tanzania that undermine will be the most vulnerable to dry conditions. Climate Change: Observed Trends and Projections | 19 FIGURE 9. Projected Average Number of Consecutive Dry Days Per Month during Annual Dry Period (May–October) Source: World Bank Climate Change Knowledge Portal KEY MESSAGES: CLIMATE-RELATED HAZARDS The most pressing climate-related hazards are floods and droughts. Additional climate-related hazards include landslides, cyclones, heatwaves, and wildfires. Floods: • Heavy rainfall and sea-level rises contribute to regular riverine, urban, and coastal flooding, with the greatest risks of flooding occurring annually in March and April. • Northern, eastern, and southern coastal regions are at the highest risk of flooding. • Extreme precipitation is projected to increase during the 2030s and 2050s, exacerbating flooding risks, especially in the southeastern and northwestern regions of the mainland. • Projected figures for 5-day cumulative rainfall show average annual increases of approximately 9 mm in the 2030s and 17 mm in the 2050s, with the largest increases likely to occur in January. Droughts: • Droughts and dry spells are frequent occurrences in Tanzania; they undermine poverty alleviation, food security, and improved health outcomes. • Drought projections for Tanzania are uncertain however, though projected declines in precipitation are likely to lead to increased occurrences of dry spells through the mid-century. • By the 2050s, the lack of rainfall during the driest period of the year (May–October) will lead to 23 consecutive dry days each month, on average, during the 2030s and 2050s. • By the 2050s, Mbeya, Tabora, Geita, Kigoma, Katavi, Rukwa, Shinyanga, Singida, and Ruvuma are expected to be consecutively dry throughout July and August. 20 | Climate and Health Vulnerability Assessment: Tanzania SECTION III. CLIMATE-RELATED HEALTH RISKS 35. Tanzania faces significant health challenges from communicable diseases and noncommunicable diseases (NCDs), and climate change will worsen the severity of these health challenges. In 2020, Tanzania had a crude death rate of 6.12 per 1,000 people, a neonatal mortality rate of 20.1 per 1000 live births, and an un- der-five mortality rate of 48.9 per 1,000 live births; though these figures have been decreasing, they remain high.53,54 Although there had been a drastic decrease in Tanzania’s maternal mortality ratio from 832 in 2012 to 642 per 100,000 live births in 2016, the country still has a very high maternal mortality ratio.55 Tanzania’s life expectancy increased from 50.81 in 2000 to 65.81 in 2020 and is higher than Sub-Saharan Africa’s average life expectancy of 61.95.56 Moreover, Tanzania’s population of 59.7 million people (as of 2020) is projected to increase to 129.4 million at a population growth rate of 2.98 percent by 2050.57 36. Climate change, coupled with high population climate may exacerbate health inequalities, rates, will continue to worsen the burden of especially among certain vulnerable groups disease, health, and income disparities, and including the poor, rural populations, those negatively impact the country’s economic living in informal urban settlements, women development. Communicable, nutritional, and young children, the elderly, those living neonatal, and maternal diseases are the with preexisting conditions and disabilities, and leading causes of morbidity and mortality displaced populations. Therefore, investment combined in the country.58 Of the 10 leading in adaptation and mitigation measures must causes of death in Tanzania, lower respiratory carefully consider groups who would directly infections, tuberculosis, malaria, nutritional benefit from or may be disadvantaged by diseases, ischemic heart disease, and diarrheal adopted measures. diseases are climate-sensitive diseases.59 38. Using the Haines and Ebi (2019) framework 37. Risks to health outcomes from climate are as a guide, Tanzania’s Climate and Health not evenly distributed within the population; Vulnerability Assessment (CHVA) assesses some groups are at greater risk than others. six climate-related health risk categories. The factors that affect a population’s vulner- These include risks to (a) nutrition, (b) vector- ability to climate are often similar to those borne diseases (VBDs), (c) waterborne diseases that affect health more broadly.60 However, (WBDs), (d) heat-related conditions, (e) air 21 quality health, (f) direct injuries and mortality, through a food security lens, as it relates to along with (g) mental health and well-being. weather and climate impacts on agricultural Each category is assessed, in terms of current productivity. Agricultural productivity is a key and future risks, with considerations for both determinant of food availability; it is affected national and subnational peculiarities, where by weather and climate in a multitude of ways, possible. It is important to note that these from short-term shocks (for example, natural seven health risk categories represent only the disasters) to long-term changes in agroeco- most pressing health risks to the population logical conditions that can drastically reduce in Tanzania, as identified in the review of yields or redefine spatiotemporal patterns of key country health reports. They include crop suitability. the Ministry of Health and Social Welfare (MoHSW) documents, WHO’s Health and 40. Tanzania is challenged by acute food Climate Change Country Profile, the Climate insecurity conditions, and climate change Change Knowledge Portal (CCKP) of World threatens to worsen the already dire situation. Bank, nationally determined contributions In 2019, the prevalence of severe food (NDCs), and partner reports. insecurity among the Tanzanian population was 56.4 percent — an increase from 55 percent in 2018.62 The results of the IPC FOOD SECURITY AND (Integrated Food Security Phase Classifi- cation) Acute Food Insecurity Analysis in 16 NUTRITION RISKS districts of Tanzania reveal that an estimated 39. Weather and climate are the foundational one million people (20 percent of 4.8 million drivers of healthy and sustainable diets. The people) experienced severe acute food mechanisms by which climate change affects insecurity between November 2019 and April nutrition via the food system are profound; 2020, and about half a million people (10 they include acute and chronic effects on percent of 4.8 million people) were projected agricultural production, storage, processing, to experience severe acute food insecurity distribution, and consumption. Nutritionally between May and September 2020.63 Approx- secure and stable diets depend on agricul- imately 4 million people (7.1 percent of the tural production and the complex interactions population) still lacked access to sufficient of demand, economics, legislation, conflict, food as of November 2021, even though food waste, nutrient losses, food safety, this figure constitutes a decrease from 4.9 and access.61 Climate variability is already million in January 2021.64 Rural Tanzanians (84 contributing to increases in global hunger and percent) are more vulnerable to food insecurity malnutrition. While a comprehensive analysis than urban residents (64 percent),65 with the of climate change’s impact on the food system northern and central regions experiencing the is beyond the scope of this assessment, this highest vulnerability to food insecurity.66 The CHVA examines climate and nutrition linkages key drivers of food insecurity in Tanzania are Approximately 4 million people (7.1 percent of the population) still lacked access to sufficient food as of November 2021, even though this figure constitutes a decrease from 4.9 million in January 2021. 22 | Climate and Health Vulnerability Assessment: Tanzania prolonged dry episodes triggering drought struggles with hunger and malnutrition have conditions, unpredicted rains, and the 2017 an immense impact on the country’s human fall armyworm infestation destroying mainly capital and economic development. grains, especially maize — the main food crop in Tanzania.67 These conditions have led to 42. Projected increases in population growth, poor harvests, thereby limiting food avail- coupled with climate change impacts on ability, as well as increasing demand and in the agricultural sector, will continue to turn food prices, which have undermined the worsen extreme hunger, food insecurity, and capacity of the majority of poor Tanzanians malnutrition in the Tanzanian population. to afford food. Agriculture — the main source of livelihood for over 75 percent of the rural population that 41. Extreme hunger and malnutrition, coupled accounts for nearly one-third of the country’s with pervasive poverty, are threatening GDP — is predominantly smallholder-based Tanzania’s economic, social, and human and relies primarily on rudimentary tools.71 development progress. Although Tanzania Climate change’s impacts on the length of the has registered substantial economic growth growing season will disrupt food production over the past two decades, this achievement by reducing food quantity and quality, thus has not been equally reflected in addressing limiting food availability, access, and afford- food insecurity, ending poverty, and narrowing ability, and thereby worsening food insecurity inequality. According to the World Food and malnutrition. Projected temperature Programme (WFP), even though Tanzania increases and increases in extreme precip- produces enough food to feed the population, itation triggering heavy rain, particularly the high levels of hunger persist, especially among projected consecutive dry days from May to the country’s rural poor and marginalized October (dry season), will lead to crop losses. households, largely due to limited access The regions of Mbeya, Tabora, Geita, Kigoma, to food.68 Tanzania’s malnutrition rates remain Katavi, Rukwa, Shinyanga, Singida, and Ruvuma high, with over 600,000 children reportedly would be the most affected by the prolonga- suffering from acute malnutrition; as of 2015, tion of the dry season throughout July and about 32 percent of children under five were August by the 2050s, which would affect crop stunted, 5 percent were wasted, and 14 percent yields. Warmer temperatures and unpredicted were underweight.69 Results of the 2018 dry spells will likely increase the severity of Standardized Monitoring and Assessment of insect pest populations, thus causing the Relief and Transitions (SMART) survey show crops to wither prematurely, thereby reducing that regions with the highest prevalence of harvesting with impacts on food security. The stunting occurred in Njombe (54 percent), regions of northern and central Tanzania are Rukwa (48 percent), Songwe (43 percent), already struggling with severe food insecurity Iringa (47 percent), Kigoma (42 percent), and and threatened livelihoods (the destruction Ruvuma (41 percent). Chronic malnutrition of crops and deaths of livestock) triggered by also causes nutritional challenges, including prolonged droughts.72 Under future climate anemia among women, who account for over scenarios, projected increases in temperature 60 percent of the agricultural labor force in and precipitation in the 2050s will worsen Sub-Saharan Africa.70 Give that women are food insecurity, hunger, and malnutrition in both agricultural workers and caregivers, their Tanzania. Climate-Related Health Risks | 23 VECTOR-BORNE DISEASE RISKS Plasmodium falciparum — primarily transmitted by anopheles gambiae (An. gambiae s.s. and 43. Climate is a key driver of spatiotemporal An. arabiensis) and anopheles funestus — is distributions and transmission dynamics of responsible for about 96 percent of all severe vector-borne diseases (VBDs) in Tanzania. malaria cases in Tanzania.77 Tanzania has two Climate variability causes vector and host main malaria transmission seasons: the first ranges to expand or contract, shifting disease season is between March and May following distribution, seasonality, and / or facilitating the long rains and the second season is from the emergence or reemergence of VBDs. October to December.78 Overall, for both Investigating the species distribution and seasons, the northern, northeast, eastern, seasonality of vectors is valuable for under- central, and the Kilombero Valley of southern standing plausible VBD distributions and Tanzania have the highest suitability for malaria planning efficient, spatially targeted methods transmission; moreover, these areas are of control. This assessment focuses on densely populated. mosquito borne VBDs given their importance in Tanzania; while there are other VBDs present in Tanzania including filariasis, chikungunya, dengue, yellow fever, and zika, there is limited WATERBORNE DISEASE RISKS information and surveillance.73 Spatial models 45. Tanzania experiences floods, extreme (see Figures 10 and 11) were constructed to droughts, and heat waves, which affect the demonstrate the plausible spatial distributions quality and quantity of safe water; this in of the vectors of malaria to assess the suitability turn has direct implications for the burden and risk propensity of these diseases (see of waterborne diseases (WBDs). Climate Annex A for information on model inputs and change, including rising temperatures and construction). The results of these analyses extreme precipitation, have increased the should be treated as a conservative estimation occurrences and severity of flash floods in of the areas of Tanzania that exhibit suitable Tanzania. Flash floods related to erratic rains conditions for vector breeding and suitable (mostly in March and April) and decreased conditions for vector breeding where humans water levels are the leading causes of surface are present (that is, populated areas). water and groundwater pollution. Increases in widespread WBD outbreaks, such as cholera 44. Despite longstanding efforts by the country to and diarrheal diseases in Tanzania, have control malaria, the disease continues to be been attributed to poor sanitation, improper a considerable public health threat. Tanzania hygiene, and the consumption of contami- has one of the highest malaria prevalence nated drinking water in both urban and rural rates (13.4 percent of malaria cases) in Eastern areas.79 Between August 2015 and January and Southern Africa, and malaria is a leading 2018, there were an estimated 33,421 cholera cause of death for children under five years of cases and 542 deaths across Tanzania (86 age in Tanzania.74 An estimated 93 percent of percent) and Zanzibar, with the highest cases the population of mainland Tanzania is at risk in the regions of Nyasa, Mbeya, Songwe, of being infected by malaria.75 Communities Manyara, Kigoma, Uvinza, Kigoma, Dar es around the shores of Lake Victoria have the Salaam, and Dodoma.80 highest malaria prevalence (41 percent).76 24 | Climate and Health Vulnerability Assessment: Tanzania FIGURE 10. Vector-Borne Diseases — Suitability for Season 1: March–May Sources: Temperature (NASA, NEX-GDDP) Land Cover (Copernicus Global Land Service, Proba-V-C3), Water Resources (European Commission’s Joint Research Centre, GSW1_0), Flow Accumulatio n(World Wide Fund for Nature, HydroSHEDS), Population (European Commission’s Joint Research Centre, GHSL/P2016/POP_GPW_GLOBE_V FIGURE 11. Vector-Borne Diseases — Suitability for Season 2: October–December Sources: Temperature (NASA, NEX-GDDP) Land Cover (Copernicus Global Land Service, Proba-V-C3), Water Resources (European Commission’s Joint Research Centre, GSW1_0), Flow Accumulatio n(World Wide Fund for Nature, HydroSHEDS), Population (European Commission’s Joint Research Centre, GHSL/P2016/POP_GPW_GLOBE_V Climate-Related Health Risks | 25 46. Urban residents vulnerable to WBD outbreaks 47. The burden of disease, attributed to due to poor sanitation, the inadequate inadequate safe water, improper sanitation, drainage systems that are unable to and poor hygiene in Tanzania, remains high. withstand the pressure of floods, and WBDs, due to the household use of unsafe and lack of wastewater and sewage treatment contaminated water, along with the improper plants.81 For example, Picarelli et al. (2017), disposal of excreta, account for nearly one-half in their paper on “weather shocks and health of all the illnesses affecting children (see Table in Dar es Salaam,” show a drastic increase 4) and adult Tanzanians.84 WBDs, responsible in the incidence of cholera outbreaks, with for 23,900 deaths per year among the under- increased rainfall, especially in flood-prone fives, are one of the leading causes of ill health informal settlements.82 Therefore, cholera is and deaths among Tanzanian children.85 Nearly endemic in Tanzania, particularly in urban a third of Tanzania’s population lives in arid to areas like Dar es Salaam. Climate change semi-arid areas, with limited access to clean and associated flash floods will continue to and safe water.86 Most of this population use worsen the situation.83 groundwater (from wells and boreholes) as TABLE 4. Two-Week Prevalence of Diarrhea in Children under 5 years in Tanzania, 2015/2016 BACKGROUND CHARACTERISTICS PERCENTAGE WITH DIARRHEA Tanzania Mainland/Zanzibar Mainland 11.8 Urban 14.2 Rural 11.0 Zanzibar 10.5 Unguja 10.2 Pemba 10.9 Source of drinking water Improved 12.2 Not improved 11.3 Toilet facility type Improved, not shared 12.2 Shared 15.3 Non-improved 11.1 Zone Western 11.6 Northern 8.0 Central 10.2 Southern Highlands 10.1 Southern 16.3 Southwest Highlands 15.5 Lake 12.0 Eastern 12.4 Zanzibar 10.5 Source: Tanzania Demographic and Health Survey (DHS), 2015/2016. 26 | Climate and Health Vulnerability Assessment: Tanzania the primary water source for the household, (see Figure 12). Extreme droughts increase which is sometimes contaminated due to the water temperatures and lead to reduced proximity to drainage systems. Furthermore, water levels, encouraging the growth of because of water scarcity, communities are harmful algal blooms. This compromises forced to bathe and wash their clothes close water quality, making the water unsafe for to these water sources, further contaminating household use for communities neighboring them. This is the same contaminated water Lake Victoria, Lake Tanganyika, and the Upper they carry home for household use, thereby Ngerengere Catchment in Morogoro. When increasing the occurrences of diseases. In there is drought-induced water scarcity, rural addition, improper water handling, including communities are often forced to resort to collection, transportation, and storage, is also low-quality watering holes, thereby increasing instrumental in the spread of WBDs in urban their vulnerability to WBDs.88 Furthermore, towns in Tanzania.87 extreme droughts are often followed by water and food insecurity, malnutrition, the migration 48. Prolonged droughts seriously threaten water of populations (often rural to urban migration), security, forcing communities to travel long and increased poverty. These trends further distances in search of water for the household increase the occurrences of WBDs and the FIGURE 12. Map of Tanzania Showing Projected Water Stress (2040) Source: Hofste, R., S. Kuzma, S. Walker, E.H. Sulanudaja, et al. 2019. “Aqueduct 3.0: Updated Decision-Relevant Global Water Risk Indicators.” Technical Note. Washington, DC: World Resources Institute. Available online at: https://www.wri.org Climate-Related Health Risks | 27 communities’ susceptibility to WBDs and of heat stress, heat rash, cramps, exhaustion, the spread of WBD outbreaks. For girls and dehydration, and the acute exacerbation of women, drought-induced water scarcity also pre-existing conditions including respiratory means walking longer distances in search of and cardiovascular diseases. Long-term mental water, which increases their vulnerability to health risks are also an important effect rape, violence, missed school days, and the to consider. In addition to the impacts on concomitant adverse impacts on their mental individuals, the occurrence of the exposure health and well-being.89 of the whole population during an extreme heat event can lead to significant increases 49. Projected rises in temperature and precipita- in hospitalizations, thereby imposing strains tion will continue to increase the frequency on health systems.90 Extreme heat-related and severity of flash floods and prolonged injuries and mortalities have commonly been droughts, with immense impacts on human registered in the Mara regions, especially health. These patterns are expected across among mine workers and in Dar es Salaam.91 many countries, with developing countries being hit the hardest. For countries like 51. Extreme heat exposure will become more Tanzania, climate change impacts on health, common throughout the mid-century, with due to increasing WBDs, will be worsened populations in the Dar es Salaam region by a combination of factors, including high and the regions of Zanzibar at greatest risk population rates, poor urban planning, informal (see Figure 13). In particular, the increase in settlements, and poverty. As shown in Section the number of days with temperatures above II of this report, Tanzania will continue to 35°C and the days when the heat index is experience increases in the intensity of rainfall above 35°C, that is, capturing the “feel like” and flash floods, which are associated with experience, along with the number of tropical water contamination and related increases nights, will increase the risks of cardiovascular in disease outbreaks. Projected increases or respiratory morbidities. This is because the in temperatures, especially in the regions of body will struggle to cope with high tempera- Western Tanzania, will increase the vulnerability tures and have less time during the day to of communities to WBDs such as cholera and recover from the heat exposure. other diarrheal disease outbreaks. Increased water temperatures and low water levels will increase the growth of harmful algal blooms AIR QUALITY RELATED HEALTH RISKS and cases of food poisoning from affected 52. Ambient and household air pollution pose a aquatic foods, therefore resulting in outbreaks such as typhoid and campylobacter infections. considerable risk to the health of Tanzanians; however, the attribution of ongoing climate change and health outcomes to air pollution exposure in Tanzania is uncertain. The HEAT-RELATED MORBIDITY government of Tanzania has made some AND MORTALITY efforts to address the impacts of air pollution 50. The health risks of heat are wide-ranging, on health. It has signed international and including effects on mortality, heat-related regional treaties, including the 2008 Libreville injuries, mental health, and well-being. Health Declaration on Health and Environment in effects caused by heat include the direct effect Africa and the Health and Pollution Action 28 | Climate and Health Vulnerability Assessment: Tanzania FIGURE 13. Map of Tanzania Showing Projected Number of Days with Heat Index >35°C Source: Natural Earth and Aster GDEM Version 3 Plan (HPAP) in 2019.92 Amidst Tanzania’s the Tanzanian population, include respiratory efforts to address the health impacts of air tract infections, acute respiratory illnesses, pollution, indoor air pollution remains the single chest pain, eye problems, cough, pneumonia, largest driver of poor health.93,94 In 2019 alone, and tuberculosis.97,98 According to the World household air pollution was responsible for Bank, Tanzania’s annual mean exposure for about 39,200 deaths.95 Women and children fine particulate matter 2.5 (PM2.5) was 29 are disproportionately affected due to their micrograms per cubic meter (µg/m³) in 2017,99 prolonged exposure to indoor air pollution higher than the WHO’s recommended value during meal preparation, with domestic biomass of 5µg/m³.100 combustion being the biggest contributor to household indoor air pollution. The main 53. Projected increases in temperatures, coupled sources of outdoor pollution in Tanzania are with longer and drier regimes, are likely to vehicular traffic, industrial activities (steel lead to the further deterioration of air quality and cement), agricultural activities, mining, in Tanzania. Tanzania is already vulnerable improper waste disposal, and human activities to wildfires, and the projected increases in (charcoal burning and forest fires).96, Common temperatures during the extended dry months diseases, associated with air pollution among of June to October will likely increase the Climate-Related Health Risks | 29 FIGURE 14. Map of Tanzania Showing Tropospheric Nitrogen Dioxide (NO2) Source: Sentinel-SP OFFL NO2: Offline Nitrogen Dioxide occurrences, intensity, and spread of these DIRECT MORTALITY AND INJURIES wildfires, thereby increasing air pollution.101 In 54. Flash floods, caused by heavy rains, addition, rising temperatures and atmospheric mudslides, and landslides are associated carbon dioxide will likely extend the allergy with mortality and direct injuries (see Table 5). season due to the impact on plant phonologies. Globally, floods are one of the leading causes Although not well-documented in Tanzania, of natural disaster-related injuries and deaths, recent research elsewhere has shown that with over 6,000 deaths in 2020 alone. In prolonged exposure to air pollution increases Tanzania, there were more than 450 deaths the risks of some cancers, such as childhood and over 240 natural disaster-related injuries leukemia and bladder cancer, dementia, and between 2000 and 2019.103 In 2020, heavy rains autoimmune disorders including rheumatoid and flooding caused 40 fatalities in the regions arthritis.102 Prolonged dry seasons and the of Mwanza, Morogoro, Lindi, and Manyara.104 lack of rainfall will likely increase exposure On April 16, 2014, flooding, following three to particulate matter from industrial activities, days of heavy rain, caused 41 deaths in Dar construction, mining, vehicle fumes, dusty es Salaam. In particular, the coastal regions roads, and wildfires, due to a lack of rains of northern, eastern, and southern Tanzania to settle the fine and coarse particles to the are particularly vulnerable to deaths caused ground. by heavy rain-induced floods. 30 | Climate and Health Vulnerability Assessment: Tanzania TABLE 5. Extreme Weather Events Injuries and Mortality for Tanzania from 2000 to 2022 EXTREME EVENTS SUBTYPE EVENTS COUNT TOTAL DEATHS TOTAL AFFECTED Flood Flash flood 6 50 103,904 Riverine flood 16 177 174,569 Other 11 164 158,982 Drought Drought 4 - 6,854,000 Landslide Landslide 1 13 150 Storm Convective storm 4 47 6,394 Tropical cyclone 1 - 2,000,000 Other 1 10 30,001 Source: https://public.emdat.be/data. MENTAL HEALTH AND estimated 5.3 percent of the global disease burden. Tanzania is exposed to numerous WELLBEING RISKS natural hazards, including severe flooding, 55. Tanzania has limited research on the impacts mudslides, landslides, sea-level rises, coastal of climate change on mental health. As storm surges, prolonged droughts, wildfires, such, to assess mental health in the context and heat waves. These natural hazards, of climate change in this assessment, the full especially floods and prolonged droughts, spectrum of mental health, including psycho- exert significant impacts on people’s socio- logical, emotional, and social well-being, is economic activities and livelihoods, which considered. This allows for the incorporation also in turn produce adverse short- and of considerations of well-being and resilience; long-term effects on their mental health and doing so is particularly relevant in Tanzania, well-being. Socioeconomically disadvantaged where there is a background strain on the communities, especially those in rural areas, resilience of the population, as well as limited including children, women, the sick, and the opportunities for psychological or psychiatric elderly, are disproportionately affected by assessments and diagnoses to inform the the adverse effects of climate change due analysis. The concept of mental health and to their limited capacity to adapt. Confronted well-being is thus framed as a spectrum of with climate change-related hazards and “psychosocial health.” This incorporates the their impacts on livelihoods, coupled with diverse psychological and social strains of the households’ inability to adapt, people are climate change impacts, such as food and likely to be more susceptible to anxiety, worry, water insecurities, destruction of livelihoods distress, sleep disorders, mood disorders, and property, poverty, as well as living in very depression, substance use disorders, and hot and humid conditions. posttraumatic stress disorders. 56. In Tanzania, mental health conditions are a 57. Climate change and the resulting socio- growing concern, with the country’s neuro- economic and livelihood insecurities have psychiatric disorders accounting for an immensely affected the mental health of Climate-Related Health Risks | 31 low-income Tanzanians and created new → Migration: The negative impacts of climate vulnerabilities for those who are already change on agriculture as the main source of experiencing mental health and substance livelihood have led to rural-urban migrations, use disorders. In Tanzania, there are various with implications for physical and mental health. factors impact mental health, but here, we Once in urban areas, the new migrants, who focus on climate-related factors. Climate are away from their social support networks, change impacts on Tanzanians’ mental health struggle to find a new source of livelihood, and well-being outcomes are mediated by thus increasing their susceptibility to stress, severe socioeconomic and contextual factors, anxiety, fear, depression, violence, crime, including the following: suicidal tendencies, and substance use. → Food insecurity: Food insecurity, hunger, and → Water and pasture scarcity: Among the malnutrition pose a big challenge in Tanzania. pastoral communities like the Maasai, the In a country where more than 67 percent of deaths of their cattle, goats, and sheep the population live in rural areas and rely (main sources of livelihood), resulting from solely on agriculture as the main source of pasture and water scarcity following prolonged food supply, adverse weather events due to droughts, have increased levels of stress, climate change impacts, which lead to food depression, and anxiety.107 insecurity, can trigger anxiety, stress, sleep- → Loss of loved ones and property damage: lessness, and depression.105 Flash floods can lead to mental health → Poverty: In 2021, an estimated 29 million disorders, as this phenomenon can result in the Tanzanians lived in extreme poverty;106 most loss of loved ones; physical injuries; property of them are rural residents. Agriculture is a damage including housing, household items, source of livelihood and employment for over and farm equipment; and the destruction of 70 percent of the Tanzanian population. The businesses (small income-generating activities). negative impacts of floods and prolonged droughts on agriculture, coupled with low adaptive capacity, have increased unem- ployment, poverty, substance use, domestic violence, and mental disorders, especially in regions prone to floods and droughts. 32 | Climate and Health Vulnerability Assessment: Tanzania TABLE 6. Summary of Climate Change Impacts on Health Outcomes CURRENT RISK PROJECTED RISK Food Security • Tanzania is challenged by acute food • Projected increases in population growth, and Nutrition insecurity. coupled with climate change impacts on • The prevalence of severe food insecurity the agricultural sector, will continue to among the Tanzanian population was worsen extreme hunger, food insecurity, 56.4 percent in 2019 — an increase from and malnutrition. 55 percent in 2018. • Rural Tanzanians (84 percent) are more vulnerable to food insecurity than urban residents (64 percent). Vector-borne • Tanzania has one of the highest malaria • Projected changes in rainfall patterns diseases prevalence rates (13.4 percent of malaria and intensity, as well as temperature cases) in Eastern and Southern Africa. increases, will likely increase the suitabil- • An estimated 93 percent of the popu- ity for mosquito distribution and malaria lation of mainland Tanzania (especially transmission in Tanzania. those in the northern and central parts) is at risk of contracting malaria. • Malaria is one of the leading causes of deaths among children under 5 years of age in Tanzania. Waterborne • Waterborne diseases (WBDs) are one of • Projected increases in temperatures will diseases the leading causes of ill health and deaths increase the vulnerability of communities, among Tanzanian children: they are especially fishing and coastal communi- responsible for 23,900 deaths per year ties, to WBD outbreaks. among the under-fives. • Projected increases in extreme rainfall • The growing occurrences of flash floods and associated floods will likely increase are associated with increased WBD drinking water contamination and WBD outbreaks. outbreaks. • Decreased water levels, due to increased water temperatures, are a leading cause of surface water and groundwater con- tamination. Heat-related • Populations in the Mara region and Dar es • Extreme heat exposure will become more morbidity and Salaam are highly vulnerable to extreme common throughout the mid-century, mortality heat-related injuries and mortalities. with populations in the Dar es Salaam region and the regions of Zanzibar at the greatest risk. Climate-Related Health Risks | 33 CURRENT RISK PROJECTED RISK Air quality and • Indoor air pollution remains the single • Projected increases in temperatures, respiratory largest driver of poor health. coupled with longer and drier regimes, health • Domestic biomass combustion is the are likely to lead to the further deteriora- leading contributor to household indoor tion of air quality in Tanzania. air pollution, with women and children • Rising temperatures and atmospheric disproportionately affected due to carbon dioxide will likely extend the their prolonged exposure to indoor air allergy season due to the impact on plant pollution. phonologies. • The leading causes of outdoor air pollution are vehicular traffic, industrial ac- tivities (steel and cement), agricultural ac- tivities, mining, improper waste disposal. Direct injuries • Floods are responsible for the most • Projected increases in flooding, associ- and mortalities deaths and injuries in the country. ated with increasing temperatures and • Flash floods caused by heavy rains, precipitation, will likely cause more deaths mudslides, and landslides threaten lives and direct injuries in the 2050s. and livelihoods, with those living in south- eastern and northeastern Tanzania at the greatest risk. Mental health • Mental health conditions are a growing • Increased temperatures are likely to and well-being concern, with the country’s neuropsychiat- continue to affect agricultural productivity, ric disorders accounting for an estimated water availability, and livelihoods, thus 5.3 percent of the global disease burden. increasing poverty, with implications for • Climate change and the resulting socio- mental health outcomes. economic and livelihood insecurities have affected the mental health of low-income Tanzanians immensely and created new vulnerabilities for those who are already experiencing mental health and substance use disorders. 34 | Climate and Health Vulnerability Assessment: Tanzania SECTION IV. CLIMATE ADAPTIVE CAPACITY OF THE HEALTH SYSTEM HEALTH SYSTEM OVERVIEW 58. Tanzania’s health system is hierarchical and aligned with political-administra- tive levels.108 The government owns over 60 percent of the health facilities in the country at multiple levels,109 including (a) the national hospital (highest level), (b) zone hospitals (tertiary level), (c) regional referral hospitals (regional level), (d) district hospitals (district level), (e) health centers (ward level, also the lowest level). The government — under the Ministry of Health (MoHSW) — also runs specialized hospitals that do not fall under any of the above categories. The health system is diverse: apart from public / government entities, the estimated 40 percent of the private health facilities are faith-based (majority), commercial, and not-for-profit (the majority being faith-based facilities), where health services are provided by traditional healers (THs), traditional herbalists, and traditional birth attendants (TBAs), and community health workers (CHWs).110 THs, traditional herbalists, and TBAs remain popular in rural areas, where there are limited public and private health care providers. 59. The Tanzanian government has made insurance scheme have faced operational commendable progress toward achieving and structural challenges, thus undermining Universal Health Coverage (UHC) through the the acceptability, membership, and financial introduction and implementation of public base of the schemes.112 The low acceptability health insurance schemes. The introduc- and uptake of the health insurance schemes tion of the National Health Insurance Fund have resulted in the provision of poor-quality (NHIF), Tiba Kwa Kadi (TIKA111), the Community health services to the members. Health Fund (CHF), and the Social Health Insurance Benefit (SHIB) has increased access 60. Tanzania’s health insurance scheme covers to health services for both the rural and urban a small percentage (15 percent) of the populations. However, the successful imple- population. For example, TIKA covers only mentation of health insurance schemes has 7.3 percent of the urban population, followed faced major challenges. For example, the by NHIF (approximately 6.6 percent), and urban-based TIKA and the rural-based CHF other health insurance programs (collec- 35 tively 2 percent); this leaves an estimated 85 gaps in the capacity of the health sector to percent of the Tanzanian population without manage emerging health risks effectively and insurance coverage.113 Low levels of health efficiently. In combination with high population insurance coverage, coupled with low-quality growth rates and COVID-19, the climate crisis health services, high costs of health care, and has the potential to overwhelm healthcare poverty, mean that the majority of poor rural systems. This is especially true for already and urban Tanzanians remain vulnerable to fragile health systems like that of Tanzania: surging climate-related health risks. it is characterized by a shortage of skilled health workers, insufficient resources, and 61. Tanzania’s fragile health system is challenged poor management.119 A study by Bajaria and by a high disease burden that includes Abdul (2020) revealed a low level of health malaria, HIV/AIDS, pneumonia, along with system preparedness and inadequate capacity maternal and child mortality. The health to detect, manage, and prevent the spread system is further challenged by a shortage of COVID-19. Only 64 percent of the health of human resources for health, constant facilities in the urban areas and 32.9 percent in stockouts of essential medicines, the lack the rural areas had adequate communication of proper staff supervision, and inadequate systems, thus highlighting spatial inequalities, health infrastructure, thus affecting the quality in terms of the health facilities with COVID-19 of health delivery, especially to the low-income preparedness measures.120 rural majority of Tanzanians.114,115 In fact, the country has one of the lowest levels of access 64. The extent to which the health system in to skilled health workers in the world, with an Tanzania has the capacity and the readiness estimated 0.31 doctors per 10,000 Tanzanians.116 to manage changes in hazards, exposure, and susceptibility will determine its resilience 62. The government has made progress in in the coming decades. This assessment improving the performance of the health examines Tanzania’s adaptive capacity121 to system in areas of improved accountability, prevent and manage climate-related health efficiency, and effectiveness. In 2020/2021, risks according to WHO’s six health system USD387.9 million were allocated to the health building blocks (see Figure 15). It should be sector, with a 40 percent contribution from noted that several factors outside the scope donors.117 However, challenges remain in of the health sector can also drive reductions the efficiency, operations, and financing of in the adaptive capacity of Tanzania’s insti- the different health system components. tutions and people to manage the health Healthcare access (accessibility, affordability, risks of climate change. These include the acceptability, availability) is characterized by country’s economic challenges, changing geographical inequalities (rural vs. urban) demographic patterns, and slowly improving and low insurance coverage. In 2019, only social conditions. The promotion of equity as an estimated 32 percent had health insurance a cross-cutting theme for enhancing adaptive coverage.118 capacity and resilience to the health risks of climate change is also critical. Adaptive 63. The emergence and reemergence of capacity is likely to be greater when access pandemics, such as COVID-19 (coronavirus to resources within a community, nation, or disease 2019) and Ebola, have highlighted the world is equitably distributed. 36 | Climate and Health Vulnerability Assessment: Tanzania FIGURE 15. WHO’s Health System Building Blocks. Leadership & Governance Health Workforce Financing Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential Medical Products & Technologies Source: World Health Organization. 2015. Operational Framework for Building Climate Resilient Health Systems. LEADERSHIP AND GOVERNANCE • HSSP III (2009–2015), • Tanzania Emergency Preparedness and 65. The government of Tanzania recognizes Response Plan (2012), climate change and its impacts on the • Disaster Management Act (2014), country’s development. As a result, the • National Operational Guidelines for Disaster government has already been developing Management (2014), strategies and policies to guide climate • National Environmental Action Plan (2012– change mitigation and adaptation action. 2017), Although there was no single policy explicitly • Disaster Management Act (2014 / 2015), addressing climate change before the 2012 • Intended Nationally Determined Contri- National Climate Change Strategy (2012), butions (INDCs) (2015), Tanzania’s 1997 National Environmental • HSSP IV (2015–2020), Management Act highlights the negative • Tanzania’s All Hazard Health Emergency impacts of climate change on the country’s Preparedness and Response Plan (2016), economic development and calls for action. • Nationally Determined Contributions (NDCs) Some other policies, strategies, and plans (2021), adopted by Tanzania in the effort to address • National Environmental Policy (2021), climate include the following: • Tanzania Disaster Communications Strategy (2012), • Health Sector Strategic Plan II (HSSP II) • Tanzania Health National Adaptation Plan (2003–2008), (2018–2023), • National Environment Management Act • National Climate Change Response Strategy (EMA) (2004), (2021), and • Disaster Management Act (2005), • HSSP V (2021–2026). Climate Adaptive Capacity of The Health System | 37 66. Zanzibar works as a separate entity, although of renewable energy, and increased climate it is part of the same country. Zanzibar has change research. its own MoHSW and policy landscape. Its → 2004 — The 2004 Environment Management key policies on climate change and health Act (EMA), which repealed the National are as follows: Environment Management Act of 1983, was enacted to enforce the 1997 NEP. • Zanzibar Emergency Preparedness and The EMA provides a legal and institutional Response Plan (2011), framework for the sustainable management • Zanzibar Disaster management policy (2011), of the environment. It outlines key principles • Zanzibar Disaster Communication strategy for environmental management; pollution (2011), prevention and control; impact-risk • the Zanzibar Environmental Policy (2013), assessments; environmental quality standards; • the Zanzibar Climate Change Strategy waste management; public participation in (2014), and environmental management; along with • Zanzibar HSSP III (2014–2018). compliance, monitoring, and enforcement. 67. The evolution of the climate change The key stakeholders include the National policy landscape in Tanzania since 1997 is Advisory Committee, the National Environment summarized as follows: Management Council, the Minister for Environment, and the Director of Environment. → 1997 — In Tanzania, the National Environ- → 2004 — The National Disaster Management mental Policy (NEP) was adopted in 1997 Policy under the Disaster Management and revised in 2021. The development of Department was approved in 2004. The the NEP resulted from a national analysis that National Disaster Management Policy highlights illuminated the poor and deteriorating state the importance of environmental conservation of the environment, thereby leading to the as a strategy to control the negative impacts call for immediate action. The environmental of natural disasters. The policy advocates for problems included the lack of access to safe capacity building to raise the local community’s water for urban and rural communities; habitat awareness about the importance of environ- and biodiversity losses; land degradation; mental management. The policy developed a environmental pollution; deforestation; along governance system with an implementation with the deterioration and degradation of plan at different levels linking the national, aquatic systems. The main objectives of the regional, district, ward, and village levels. NEP are (a) develop a framework to guide The governance system includes disaster the integration of environmental problems in management committees at different levels decision-making; (b) provide policy guidelines and outlines their respective roles and respon- and guidance on priority actions; as well as (c) sibilities as well as the responsibilities of other build a system for monitoring the evaluation of environmental policies, plans, and programs. stakeholders — non-governmental organiza- The NEP calls for regulation on the use of tions (NGOs), the media, and the civil society. public lands, the rational exploitation of land → 2007 — The development of the National and forest resources, waste management, Adaptation Programme of Action (NAPA) reduced deforestation and the promotion fulfilled the requirement by the United Nations of afforestation activities, the increased use Framework Convention on Climate Change 38 | Climate and Health Vulnerability Assessment: Tanzania (UNFCCC) to address climate change. Overall, and the Tanzania Meteorological Agency as NAPA seeks to identify key climate change signatories. adaptation actions and activities sufficient for Other documents guiding disaster management sustainable development amidst a changing include the Tanzania Emergency Prepared- climate. The main objectives of the NAPA are ness and Response Plan (TEPRP – 2012), to identify and develop immediate and priority Disaster Management Act (2014/2015), the climate change and variability adaptation National Operational Guidelines for Disaster activities; protect people’s livelihoods, the Management (2014), and Tanzania’s All Hazard environment, biodiversity, and infrastructure; Health Emergency Preparedness and Response integrate climate change adaptation activities Plan (2016). The 2016 All Hazard Health into national and subnational development Emergency Preparedness and Response Plan strategies, policies and plans; increase is a multisectoral plan spearheaded by the communities’ awareness of climate change, Tanzania Ministry of Health and Social Welfare its impacts, and adaptation activities; support MoHSW). It outlines guidelines for the health communities to improve human and techno- sector’s emergency response to all hazards, logical capacities for sustainable environment including monitoring and evaluating disaster and natural resource exploitation; support response activities, response planning, and development activities hindered by climate decision-making in the face of an emergency, change; as well as develop sustainable capacity building and resource mobilization livelihood and development activities at the for emergency response activities. The target national, regional, and community levels. audience for this emergency response plan → 2012 — The main aim of the Tanzania is all health stakeholders in the government Disaster Communication Strategy (TDCS) and private sectors. (2012) is to support and guide effective, → 2012 — The overall goal of the National timely, and reliable emergency communi- Climate Change Strategy (NCCS) is to enable cation among responders and the different Tanzania to effectively respond to climate levels of government and stakeholders. change through adaptation and mitigation The objectives of the TDCS are to ensure measures. The NCCS seeks to place climate reliable and effective communication change on the policy agenda, reduce the among emergency responders; support country’s vulnerability to climate change, emergency communication to departments and build resilience to the negative effects of communities at the different levels in the event climate change, and achieve sustainable of a disaster; guide the Tanzania Emergency development, as stipulated in the National Preparedness and Response Plan (TEPRP) Development Vision 2025, Tanzania’s 5-year by providing procedures to be followed National Development Plan, and different in case of an emergency; and ensure that sectoral policies. The NCCS recognizes the emergency responders communicate in a need for the capacity building of key sectors to timely manner and as planned at all government foster economic development and for related levels. Although the TDCS does not mention institutions to address climate mitigation and climate-related hazards as disasters for an adaptation. The policy identifies the need for emergency response, the document outlines the public to learn about climate change, its the Department of Public Health under MoHSW harmful effects, as well as adaptation and Climate Adaptive Capacity of The Health System | 39 mitigation options; to this effect, it calls for the the 2012 NCCCS covers climate change, its development and implementation of awareness impacts on the healthcare system, and climate programs. To further understand and address health-related risks, the Ministry of Health climate change, the NCCS stresses the need and Social Welfare (MoHSW) was not on the to establish adequate research capacity for National Task Force that prepared the 2012 research, build training institutions, increase NCCCS. This was thus a missed opportunity for the capacity of vulnerable and marginal- the alignment of the NCCCS with the MoHSW’s ized populations, promote local Indigenous policies, plans, programs, and priorities. knowledge in climate change responses, and → 2015 — Tanzania submitted its Intended purchase relevant technologies. Although not Nationally Determined Contributions (INDCs) a climate change-health strategy, the 2012 to the UNFCCC in 2015. Tanzania’s INDCs NCCS clearly articulates the impacts of climate were developed in consultation with repre- change on human health and identifies the sentatives from different sectors, including need to build the capacity of facilities to public and private sectors, government insti- address climate-related health risks. tutions, the civil society, along with academic → 2012 — The 2012–2017 National Climate and research institutions. Additional guidance Change Communication Strategy (NCCCS) was derived from international and national (2012) aims to improve climate change policies, strategies, action plans, and programs. awareness among stakeholders at different Tanzania’s INDCs aim to reduce GHGs, levels. The 2012 NCCCS covers six thematic while achieving sustainable development, areas: climate change mitigation, adaptation, contributing to building adaptive capacity, gender, awareness, research, and climate enhancing actions to adapt to the impacts change financing. The document provides a of climate change, and building long-term strategic framework for guiding the effective climate change resilience. Health is one of implementation and delivery of climate change the identified adaptation priority sectors of key messages / information to stakeholders, the INDCs. The intended contributions for the target audiences (international, national, health sector are integrating climate change regional, district, ward, and village levels), adaptation into health policies and programs, and responsible actors for each theme, in conducting vulnerability assessments to guide alignment with the media and national channels the health sector adaptation action plan, and of communication and procedures. building a climate-sensitive health system The 2012 NCCCS covers the impacts of climate and sanitation infrastructure. change on the health sector under two of → 2018 —Tanzania’s 2018–2023 Health National the six thematic themes. Under the themes Adaptation Plan (HNAP) to climate change of adaptation and climate change research, is the country’s first multisectoral exclusive the strategy highlights key information on document on health and climate change climate change impacts on human health, resilience. Tanzania’s HNAP aims to guide the including climate-related health risks; the country’s health system to build resilience to health systems’ response to climate-related climate change and a sustainable future for all health risks; disease surveillance, control, and Tanzanians. The HNAP seeks to (1) guide the management; gender considerations; early integration of climate change in health sector warning systems (EWS); and the dissemination policies, strategies, and programs; (2) highlight of best practices and key lessons. Although the need for an EWS for climate-sensitive 40 | Climate and Health Vulnerability Assessment: Tanzania disease outbreaks and guide its operational- sector, as well as academic and research ization; (3) support the implementation of the institutions. The guiding principles of the NDC Nationally Determined Contributions (NDCs) includes increasing long-term resilience to and the integration of key health issues into climate change impacts and reducing climate the National Adaptation Plan; (4) advocate vulnerability; enhancing transparency and for the mobilization of resources and their stakeholder participation in the implemen- allocation to support the adaptation of the tation of the NDCs per the provisions of the health sector to climate change; and (5) guide Paris Agreement; as well as contributing to the establishment of a climate change-resil- the reduction of GHG efforts as stipulated ient health sector. in the UNFCCC and toward sustainable → 2021 — Health Sector Strategic Plan V (HSSP development as per the national development V) (2021–2026), HSSP IV (2015–2020), HSSP agenda. The NDC have also set out climate III (2009–2015), HSSP II (2003–2008), and change adaptation strategies for the various HSSP I (1999). The Health Sector Strategic sectors, including health; capacity building; Plan V (HSSP V) (2021–2026) aims to achieve gender mainstreaming; disaster risk reduction; sustainable health coverage for all Tanzanians, infrastructure; agriculture; livestock; research irrespective of geographical location, age, and systematic observation; as well as water, social status, and gender by 2023. The HSSP sanitation, and hygiene (WASH). V outlines guidelines for the health sector → 2021 — Tanzania’s National Climate Change to achieve quality health services for all, by Response Strategy (NCCRS) (2021–2026) addressing the social determinants of health was developed, based on the unaddressed and improving the sector’s emergency and gaps of prior regional and national climate disaster preparedness. In addition, the HSSP change, environmental, and development V aims to promote people-centered health policies, strategies, and plans. The NCCRS services delivery. This will be attained through 2021 was prepared by a multisectoral empowering and engaging communities in taskforce: it included representatives from the planning, designing, and delivery of health the government ministries, the civil society, services. The HSSP V recognizes the impacts the local governments, the private sector, and of climate change on health and stresses development partners. The NCCRS aims to the need for the health sector to adequately build Tanzania’s resilience to climate change prepare to effectively tackle the health impacts and guide the country to attain sustainable related to change. development through accelerating the → 2021 — The NDC 2021 (which supersedes transition to low-emission development the INDC 2015). Tanzania’s NCD is guided by pathways. The NCCRS has 10 specific aims, national policies, strategies, plans, programs, including strengthening and monitoring the and international agreements, and calls for implementation of the NDCs; ensuring the action on climate change and sustainable integration of climate change into national development, including the Paris Agreement, and subnational planning and programs; the New Urban Agenda (2016), and the enhancing research and strengthening public Sustainable Development Goals (SDGs). awareness and education on climate change; The NDC was developed in consultation with and facilitating the mobilization of funds for multiple stakeholders from the government, the acquisition of technologies for climate local governments, the civil society, the private change adaptation and mitigation programs. Climate Adaptive Capacity of The Health System | 41 Furthermore, the NCCRS 2021 aims to promote to changes in the frequency and intensity gender-response climate change adaptation of extreme weather events that may affect and mitigation measures; enhance stakeholder a facility or the workers’ ability to reach the engagement and inclusion in climate action; facility, as well as through altered patterns facilitate the transfer of climate-smart tech- of climate-sensitive diseases to which health nologies in climate change adaptation and professionals may not be able to respond in mitigation; and align climate change policies a timely manner (WHO 2020). and programs with the national development agenda. Finally, the NCCRS 2021 highlights the 70. HRH in Tanzania are below the WHO impacts of climate change on the environment minimum threshold for achieving universal and human health and calls for the oper- health coverage (UHC) — 44.5 per 10,000.123 ationalization of a Health Sector National In 2018, the country had an estimated 0.5 Adaptation Plan. medical doctors and 5.67 nurses and midwives per 10,000 population. Overall, there are 68. Tanzania has made recommendable progress an estimated 2,885 registered doctors and in the integration of climate change and 31,940 nurses in total. Moreover, there is a health efforts; however, gaps remain. shortage of allied health professionals.124 Capacity building to strengthen health and For example, in 2018, there were only 4,361 climate mainstreaming is weak. In addition, medical pathologists and laboratory scientists there is weak accountability within MoHSW and 929 environmental health officers (0.21 at the regional and local levels on health and per 10,000), and in this survey no reported climate change. Furthermore, communica- community health workers (CHWs) – who play tion and collaboration between the relevant a vital role in increasing resilience in the health sectors and departments are weak, and at system. Regarding mental health, there are times, non-existent. no reports on the number of psychiatrists, psychologists, or nurses with mental health training. Although there are 2,946 workers HEALTH WORKFORCE registered as support staff, it is unclear what 69. The healthcare staff shortage is a persistent role and training they possess.125,126 challenge in Tanzania, thus limiting health service delivery and undermining the 71. There are limitations in the health workforce, overall resilience of the health system. The both in terms of professional expertise and lack of human resources for health (HRH) distribution, as well as an overarching lack positions Tanzania among the 36 African of information on the awareness of climate countries in crisis. Additionally, Tanzania change and health risks among health faces numerous health workforce challenges, workers. The health workforce, particularly including urban-rural maldistribution, a lack doctors, is concentrated in urban areas, with of proper skill mix, low quality of education, almost 70 percent of medical doctors located poor absorption capacity, rural retention in urban health facilities, leaving around 30 issues, international outmigration, along with percent of medical doctors in rural areas insufficient and irregular salary payments.122 where 65 percent of the population lives.127 Simultaneously, climate change impacts the This gap increases in the case of medical health workforce through mechanisms related specialists or consultants: 90 percent is found 42 | Climate and Health Vulnerability Assessment: Tanzania in in urban areas. On the contrary, nurses and living expenses. However, these subsidies and midwives (approximately 64 percent) are are dependent on funds availability and the mostly located in rural areas, with only 36 performance of students. On the other hand, percent in urban areas. There is an uneven non-degree training programs are coordinated distribution of the health workforce across by MOHSW, with in-service training targeted provinces, with the majority of highly skilled at career advancement, for example, from professionals stationed in Dar es Salaam. clinical assistant to clinical officer. Other training There is no data on the quantity or the level programs are organized in terms of specific of expertise on climate-related health risks topics or diseases, such as HIV, malaria, or among the health workforce.128 healthcare quality; however, these programs are not very well-coordinated.130 It is unclear 72. Labor conditions for health workers restrict whether any training workshops or modules health workforce capacity. The current on climate change’s impact on health and salaries of health workers are low and labor health service delivery have been conducted. conditions are inadequate, especially in rural areas where roads, communications, electricity, and other basic services are limited or lacking. HEALTH INFORMATION SYSTEMS Poor working conditions have triggered the 74. Tanzania has an Integrated Disease Surveil- outmigration of skilled health workers. Efforts lance and Response (IDSR) system that is to retain health personnel have focused on currently monitoring 34 priority diseases providing health insurance, a contributory and conditions; yet challenges remain in social security scheme, housing or housing data collection, entry, management, and allowance, and in-service training. However, use. The IDSR is coordinated by the Epidemi- most of these incentives are still insufficient ology Unit within MoHSW: it identifies, reports, or have been removed, such as the housing and provides guidelines for responses on (a) or housing allowances. Official documents diseases that are epidemic-prone, (b) key state that incentives have been a key topic NCDs, (c) public health emergencies of inter- of discussion; however, the current status national concern, (d) diseases of public health of incentive packages or labor conditions importance such as diarrhea, pneumonia, and is unclear.129 malaria, as well as (e) diseases targeted for eradication / elimination. In the case of malaria, 73. The health sector’s educational institutions the country has a National Malaria Control tend to be underfunded, characterized by Program in place, which integrates data on insufficient qualified educators, materials, cases, mortality, and patients in all health and infrastructure. By 2013, the country facilities with the IDSR.131 reported having 10 training institutions for medical doctors and 68 for nurses and 75. The country also has a Health Management midwives nationwide. These degree-level Information System (HMIS). This system institutions are under the responsibility of collects data from health-related adminis- the Ministry of Education and Vocational trative and operational activities, such as Training. Students attending medical colleges information from over 7,000 health facilities, are fully sponsored, while other degrees are collecting morbidity and mortality rates of the provided with soft loans to cover tuition fees population, health service delivery, essential Climate Adaptive Capacity of The Health System | 43 medical products, quality of services, along system also collects data on vulnerable with financial and administrative operations.132 and at-risk households, while identifying However, the IDSR and other health information their coping strategies. Households receive systems face challenges with data incomplete- warning messages when extreme weather ness, delays in reporting, poor data integration, events are forecasted. as well as data storage and management challenges.133,134 Council health management 78. Furthermore, the United Nations Development teams (CHMTs) and other staff handling health Programme Global Environmental Finance data lack adequate training in data collection, (UNDP-GEF) project is strengthening climate analysis, and interpretation.135 information and the EWS by transferring technologies and infrastructure for climate 76. Tanzania has a multihazard early warning monitoring and setting up weather stations. service (MHEWS) for coastal areas that This project also integrates weather information is coordinated by the Tanzania Meteoro- with agrometeorological information for logical Agency in collaboration with the activities such as crop farming and livestock.139 It DRM department. This system is aimed at uses text messages that are sent to smallholder delivering a five-day weather forecast service farmers who are registered within the short for climate-related hazards, such as heavy rain, message service (SMS) system. However, there flooding, landslides, strong winds, high waves, are no details on the implementation of the and extreme temperatures. It is focused mostly program and its effectiveness in reducing on the impact of these hazards on fishing climate-related risks. communities along the coast of the country, and particularly for Zanzibar. However, it is not clear if the MHEWS is being integrated in ESSENTIAL MEDICAL PRODUCTS AND the Health Management Information System (HIS) and contributing to understanding how TECHNOLOGIES climate-related hazards would change health 79. Tanzania has made progress in the supply emergencies. Dissemination of information of essential medicines and quality medical to other areas in the country and along other products, largely due to improved communica- climate-related risks, has lagged.136,137 tion between the Medical Stores Department (MSD) and rural health facilities. Yet there 77. Though there are other programs that are are still constant drug stock-outs as well as aimed at strengthening early warning systems delays in the delivery of essential medicines (EWS) and responding to climate-related and medical products — a situation that will hazards, the extent to which health impacts be worsened by the climate change impacts are monitored or the health department uses on transport — and will increase the disease EWS data is unknown. The Tanzania Urban burden. Improved regulatory capacity has Resilience Programme (TURP), created in 2016 led to improved quality, safe and effective (with the collaboration of the World Bank), medical equipment, along with diagnostics integrates weather and climate information and treatments, even in rural health facilities.140 for all decision-making levels in order to Tanzania has a National Essential Medicines have improved responses to climate-related List — first published in 1991 and revised in emergencies in urban areas.138 The TURP 2018 — and undated Standard Treatment 44 | Climate and Health Vulnerability Assessment: Tanzania Guidelines.141 However, gaps remain. The vulnerability to climate change-related health health sector in Tanzania is heavily dependent risks. Because of delays in the delivery of test on donor funds and donor health priorities, results from laboratories outside the district, including maternal, reproductive and child disease detection, diagnosis, and treatment health programs as well as some communicable are delayed. diseases like HIV/AIDS. This has led to the neglect of other current and emerging health issues, such as nutrition, malaria, injuries, and HEALTH SERVICE DELIVERY noncommunicable diseases (NCDs), which are 81. The introduction of the public-private partner- becoming health burdens among the Tanzanian ships (PPPs) in the health sector in Tanzania population; most of them are climate-related. has led to an improvement in healthcare There are insufficient funds to purchase basic service delivery. However, gaps and inef- essential medical products including gloves ficiencies in the management of PPPs, as and gauze, along with the equipment needed well as inadequate funding, have hindered for the diagnosis and treatment of NCDs. timely and quality service delivery which is Health facilities are faced with drug stockouts, critical, given the increasing climate change especially in the case of medicines for cancer, impacts on health. The introduction of PPPs diabetes, high blood pressure, cardiovascular in the health sector is aimed at improving and chronic respiratory diseases, which are likely to be leading disease burdens among the quality of health services, increasing the Tanzanian population in the 2050s, due access to affordable and equitable health to climate change impacts. care services to all Tanzanians, and improving effectiveness and efficiency of health service 80. The Health Technology Assessment (HTA) delivery, among other things.144 Overall, the was introduced in Tanzania in 2014 to implementation of the PPPs has improved the improve universal health coverage (UHC). quality, affordability, and access to healthcare However, there is inadequate funding and a services. lack of sufficient human resources for HTA. Following the introduction of the HTA, an 82. However, challenges remain in realizing the HTA committee was formed. Nonetheless, the core aims of the PPP. Inadequate resources, committee members lack adequate training to due to the untimely or the lack of disburse- implement the HTA efficiently and effectively. ment of financial resources by the government Furthermore, there is still a lack of sufficient to the private health sector, have hindered human resources for HTA and technical effective health service delivery.145 In addition, capacity.142 There is also a lack of funds to inadequate financial support undermines purchase medical equipment and testing kits the timely monitoring and evaluation of PPP for the diagnosis and treatment of increasing activities, which is key to compliance with the premature deaths and cardiovascular and PPP agreements for the efficient and effective respiratory diseases related to climate change. delivery of health services. Limited government In addition, Tanzania faces a severe shortage capacity to monitor the private sector, poor of laboratories, especially in rural areas,143 communication and lack of transparency, the which are, in most cases, also prone to climate limited power of the private sector to contribute change impacts, as they have the greatest to decision-making, and poor governance Climate Adaptive Capacity of The Health System | 45 mechanisms have combined to undermine services management, have an essential role the efficiency of the PPP performance in the in referring patients to hospitals and primary delivery of health services to all Tanzanians. health care facilities.147 Despite the increase in the number of health facilities between 83. Tanzania has health facilities that are mostly 2009 and 2014, the utilization of outpatient concentrated in urban areas, leaving those services had not increased concomitantly living in rural areas to travel bigger distances (about 0.7 per capita in 2013). Low utilization to receive health care; this is a situation that has been highlighted as a consequence of is worsened by floods and severe droughts low quality and limited access to essential (see Figure 16 for the locations of health medicines and products. facilities). The country has a total of 6,881 public health facilities (see Table 7) that have a 84. Key health services in Tanzania are aligned great majority of the dispensaries. The private with the needs on the current burden of sector has an important presence as well, disease; however, there are no consider- with 1,333 health facilities. Overall, primary ations for the increase in the burden of care services are the basis of healthcare in disease due to climate change. The main Tanzania: both public and private providers services contemplated in the National Health have a total of 6,942 dispensaries that Sector Strategy are (a) nutritional services; provide preventive and curative outpatient (b) reproductive, maternal, newborn, child & services.146 At the local level, the Council adolescent health (which include services for Health Management Teams (CHMTs), as the family planning); (c) communicable diseases frontline of health care and social welfare such as malaria and other neglected tropical FIGURE 16. Location of Hospitals and Population Distribution in Tanzania Source: Oak Ridge National Laboratory Open Street Map 46 | Climate and Health Vulnerability Assessment: Tanzania TABLE 7. Public Sector Facilities in Tanzania, Including Faith-Based Organizations (FBOs) (2014) PUBLIC SECTOR FACILITIES NUMBER # BEDS National general hospitals 1 1,362 National specialized hospitals 4 1,497 Regional referral hospitals (Gov) 14 3,449 Regional referral hospitals (FBO) 12 4,581 Zonal hospitals 5 2,327 Council hospitals 63 7,267 Council designated hospital 37 6,742 Voluntary Agency Hospital 103 5,595 Parastatal hospitals and health centers 29 1,214 Health centers 614 14,959 Dispensaries 5,819 Parastatal dispensaries 168 Specialized clinics 12 Total 6881 48,993 Source: Tanzania Ministry of Health and Social Welfare (2015). Health Sector Strategic Plan July 2015 – June 2020. – HSSP IV. https://www.prb.org/wp-content/uploads/2020/06/Tanzania-Health-Sector-Strategic-Plan-IV-2015-2020-1-4.pdf diseases, which are affected by temperature HEALTH FINANCING increases and changes in rainfall patterns; 86. There have been improvements in national and (d) NCDs including mental health.148 investments in health; however, Tanzania 85. In terms of the emergency preparedness of is still highly dependent on foreign donors. the health system and the continuation of Government expenditure in health, as a health services, Tanzania has made some percentage of GDP, has kept stable for the efforts in having an adequate policy and last years, which was at 3.83 percent as of planning framework.149,150 However, there is 2019.152 Although overall health expenditure still room to prepare healthcare facilities to has increased, the amount stills falls behind better cope with climate-related hazards and the threshold of the recommended 5 percent respond accordingly. Research shows that spending in order to progress toward UHC. around 60 percent of health facilities have This figure also does not meet the Abuja disaster committees and about 20 percent Declaration target for African states to allocate have developed disaster plans. Nonetheless, 15 percent of its total budget to the health most hospitals (88 percent) lack backup sector. The percentage of total government communication systems.151 expenditure accounts for approximately 40 percent of the total budget for the health sector.153,154 Climate Adaptive Capacity of The Health System | 47 87. Overall health expenditure in absolute and peri-urban areas) are aimed at reducing numbers has increased; however, it lags costs in primary care.157 Around 16 million behind the country’s overall economic growth Tanzanians (28 percent of the population) (GDP increase of 7 percent). From 2010 to are currently covered by either the CHF or 2017, the total health budget doubled, while the National Health Insurance Fund (NHIF).158 government allocations to health declined by 3 percent.155 On the other hand, per capita 89. Building resilient health systems for climate expenditure on health increased by approx- change requires budget allocation to be imately 20 percent from USD23.6 in 2010 to an integrated component in the overall USD28.5 in 2017. This increase in per capita planning of a national health plan; this is expenditure helped to reduce the gap between still lacking. Although there is a multisec- high- spending districts and low-spending toral approach and an integration of climate districts from a sixfold difference in 2013 to a change and health in the Health National fivefold difference in 2017. For example, health Adaptation Plan (HNAP) and overall health expenditure as a share of total spending was strategic planning, there is a lack of guidelines 19 percent in the district of Njombe, but only 4 on integrating a climate-resilient approach for percent in Rukwa. Nonetheless, the existence specific climate-related health risks, such as of these gaps could still exacerbate vulnera- food insecurity and malnutrition, as well as bilities, as climate shocks would impact health heat-related morbidity and mortality, which are service delivery across districts differently.156 necessary for informing rationalized resource allocation. Moreover, while Tanzania adopts 88. User fees have increased and become an risk-pooling mechanisms, it is not clear whether important source of funding, constituting it has accounted for climate-related risks.159 between 40 and 50 percent of all revenue from complementary financing sources, which 90. Climate change mitigation and adaptation will escalate inaccessibility to health services, options in the health sector have not been considering the increased burden of climate adequately promoted as cost-effective change health impacts. This affects mostly options. Arguments for implementing climate poorer households by hindering their access change mitigation policies often focus on to care, as these fees are being collected the perceived short-term financial costs. at primary levels of care. This situation may However, cost assessments are lacking and be further aggravated because of climate rarely account for the health co-benefits of change putting more strain on individuals these policies — strengthening the resilience and households in Tanzania, especially those and outcomes for human health, while also most vulnerable to climate impacts. While reducing costs for the health sector. Therefore, fees are increasing, the government is imple- additional studies are needed to quantify the menting measures to remove these financial longer-term cost savings through the health barriers. Efforts such as the Community Health co-benefits of climate change adaptation and Fund (CHF) and TIKA (a scheme for urban mitigation policies in Tanzania. 48 | Climate and Health Vulnerability Assessment: Tanzania TABLE 8. Summary of Health System Adaptive Capacity Gaps for Tanzania BUILDING BLOCK SUMMARY OF GAPS IN ADAPTIVE CAPACITY Leadership and • The country has developed a policy landscape that adequately integrates Governance climate change into adaptation planning. However, there is a need for coor- dination mechanisms that promote synergies among ministries in order to improve resilience and health outcomes. Health Workforce • HRH in Tanzania are below the WHO’s minimum threshold to achieve UHC. • There are limitations in the health workforce, both in professional expertise and distribution, as well as an overarching lack of information on the awareness of climate change and health risks among health workers. • Healthcare staff shortages are a persistent challenge in Tanzania, curtailing health service delivery and overall resilience of the health system. • The health sector’s educational institutions tend to be underfunded, character- ized by insufficient qualified educators, materials, and infrastructure. Health Information • It is not clear if the MHEWS is being integrated in the HMIS and contributing Systems and Response to the understanding of how climate-related hazards would change health emergencies. • The scaling up of current EWS to other areas in the country and along other climate-related risks has been delayed. • The IDSR system does not incorporate meteorological information to offer a better understanding of climate-related health risks. Essential Medical • There are insufficient funds to purchase basic essential medical products Products and including gloves and gauze, as well as equipment needed for the diagnosis Technologies and treatment of NCDs. • Health facilities face drug stockouts, especially in terms of medicines for cancer, diabetes, high blood pressure, cardiovascular and chronic respiratory diseases, which are likely to be leading burdens among the Tanzanian popula- tion in the 2050s. • There are insufficient human resources for HTAs and technical capacity. • Tanzania faces severe shortages of laboratories, especially in the rural areas. Health Service Delivery • Overall poor governance mechanisms have curtailed the functioning of PPPs in the health sector, and therefore, decreased the efficiency of health service delivery. Additionally, there is a lack of governmental capacity to oversee the private sector. • Health services are of low quality and there is limited access to essential medicines and products. • There are no considerations for the increase of burden of disease due to climate change, and therefore, for medical services that address the increased climate-related health risks. Climate Adaptive Capacity of The Health System | 49 BUILDING BLOCK SUMMARY OF GAPS IN ADAPTIVE CAPACITY Health Financing • Regarding health expenditure as a percentage of GDP, the country falls behind the Abuja Declaration and the target to achieve UHC. • The country has seen an increase in economic growth; however, health ex- penditure has not increased in terms of percentage of GDP. • User fees have increased and become an important source of funding, constituting between 40 and 50 percent of all revenue from complementary financing sources. • Climate change mitigation and adaptation options in the health sector have not been adequately promoted as cost-effective options. • Climate change and climate-related health morbidities and mortalities do not have budget allocations. 50 | Climate and Health Vulnerability Assessment: Tanzania SECTION V. RECOMMENDATIONS TO ENHANCE HEALTH SYSTEM RESILIENCE TO CLIMATE CHANGE 91. This section outlines a set of recommendations to enhance Tanzania’s health system resilience and adaptation to climate change, including potential health interventions and strategies that can be put in place. The recommended options are based on an assessment of both the magnitude of the current and projected climate-related health risks as well as the existing gaps in adaptive capacity to manage and / or prevent these risks. This section is organized, using the 10 com- ponents of climate-resilient health systems (see Figure 17) and drawing from the consultations and reviews of all relevant governmental policies, as well as the World Bank’s Health, Nutrition, and Population (HNP) Climate and Health Guidance Note. FIGURE 17. Who’s Operational Framework for Building Climate-Resilient Health Systems ATE RESILIENCE CLIM hip & Heal eaders nce Workf th L verna orce Go V uln pac ation t Fin alth & A Ca pt en He ate era ity & Leadership As g da essm Clim cin bil & Governance Health s ity, an Workforce Financing Preparedness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential C li o r m e h Re ima & I n f a lt s Medical ma d C l a lt h se te Products & h He ra m Pro te a rc He Technologies - g Ma t na ien Env ge m ent o t e R e s il f C li m a le ir o n in a b D et m ental & S u st a gies ri m e l o of H n ts Techno cture e a lt h I n f r a s tr u & Source: World Health Organization, 2015, Operational Framework for Building Climate Resilient Health Systems. 51 COMPONENT 1: LEADERSHIP COMPONENT 2: HEALTH WORKFORCE AND GOVERNANCE → Integrate climate change and health into the → On the one hand, health should adequately national education curriculum for health training be integrated into national climate change at all levels, including lower secondary, upper policies, strategies, and programs. On the secondary, and tertiary. other hand, climate change should also be → Establish refresher courses and continuing taken into consideration, when national education programs that focus on climate-re- health policies, strategies, and programs lated health risks. are developed. The integration of health and → Develop climate and health training materials climate change should be strengthened at for health workers to raise the awareness of all levels from the national level to the local health workers regarding the health impacts government level. of climate change. → There is a need for a coordination mechanism. → Enhance the provision of benefits on housing A National Climate Change and Health Task or housing allowances for health workers in Force should be established with expert order to improve retention. Other retention representatives from different ministries and strategies include providing better salaries departments including MOHSW the Division in rural areas and areas prone to climate of Environment (the department under Vice change hazards (floods, droughts, and heat President’s Office responsible for climate waves), including those of northern, central, change), and other key departments. Focal and coastal Tanzania, in order to increase the persons should be appointed to represent number of medical doctors and specialists the national, regional, and local levels in the in those areas. The distribution of health National Climate Change and Health Task workforce should consider the geographic Force. distribution of climate-related hazards: for • This group would further health adapta- example, areas that are prone to VBDs would tion efforts within the Division of Environ- require better capacities in laboratories for ment by taking part in strategic planning processing samples and keeping a better and activities, while also conducting and surveillance mechanism. promoting work meetings to advocate for and raise awareness on climate-related health risks. COMPONENT 3: • The National Climate Change and Health VULNERABILITY, CAPACITY, AND Task Force should ensure the dissemination of climate and health strategies and activ- ADAPTATION ASSESSMENT ities and monitor their implementation at → Conduct routine national climate health impact the subnational and local levels regularly. assessments to guide policy-making decisions. → Make routine projections of the climate-re- lated disease burden and the geographical distribution of climate-related health risks (under different scenarios). 52 | Climate and Health Vulnerability Assessment: Tanzania → Update the Human Resources for Health (HRH) national donors. This campaign should be country profile to help in the identification of spearheaded by MoHSW. gaps and need for training. → Improve institutional capacity to conduct more climate-related health research. → Strengthen communication channels between COMPONENT 4: INTEGRATED RISK climate and health researchers and policy MONITORING AND EARLY WARNING makers. → The Health Management Information System → Create mechanisms for disseminating climate (HMIS) and the monitoring / surveillance should and health findings and translating them into account for climate-related health risks and policies. indicators. This would require cross-sec- toral work that will involve the Tanzania Meteorological Agency, water & sanitation, COMPONENT 6: CLIMATE-RESILIENT DRM, agriculture, environment responsible AND SUSTAINABLE TECHNOLOGIES entities, among others, integrating climate and environment data with disease surveillance AND INFRASTRUCTURE and early warning mechanisms (climate-in- → Map health facilities including laboratories formed disease surveillance). and assess their resilience to climate change. → Promote a comprehensive risk assessment → Advocate for the strengthening of climate-re- framework involving different-level stake- silient health as well as water sanitation and holders (researchers, health policy makers, hygiene (WASH) infrastructure and technolo- communities, and donors) and approaches. gies to attract more funding for supporting the → Enhance early warning mechanisms and capacity development, planning, monitoring communication on climate change hazards and evaluation of health facilities for WASH among the different-level stakeholders. provisions. → Map climate-related health risks to facilitate → Develop climate-resilient infrastructure design the identification of vulnerable populations guidelines and ensure adherence to these and their exposure to climate-related hazards. guidelines. → Develop a list of key climate-related health → Develop a WASH and climate change risks (present and projected) and indicators adaptation strategy. for targeted monitoring and surveillance that should take into consideration geographical differences. COMPONENT 7: MANAGEMENT OF ENVIRONMENTAL DETERMINANTS OF HEALTH COMPONENT 5: HEALTH AND CLIMATE RESEARCH → Strengthen collaboration among different sectors, in terms of the monitoring and → Create awareness and advocate for the management of climate-related health and importance of conducting climate and health environmental risks. Environmental efforts research to attract policy makers and inter- have not included health-related risks. Recommendations to Enhance Health System Resilience to Climate Change | 53 → MoHSW should establish coordination past and current climate conditions and mechanisms to integrate health risks that are projected climate change. These health linked to environmental efforts and policies, programs should account for geographical that is, air quality efforts should incorporate differences in climate change exposure and interventions aimed at improving health climate-related health risks. outcomes, such as respiratory diseases. Another example involves the Ministry of Water and the consideration of how their COMPONENT 9: EMERGENCY policies and programs would benefit health PREPAREDNESS AND MANAGEMENT outcomes by strengthening water treatment facilities, for instance, which would reduce → Enhance health system resilience to climate-re- WBDs. lated hazards. For example, the health impacts → Include health in environmental impact of climate change should be integrated into assessments and enforce requirements emergency preparedness and the routine stipulated in the health impact assessments. climate resilience assessment of health facilities and infrastructure. → Reinforce the awareness of the health implications of poor sanitary and improper waste disposal practices, including open COMPONENT 10: CLIMATE AND defecation, amidst a changing climate (that is, the connection between flash floods and HEALTH FINANCING diarrheal disease outbreaks). → Ensure that strategic purchasing includes climate-related health risk considerations. It is recommended that this involves a move COMPONENT 8: CLIMATE-INFORMED toward a provider payment mechanism that HEALTH PROGRAMS incentivizes healthcare providers to focus on climate-related health outcomes, partic- → Develop and disseminate awareness ularly in relation to those most vulnerable to campaigns on climate-related health risks, climate-related health risks. The mechanism by using radio, television, and push notifica- should be guided by detailed, subnational tions, as well as engaging with community climate information on population needs leaders to ensure better communication related to ongoing climate exposures. channels in the most vulnerable and remote communities. Campaigns should focus on → Put in place a detailed resource mobilization preventive measures and the management of plan for resources to support climate-related environmental determinants of health, such emergency responses and climate and health as the use of water and how to treat it to research. reduce pollutants and bacteria. → Advocate for the allocation of funds to → Need for bottom-up climate change and health strengthen the health sector’s resilience to initiatives to ensure sustainability of programs climate-related hazards. and local impact. → Ensure that climate-related health risks are → Strengthen and conduct routine health integrated into national, regional, and local programs by taking into consideration the programs and associated budgets. 54 | Climate and Health Vulnerability Assessment: Tanzania SUMMARY OF RECOMMENDATIONS TO ENHANCE HEALTH SYSTEM RESILIENCE TO CLIMATE CHANGE IN TANZANIA BUILDING BLOCK RECOMMENDATIONS • Adequately integrate health into national climate change policies, strategies, and programs. Leadership and Governance • Strengthen the coordination mechanism by establishing a National Climate Change and Health Task Force with expert representatives from different minis- tries and departments. • Integrate climate change and health into the national education curriculum for health training at all levels. • Establish refresher courses and continuing education programs that focus on climate-related health risks. Health Workforce • Develop climate and health training materials for health workers to raise awareness on the health impacts of climate change among health workers. • Enhance the provision of benefits on housing or housing allowances for health workers in order to improve retention. • Develop a Climate Change Health Risk Assessment model to guide planning, decision-making, and resource allocation. Vulnerability, • Conduct routine national climate health impact assessments to guide policy-mak- Capacity, and ing decisions. Adaptation • Conduct routine projections of climate-related disease burden and geographical Assessment distribution of climate-related health risks. • Update the HRH country profile to help in the identification of gaps and need for training. • The HMIS and the monitoring / surveillance should account for climate-related health risks and indicators. • Integrate climate and environment information with disease surveillance and early warning mechanisms. • Enhance early warning mechanisms and communication on climate change Integrated Risk hazards among the different-level stakeholders. Monitoring and • Map climate-related health risks to facilitate the identification of vulnerable popu- Early Warning lations and their exposure to climate-related hazards. • Promote a comprehensive risk assessment framework involving different-level stakeholders (researchers, health policy makers, communities, and donors) and approaches. • Develop a list of key climate-related health risks and indicators for targeted moni- toring and surveillance. Recommendations to Enhance Health System Resilience to Climate Change | 55 BUILDING BLOCK RECOMMENDATIONS • Create awareness and advocate for the importance of conducting climate and health research to attract policy makers and international donors. • Improve institutional capacity to conduct more climate-related health research. Health and Climate Research • Strengthen communication channels between climate and health researchers and policy makers. • Create mechanisms for the dissemination of climate and health findings and their translation into policies. • Map health facilities and assess their resilience to climate change. Climate Resilient and Sustainable • Advocate for climate-resilient health and WASH infrastructure and technologies. Technologies and • Develop a WASH and climate change adaptation strategy. Infrastructure • Develop climate-resilient infrastructure design guidelines and implement them. • Strengthen collaboration among different sectors, in terms of monitoring and managing climate-related health and environmental risks. Management of • MoHSW should establish coordination mechanisms in order to integrate health Environmental risks that are linked to environmental efforts and policies. Determinants of • Include health in environmental impact assessments and enforce assessments. Health • Reinforce awareness on the health implications of poor sanitary and improper waste disposal practices, including open defecation, amidst a changing climate. • Develop and disseminate awareness campaigns on climate-related health risks. • Need for bottom-up climate change and health initiatives to ensure sustainability Climate-informed of programs and local impact. Health Programs • Strengthen and conduct routine health programs that take into consideration past and current climate conditions, along with projected climate change. Emergency Preparedness and • Enhance health system resilience to climate-related hazards. Management • Ensure that strategic purchasing includes climate-related health risk consider- ations. • Put in place a detailed mobilization plan for resources to support climate-related Climate and emergency responses climate and health research. Health Financing • Advocate for the allocation of funds to strengthen the health sector’s resilience to climate-related hazards. • Ensure that climate-related health risks are integrated into national, regional, and local programs and associated budgets. 56 | Climate and Health Vulnerability Assessment: Tanzania ANNEXES ANNEX A. METHODS FOR THE ESTIMATION OF MOSQUITO SUITABILITY UNDER REPRESENTATIVE CONCENTRATION PATHWAY (RCP) 8.5 IN TANZANIA METHODS FOR THE ESTIMATION OF MOSQUITO SUITABILITY UNDER RCP 8.5 IN TANZANIA Model Construction Spatiotemporal distributions of Anopheles (An.) gambiae s.s., Anopheles funestus, and Anopheles arabiensis mosquitoes was determined, using a raster-based suitability model constructed with the Google Earth Engine by adapting methodology presented by Frake et al. (2020).160 This methodology uses abiotic variables specific to the thermal tolerances of vector species and biotic variables that consider the species’ habitat preferences. • Suitable areas are defined as patches of landscape that facilitate the development of malaria mosquitoes through the production and persistence of oviposition sites and where tempera- tures do not exceed or fall below thermal tolerances. • Parameter thresholds for all input variables were selected based on a literature review of An. gambiae s.s, An. funestus, and An. arabiensis habitats: temperature, landcover, precipitation, flow accumulation, and water resources (Table A1). Thresholds were then used to create binary maps for each predictor (that is, suitable [1] or unsuitable [0]) that were combined, using Boolean logic to produce suitability maps across three epochs — historical reference period (1986–2005), 2030–2049, and 2040–2059 — during Tanzania’s two historic malaria transmission periods: March–May and October–December.161 • Population vulnerability was demonstrated by spatially overlaying suitability maps for malaria mosquitoes in Tanzania with population data from the Global Human Settlement Layers (2015) to calculate the number of Tanzanians residing in suitable areas, by region. Population data were held constant in all models, in the absence of spatial population projection data. Output spatial resolution of products is 1000 meters: this analysis was performed at the landscape, not microscale level. Microscale variations in climatological and land use and land cover can and do affect species actual distributions. 57 TABLE A1. Model Parameterization and Data Sources for Habitat Characterization INDICATOR DATA SOURCE PRODUCT SPATIAL THRESHOLD RESOLUTION Temperature The National Aero- NEX-GDDP 0.25 degrees An. gambiae s.s. nautics and Space Min: 18°C Administration Max: 34°C (NASA) An. arabiensis Min: 13°C Max: 35°C An. funestus Min: 14°C Max: 35°C Land Cover Copernicus Global Proba-V-C3 100 m See Annex Table 2* Land Service Water Joint Research GSW1_0 30 m >0 percent water Resources Centre (JRC) occurrence Flow Accumu- World Wildlife Fund HydroSHEDS 500 m lation (WWF) Population JRC GHSL/P2016/POP_GPW_ GLOBE_V1 Suitability Data and Parameters Temperature Temperature is critical to mosquito development and life history. Temperatures that are either too low or too high can increase mortality during aquatic or adult stages. Bayoh and Lindsay (2003) demon- strated that the upper and lower thresholds for An. gambiae s.s. aquatic development were 18°C and 34°C, respectively.162 The lower development thresholds for An. arabiensis and An. funestus have been demonstrated at 13°C and 14°C, respectively, while the upper limits for survival for both species are 35°C.163 Data were acquired from the NASA NEX-GDDP at a 0.25-degree spatial resolution. Land Use and Land Cover There is a significant relationship between land use and land cover (LULC) and the distribution of mosquito species, with many species demonstrating strong preferences for specific land cover types. LULC data were acquired from the Copernicus Global Land Service Proba-V-c3 product. To determine whether classes were suitable for An. gambiae s.s., An. funestus, An. arabiensis mosquitoes, class descriptions were compared to the habitat preferences of the species according to the literature review. To account for these species’ preferences, Proba class values — 20, 30, 40, 50, 60, 90, 111, 112, 113, 114, 115, 116, 121, 122, 123, 124, 125, and 126 — were set to “suitable” (Tablea A2-A4). 58 | Climate and Health Vulnerability Assessment: Tanzania TABLE A2. Copernicus Global Land Cover Layers: CG:S-LC100 Collection 2 Global Landcover Map Classifications for Anopheles gambiae s.s. CLASS CLASS DESCRIPTION SUITABLE AN. VALUE GAMBIAE S.L. LAND COVER 0 Unknown. No or not enough satellite data available. No 20 Shrubs. Woody perennial plants with persistent and woody stems, and without any defined Yes main stem being less than 5 m tall. The shrub foliage can be either evergreen or deciduous. 30 Herbaceous vegetation. Plants without persistent stems or shoots above the ground and Yes lacking a definite firm structure. Tree and shrub cover is less than 10%. 40 Cultivated and managed vegetation / agriculture. Lands covered with temporary crops, Yes followed by harvest and a bare soil period (for example, single and multiple cropping systems). Note that perennial woody crops will be classified as the appropriate forest or shrub land cover type. 50 Urban / built-up. Land covered by buildings and other constructed structures. Yes 60 Bare / sparse vegetation. Lands with exposed soil, sand, or rocks, and vegetation cover never Yes more than 10% during any time of the year. 70 Snow and ice. Lands under snow or ice cover throughout the year. No 80 Permanent water bodies. Lakes, reservoirs, and rivers. Can be either freshwater or saltwater No bodies. 90 Herbaceous wetland. Lands with a permanent mixture of water and herbaceous / woody veg- Yes etation. The vegetation can be present in salt, brackish, or fresh water. 100 Moss and lichen. No 111 Closed forest, evergreen needle leaf. Tree canopy > 70%, almost all needle leaf trees remain Yes green all year. Canopy is never without green foliage. 112 Closed forest, evergreen broadleaf. Tree canopy > 70%, almost all broadleaf trees remain Yes green year-round. Canopy is never without green foliage. 113 Closed forest, deciduous needle leaf. Tree canopy > 70%, consists of seasonal needle leaf Yes tree communities with an annual cycle of leaf-on and leaf-off periods. 114 Closed forest, deciduous broad leaf. Tree canopy > 70%, consists of seasonal broadleaf tree Yes communities with an annual cycle of leaf-on and leaf-off periods. 115 Closed forest, mixed. Yes 116 Closed forest, not matching any of the other definitions. Yes 121 Open forest, evergreen needle leaf. Top layer — trees 15–70% and second layer — mixture of Yes shrubs and grassland, almost all needle leaf trees remaining green all year. Canopy is never without green foliage. 122 Open forest, evergreen broad leaf. Top layer — trees 15–70% and second layer — mixture of Yes shrubs and grassland, almost all broadleaf trees remaining green year-round. Canopy is never without green foliage. 123 Open forest, deciduous needle leaf. Top layer — trees 15–70% and second layer — mixture of Yes shrubs and grassland, consists of seasonal needle leaf tree communities with an annual cycle of leaf-on and leaf-off periods. 124 Open forest, deciduous broadleaf. Top layer — trees 15–70% and second layer — mixture of Yes shrubs and grassland, consists of seasonal broadleaf tree communities with an annual cycle of leaf-on and leaf-off periods. 125 Open forest, mixed. Yes 126 Open forest, not matching any of the other definitions. Yes 200 Oceans, seas. Can be either freshwater or saltwater bodies. No Annexes | 59 TABLE A3. Copernicus Global Land Cover Layers: CG:S-LC100 Collection 2 Global Landcover Map Classifications for Anopheles arabiensis CLASS CLASS DESCRIPTION SUITABLE AN. VALUE GAMBIAE S.L. LAND COVER 0 Unknown. No or not enough satellite data available. No 20 Shrubs. Woody perennial plants with persistent and woody stems, and without any defined main Yes stem being less than 5 m tall. The shrub foliage can be either evergreen or deciduous. 30 Herbaceous vegetation. Plants without persistent stems or shoots above the ground and a lacking Yes definite firm structure. Tree and shrub cover is less than 10%. 40 Cultivated and managed vegetation / agriculture. Lands covered with temporary crops, followed Yes by harvest and a bare soil period (for example, single and multiple cropping systems). Note that perennial woody crops will be classified as the appropriate forest or shrub land cover type. 50 Urban / built-up. Land covered by buildings and other constructed structures. Yes 60 Bare / sparse vegetation. Lands with exposed soil, sand, or rocks, and vegetation cover never more Yes than 10% during any time of the year. 70 Snow and ice. Lands under snow or ice cover throughout the year. No 80 Permanent water bodies. Lakes, reservoirs, and rivers. Can be either freshwater or saltwater bodies. No 90 Herbaceous wetland. Lands with a permanent mixture of water and herbaceous / woody vegeta- Yes tion. The vegetation can be present in salt, brackish, or fresh water. 100 Moss and lichen. No 111 Closed forest, evergreen needle leaf. Tree canopy > 70%, almost all needle leaf trees remaining No green all year. Canopy is never without green foliage. 112 Closed forest, evergreen broadleaf. Tree canopy > 70%, almost all broadleaf trees remaining green No year-round. Canopy is never without green foliage. 113 Closed forest, deciduous needle leaf. Tree canopy > 70%, consists of seasonal needle leaf tree No communities with an annual cycle of leaf-on and leaf-off periods. 114 Closed forest, deciduous broadleaf. Tree canopy > 70%, consists of seasonal broadleaf tree commu- No nities with an annual cycle of leaf-on and leaf-off periods. 115 Closed forest, mixed. No 116 Closed forest, not matching any of the other definitions. No 121 Open forest, evergreen needle leaf. Top layer — trees 15–70% and second layer — mixed shrubs No and grassland, almost all needle leaf trees remaining green all year. Canopy is never without green foliage. 122 Open forest, evergreen broad leaf. Top layer — trees 15–70% and second layer — mixed shrubs and No grassland, almost all broadleaf trees remaining green year-round. Canopy is never without green foliage. 123 Open forest, deciduous needle leaf. Top layer — trees 15–70% and second layer — mixed shrubs No and grassland, consists of seasonal needle leaf tree communities with an annual cycle of leaf-on and leaf-off periods. 124 Open forest, deciduous broadleaf. Top layer — trees 15–70% and second layer — mixed shrubs No and grassland, consists of seasonal broadleaf tree communities with an annual cycle of leaf-on and leaf-off periods. 125 Open forest, mixed. Yes 126 Open forest, not matching any of the other definitions. Yes 200 Oceans, seas. Can be either freshwater or saltwater bodies. No 60 | Climate and Health Vulnerability Assessment: Tanzania TABLE A4. Copernicus Global Land Cover Layers: CG:S-LC100 Collection 2 Global Landcover Map Classifications for An. funestus CLASS CLASS DESCRIPTION SUITABLE AN. VALUE GAMBIAE S.L. LAND COVER 0 Unknown. No or not enough satellite data available. No 20 Shrubs. Woody perennial plants with persistent and woody stems, and without any defined main Yes stem being less than 5 m tall. The shrub foliage can be either evergreen or deciduous. 30 Herbaceous vegetation. Plants without persistent stems or shoots above the ground and lacking a Yes definite firm structure. Tree and shrub cover is less than 10%. 40 Cultivated and managed vegetation / agriculture. Lands covered with temporary crops, followed Yes by harvest and a bare soil period (for example, single and multiple cropping systems). Note that perennial woody crops will be classified as the appropriate forest or shrub land cover type. 50 Urban / built-up. Land covered by buildings and other constructed structures. Yes 60 Bare / sparse vegetation. Lands with exposed soil, sand, or rocks, and vegetation cover never more No than 10% during any time of the year. 70 Snow and ice. Lands under snow or ice cover throughout the year. No 80 Permanent water bodies. Lakes, reservoirs, and rivers. Can be either freshwater or saltwater bodies. No 90 Herbaceous wetland. Lands with a permanent mixture of water and herbaceous / woody vegeta- Yes tion. The vegetation can be present in salt, brackish, or fresh water. 100 Moss and lichen. No 111 Closed forest, evergreen needle leaf. Tree canopy > 70%, almost all needle leaf trees remaining Yes green all year. Canopy is never without green foliage. 112 Closed forest, evergreen broadleaf. Tree canopy > 70%, almost all broadleaf trees remaining green Yes year-round. Canopy is never without green foliage. 113 Closed forest, deciduous needle leaf. Tree canopy > 70%, consists of seasonal needle leaf tree Yes communities with an annual cycle of leaf-on and leaf-off periods. 114 Closed forest, deciduous broadleaf. Tree canopy > 70%, consists of seasonal broadleaf tree commu- Yes nities with an annual cycle of leaf-on and leaf-off periods. 115 Closed forest, mixed. Yes 116 Closed forest, not matching any of the other definitions. Yes 121 Open forest, evergreen needle leaf. Top layer — trees 15–70% and second layer — mixed shrubs Yes and grassland, almost all needle leaf trees remain green all year. Canopy is never without green foliage. 122 Open forest, evergreen broad leaf. Top layer — trees 15–70% and second layer — mixed shrubs Yes and grassland, almost all broadleaf trees remain green year-round. Canopy is never without green foliage. 123 Open forest, deciduous needle leaf. Top layer — trees 15–70% and second layer — mixed shrubs Yes and grassland, consists of seasonal needle leaf tree communities with an annual cycle of leaf-on and leaf-off periods. 124 Open forest, deciduous broadleaf. Top layer — trees 15–70% and second layer — mixed shrubs Yes and grassland, consists of seasonal broadleaf tree communities with an annual cycle of leaf-on and leaf-off periods. 125 Open forest, mixed. Yes 126 Open forest, not matching any of the other definitions. Yes 200 Oceans, seas. Can be either freshwater or saltwater bodies. No Annexes | 61 Precipitation Water is fundamental to mosquito larvae development. To estimate areas likely to become inundated, the annual average precipitation was calculated from the Climate Hazards Group InfraRed Precipita- tion and Station Data (CHIRPS v2.0). Likewise, flow accumulation was derived from the HydroSHEDS Flow Accumulation product to determine the natural drainage from a given pixel to an adjacent, downslope pixel in order to determine the areas of inundation for larval oviposition sites. Finally, a water resources layer, derived from the JRC Global Surface Water Bodies Mapping Layer v1.0 product, was developed by buffering the water bodies by 250 m to approximate water-rich soils that would support larval development. 62 | Climate and Health Vulnerability Assessment: Tanzania ANNEX B. VECTOR-BORNE DISEASE SUITABILITY PER REGION — SEASON 1: MARCH–MAY TABLE B1. Vector-Borne Disease Suitability Per Region and Vulnerable Population in the Past, Present, and Future — Season 1: March–May PERCENT AREA POPULATED, SUITABLE OVERALL SUITABILITY VULNERABLE POPULATION REGION HISTORIC 2030S 2050S HISTORIC 2030S 2050S HISTORIC 2030S 2050S Mainland Tanzania Arusha 44.95 44.95 44.32 95.33 95.33 91.42 1985570 1985570 1967922 Dar-es-salaam 89.68 89.68 89.68 98.79 98.79 98.79 563584 5635844 5635844 Dodoma 21.74 21.74 21.74 99.34 99.34 99.34 2430118 2430118 2430118 Geita 14.35 14.35 14.35 93.54 93.54 93.54 2179487 2179487 2179487 Iringa 9.45 9.45 9.45 99.80 99.80 99.80 1069239 1069239 1069239 Kagera 10.86 10.86 10.86 70.82 70.82 70.82 2796196 2796196 2796196 Katavi 16.35 16.35 16.35 95.00 95.00 95.00 683211 683211 683211 Kigoma 8.94 8.94 8.94 80.49 80.49 80.49 2500794 2500794 2500794 Kilimanjaro 36.75 36.75 36.75 99.43 99.43 99.43 1883654 1883654 1883654 Lindi 19.03 19.03 19.03 99.89 99.89 99.78 959000 959000 958896 Manyara 36.77 36.77 36.77 99.89 99.89 99.89 1688364 1688364 1688364 Mara 30.74 30.74 30.74 70.00 70.00 70.00 2028963 2028963 2028963 Mbeya 21.45 21.45 21.45 96.96 96.96 96.96 3285500 3285500 3285500 Morogoro 13.09 13.09 11.28 99.94 99.94 90.78 2593247 2593247 2461616 Mtwara 13.54 13.54 13.54 99.71 99.71 99.71 1404733 1404733 1404733 Mwanza 15.72 15.72 15.72 46.89 46.89 46.89 3194439 3194439 3194439 Njombe 21.70 21.70 21.70 99.86 99.86 99.86 790434 790434 790434 Pwani 10.51 10.51 7.22 99.63 99.63 79.47 1244935 1244935 968116 Rukwa 11.61 11.61 11.61 76.81 76.81 76.81 1178359 1178359 1178359 Ruvuma 9.0 9.00 9.00 99.96 99.96 99.96 1596947 1596947 1596947 Shinyanga 37.12 37.12 37.12 99.98 99.98 99.98 1791925 1791925 1791925 Simiyu 54.84 54.84 54.84 97.28 97.28 97.28 1906861 1906861 1906861 Singida 55.25 55.25 55.25 99.90 99.90 99.90 1582819 1582819 1582819 Tabora 15.91 15.91 15.91 99.96 99.96 99.96 2740514 2740514 2740514 Tanga 35.95 35.95 32.02 99.92 99.92 70.57 2391781 2344306 1642764 Zanzibar Kaskazini Pemba 62.55 62.55 52.12 92.86 92.86 73.17 227618 227618 172365 Kaskazini Unguja 46.57 46.57 40.34 96.78 96.78 78.54 217573 217573 173696 Kusini Pemba 48.03 48.03 46.49 95.61 95.61 92.11 208270 208270 201998 Kusini Unguja 31.38 31.38 31.38 97.41 97.41 97.41 129564 129564 129564 Mjini Magharibi 58.62 58.62 58.62 98.28 98.28 98.28 730476 730476 730476 Total 52995468 53008974 51775830 Source: Buchhorn, M. ; Lesiv, M. ; Tsendbazar, N. - E. ; Herold, M. ; Bertels, L. ; Smets, B. Copernicus Global Land Cover Layers—Collection 2. Remote Sensing 2020, 12Volume 108, 1044. DOI 10.3390/rs12061044 Annexes | 63 ANNEX C. VECTOR-BORNE DISEASE SUITABILITY PER REGION — SEASON 2: OCTOBER–DECEMBER TABLE C1. Vector-Borne Disease Suitability Per Region and Vulnerable Population in the Past, Present, and Future — Season 2: October–December PERCENT AREA POPULATED, SUITABLE OVERALL SUITABILITY VULNERABLE POPULATION REGION HISTORIC 2030S 2050S HISTORIC 2030S 2050S HISTORIC 2030S 2050S Mainland Tanzania Arusha 45.04 44.97 44.39 97.19 95.21 91.31 1985570 1985570 1967922 Dar-es-salaam 89.94 89.94 89.94 99.20 99.20 99.20 563584 5635844 5635844 Dodoma 21.74 21.70 19.78 99.31 99.05 83.83 2430118 2430118 2430118 Geita 14.24 14.24 14.24 93.56 93.56 90.69 2179487 2179487 2179487 Iringa 9.45 8.82 7.93 99.80 97.07 81.96 1069239 1069239 1069239 Kagera 10.94 10.94 10.94 70.76 70.76 70.76 2796196 2796196 2796196 Katavi 16.41 15.99 5.69 95.00 90.14 56.60 683211 683211 683211 Kigoma 8.91 8.91 8.73 80.44 80.44 69.24 2500794 2500794 2500794 Kilimanjaro 36.89 36.89 36.89 99.49 99.49 99.49 1883654 1883654 1883654 Lindi 19.02 19.02 18.99 99.87 98.99 89.41 959000 959000 958896 Manyara 36.86 36.86 36.86 99.89 99.89 99.89 1688364 1688364 1688364 Mara 30.58 30.58 30.58 69.71 69.71 69.71 2028963 2028963 2028963 Mbeya 21.51 20.89 17.81 96.95 95.10 83.10 3285500 3285500 3285500 Morogoro 11.64 8.31 6.01 95.59 76.37 41.81 2593247 2593247 2461616 Mtwara 13.64 13.64 12.65 99.76 99.76 74.92 1404733 1404733 1404733 Mwanza 15.83 15.83 15.83 46.89 46.89 46.89 3194439 3194439 3194439 Njombe 21.69 21.69 21.36 99.89 99.89 97.02 790434 790434 790434 Pwani 10.71 9.93 6.71 99.66 94.34 61.92 1244935 1244935 968116 Rukwa 11.70 11.55 11.51 76.89 69.51 61.17 1178359 1178359 1178359 Ruvuma 8.94 8.89 7.77 99.96 97.42 76.14 1596947 1596947 1596947 Shinyanga 37.51 37.51 37.51 99.99 99.99 99.99 1791925 1791925 1791925 Simiyu 54.53 54.53 54.53 97.28 97.28 97.28 1906861 1906861 1906861 Singida 55.24 55.24 51.98 99.90 99.90 91.08 1582819 1582819 1582819 Tabora 15.80 15.80 8.73 99.95 99.95 52.45 2740514 2740514 2740514 Tanga 36.14 36.14 35.70 99.93 99.93 97.23 2391781 2344306 1642764 ZANZIBAR Kaskazini 227618 227618 172365 Pemba 61.91 61.91 61.91 93.36 93.36 93.36 Kaskazini 217573 217573 173696 Unguja 45.00 45.00 45.00 95.65 95.65 95.65 Kusini Pemba 49.34 49.34 49.34 94.98 94.98 94.98 208270 208270 201998 Kusini Unguja 32.11 32.11 32.11 97.94 97.94 97.94 129564 129564 129564 Mjini Magharibi 60.34 60.34 60.34 97.41 97.41 97.41 730476 730476 730476 Total 52995468 53008974 51775830 Source: Buchhorn, M. ; Lesiv, M. ; Tsendbazar, N. - E. ; Herold, M. ; Bertels, L. ; Smets, B. Copernicus Global Land Cover Layers—Collection 2. Remote Sensing 2020, 12Volume 108, 1044. DOI 10.3390/rs12061044 64 | Climate and Health Vulnerability Assessment: Tanzania ANNEX D: KEY RECOMMENDATIONS AND RELEVANT LINE MINISTRIES IN TANZANIA HIGH-LEVEL RECOMMENDATIONS RELEVANT LINE MINISTRIES WHO’S CLIMATE AND HEALTH OPERATIONAL COMPONENT • Adequately integrate health into Ministry of Health, and Social Welafre ) Leadership and Gov- climate change policies, strategies, and MoHSW); Regional Medical Officers; ernance programs at both the national and subna- District Medical Officers (DMOs); Vice tional levels. President’s Office (Division of Environ- • Strengthen climate-health coordination ment) through the establishment and financing of a National Climate Change and Health Task Force. • Develop health workforce capacity to MoHSW; Ministry of Education, Science Health Workforce manage climate-related health risks. and Technology (Division of Higher • Enhance health workforce retention Education); Medical Association of packages in areas prone to climate Tanzania (MAT); Tanzania Medical change-related hazards. Student’s Association (TAMSA) • Integrate climate and environment in- MoHSW; Epidemiology Unit; Public Health Integrated Risk formation with disease surveillance and Emergency Operations Center, Disease Monitoring and Early early warning mechanisms. Control Section; President’s Office, Warning  Regional Administrative and Local Gov- ernment (PO-RALG); Regional and Council Medical Offices; Tanzania Meteorological Agency • Advocate for climate and health MoHSW; MAT; TAMSA; Tanzania National Health and Climate research. Institute for Medical Research (NIMR); Research  Ministry of Education, Science and Tech- nology (Division of Higher Education); Higher Institutions of Learning • Advocate for strengthening climate-resil- MoHSW (Directorate of Preventative Climate Resilient and ient health and WASH infrastructure and Health Services); PO-RALG; Ministry of Sustainable Technol- technologies. Water (MoW); Rural Water Supply and ogies and Infrastruc- • Develop a WASH and climate change Sanitation Agency (RUWASA) ture  adaptation Strategy. • Reinforce public awareness on the health MoHSW; Regional and Council Medical Management of En- implications of poor sanitary and waste Offices; PO-RALG, RUWASA vironmental Determi- disposal practices, including open defe- nants of Health  cation, amidst a changing climate. • Strengthen and conduct routine health MoHSW (Directorate of Preventative Climate-informed programs, taking into consideration Health Services); Epidemiology Unit; Health Programs  past and current climate conditions, and Public Health Emergency Operations projected climate change. Center, Disease Control Section; Tanzania Food and Nutrition Center (TFNC); PO-RALG • Integrate climate-related health risks MoHSW, Ministry of Finance and Planning Climate and Health into national, regional, and local health Financing budgets. Annexes | 65 ANNEX E: CATEGORIZATION OF RECOMMENDATIONS (SHORT — LESS THAN 2 YEARS; MEDIUM — 2–5 YEARS; AND LONG TERM — MORE THAN 5 YEARS) COMPONENTS SUMMARY OF RECOMMENDATIONS Leadership and Governance Medium Term: Adequately integrate health into national climate change policies, strategies, and programs. Strengthen the coordination mechanism by establishing a National Climate Change and Health Task Force with expert representatives from different ministries and departments. Health Workforce Short Term: Develop climate and health training materials for health workers to raise awareness on the health impacts of climate change among health workers. Enhance the provision of benefits on housing or housing allowances for health workers to improve retention. Medium Term: Establish refresher courses and continuing education programs that focus on cli- mate-related health risks. Long Term: Integrate climate change and health into the national education curriculum for health training at all levels. Vulnerability, Capacity, and Short Term: Adaptation Assessment Develop a climate change health risk assessment model to guide planning, deci- sion-making, and resource allocations. Medium Term: Conduct routine national climate health impact assessments to guide policy-making decisions. Update the Human Resources for Health (HRH) country profile to help in the identifi- cation of the gaps and needs for training. Long Term: Conduct routine projections of climate-related disease burden and geographical distribution of climate-related health risks. Integrated Risk Monitoring Short Term: and Early Warning The Health Management Information System (HMIS) and the monitoring / surveil- lance should account for climate-related health risks and indicators. Integrate climate and environment information with disease surveillance and early warning mechanisms. Enhance early warning mechanisms and communication on climate change hazards among the different-level stakeholders. Map climate-related health risks to facilitate the identification of vulnerable popula- tions and their exposure to climate-related hazards. Promote a comprehensive risk assessment framework involving different-level stakeholders (researchers, health policy makers, communities, and donors) and approaches. Develop a list of key climate-related health risks and indicators for targeted monitor- ing and surveillance. 66 | Climate and Health Vulnerability Assessment: Tanzania COMPONENTS SUMMARY OF RECOMMENDATIONS Health and Climate Research Short Term: Create awareness and advocate for the importance of conducting climate and health research to attract policy makers and international donors. Strengthen communication channels between climate and health researchers and policymakers. Create mechanisms for disseminating climate and health findings and translating them into policies. Medium Term: Develop a resource mobilization strategy / plan for funds to support climate and health research. Long Term: Improve institutional capacity to conduct more climate-related health research. Climate-Resilient and Sus- Short Term: tainable Technologies and Map health facilities and assess their resilience to climate change. Infrastructure Advocate for climate-resilient health and WASH infrastructure and technologies. Medium Term: Develop a WASH and climate change adaptation strategy. Develop climate-resilient infrastructure design guidelines and implement them. Management of Environmen- Short Term: tal Determinants of Health Reinforce awareness on the health implications of poor sanitary and improper waste disposal practices, including open defecation, amidst a changing climate. Medium Term: Strengthen collaboration between different sectors, in terms of monitoring and managing climate-related health and environmental risks. MoHSW should establish coordination mechanisms to integrate health risks that are linked to environmental efforts and policies. Include health in environmental impact assessments and assessments should be enforced. Climate-informed Health Short Term: Programs Develop and disseminate awareness campaigns on climate-related health risks. Strengthen and conduct routine health programs by taking into consideration past and current climate conditions, and projected climate change. Medium Term: Need for bottom-up climate change and health initiatives to ensure the sustainability of programs and local impact. Emergency Preparedness Long Term: and Management Enhance health system resilience to climate-related hazards. Climate and Health Financing Short Term: Ensure that strategic purchasing includes climate-related health risk considerations. Medium Term: Set up a detailed mobilization plan for resources to support climate-related emergency responses. Advocate for the allocation of funds to strengthen the health sector’s resilience to climate-related hazards. Ensure that climate-related health risks are integrated into national, regional, and local programs, along with associated budgets. Annexes | 67 ANNEX F: MENU OF ADAPTATION RECOMMENDATIONS   FOOD SECURITY AND VECTOR-BORNE WATERBORNE HEAT-RELATED AIR QUALITY DIRECT INJURIES MENTAL HEALTH NUTRITION   DISEASES (VBDS)  DISEASES (WBDS) MORBIDITY AND AND MORTALITY AND WELL-BEING  MORTALITY Leadership • Enhance coordina- • Need for • Promote • Integrate heat • Strengthen the •   • Integrate and Gover- tion among subna- collaborative coordination adaptation enforcement of air climate change nance tional, district, and efforts in the efforts in the strategies into quality standards. impacts on community levels for development development national and mental health • Coordinate the improved imple- and adaptation and adaptation subnational and wellbeing climate and air mentation of climate of control and of control and health policies. into health quality policies. change, agriculture, prevention prevention policies and food security, and mechanisms mechanisms strategies. nutrition policies and to address to address programs. climate change climate change impacts on impacts on VBDs. WBDs. 68 | Climate and Health Vulnerability Assessment: Tanzania Health • Integrate climate • Enhance • Improve the • Enhance • Develop on- • Improve the • Training of workforce  change impacts on health training of the health the-job training capacity of more health food security and workforce the health workforce materials and community workers to nutrition into health training on the workforce on training on the refresher courses health workers manage workforce training. increased risk the impacts management to facilitate the (CHWs) to mental health of VBD burden of climate of heat-related improved man- better manage and wellbeing in new regions change illnesses. agement of air direct injuries, issues. due to climate on WBDs, quality-related including change. including illnesses. training, facili- water san- tation, and the itation and provision of hygiene sufficient first (WASH). aid kits. Vulner- • Enhance the • Support com- •  Enhance • Improve • Strengthen • Improve • Develop ability, vulnerability and munity-based assessments community assessments assessments assessments capacity, adaptation assess- adaptation to quantify the capacity and to quantify the to quantify the to quantify and adap- ment to evaluate measures to magnitude resilience to magnitude of magnitude of climate change tation as- the extent of climate address VBDs. of climate hot conditions climate change the impacts impacts on sessment  change impacts on change by conducting impacts on air of climate mental health food security and impacts on routine adap- quality deterio- hazards on and wellbeing, nutrition. WBDs. tation assess- ration and health direct injuries as well as the ments and risks. and mortali- most at-risk disseminating ties, as well populations. findings. as vulnerable populations.   FOOD SECURITY AND VECTOR-BORNE WATERBORNE HEAT-RELATED AIR QUALITY DIRECT INJURIES MENTAL HEALTH NUTRITION   DISEASES (VBDS)  DISEASES (WBDS) MORBIDITY AND AND MORTALITY AND WELL-BEING  MORTALITY Integrat- • Ensure the timely • Promote • Integrate • Improve heat • Enhance the • Improve • Enhance ed risk dissemination and a holistic climate data and heat wave integration of climate climate monitoring communication of approach to into WBD sur- recording climate data con- change EWS change EWS and early early warning infor- the climate risk veillance and / data to siderations into air and the timely to facilitate warning  mation to facilitate a management monitoring to support quality monitoring communica- community timely and effective of VBDs that inform policy robust heat and management. tion of weather and household    food security involves health and practice. early warning information preparedness response. policy makers, systems (EWS) to facilitate and response, researchers, for regions community including and communi- most at risk and household the effective ties. of heat waves preparedness dissemination now and in the and response of climate future. to prevent change direct injuries information and mortali- on extreme ties. events. Health and • Strengthen the • Enhance • Support • Promote • Advocate for • Enhance climate financial mobiliza- research research (both research research to research on research  tion plan for funds initiatives applied and initiatives (both advance the mental health to support climate (both applied targeted) for applied and understanding and wellbeing,    change, agriculture, and targeted) WBDs and targeted) for of the impacts of especially food security, and for VBDs and population heat risk in climate change in climate nutrition research communi- groups / communities on air quality change prone in order to inform ties with the communities experiencing (both indoor and regions and policies and highest risk of most at risk of heat waves ambient). communities. programs at the VBDs. WBDs. now and in the national, subnation- future. al, and local levels. Climate- • Improve labo- • Improve labo- • Integrate heat • Support clean • Implement resilient ratory capabil- ratory capabili- adaptation and sustainable climate change and sus- ities ties (laboratory strategies into energy like clean infrastructure tainable equipment infrastructure cooking and planning, • (laboratory technolo- and supplies) (including lighting options roads with equipment gies and to facilitate health facil- in health facilities, proper and supplies) infrastruc- the detection, ities), urban households, and drainage, and to facilitate ture  diagnosis, and planning, and schools (use of strict building the detection, treatment of landscape. solar for lighting standards. diagnosis, and WBDs. and energy saving treatment of stoves). VBDs. Annexes | 69   FOOD SECURITY AND VECTOR-BORNE WATERBORNE HEAT-RELATED AIR QUALITY DIRECT INJURIES MENTAL HEALTH NUTRITION   DISEASES (VBDS)  DISEASES (WBDS) MORBIDITY AND AND MORTALITY AND WELL-BEING  MORTALITY Manage- • Strengthen commu- • Strengthen • Enhance • Inclusion of • Promote planting • Plant trees and • Plant drought ment of nity-led sustainable community WASH facilities heat ad- of trees to collect grass to hold tolerant trees environ- food security options awareness in health aptation in dust and smoke the soil during for shade mental de- and food insecurity on climate facilities and communal particles heavy rains during hot terminants mapping, especially change communities, building plans to prevent days. • Promote the of health  in regions prone to impacts on especially in mudslides and • Planting of use of clean climate change now VBDs and flood-prone flooding. drought-toler- and sustainable and in the future. prevention areas. ant trees. energy, such as action options, clean cooking and including the lighting options in disposal of health. facilities, empty con- households, and tainers near schools (use of homes and 70 | Climate and Health Vulnerability Assessment: Tanzania solar for lighting the clearing and energy saving of vegeta- stoves. tion close to homes. Climatein- • Need for bottomup • Strengthen • Strength- • Integrate • Diversify formed climate change, community en health heat data livelihoods to health agriculture, food awareness promotion into health reduce de- program  security and nutrition on climate campaigns programs, pendency on initiatives to ensure change on the con- including agriculture. the sustainability of impacts on struction of reproductive • Enhance programs and local VBDs and pit latrines, and maternal climatesmart impact. prevention the proper health, mental agriculture, es- action options, disposal of health, along • Improve the pecially in rural including wastes, hand with food awareness of areas prone the disposal washing, security and communities and to prolonged of empty along with the nutrition. extension workers droughts. containers and boiling and on climate change the clearing of storage of and food security bushes near drinking water. and nutrition homes, as well policies. as sleeping under treated mosquito nets.   FOOD SECURITY AND VECTOR-BORNE WATERBORNE HEAT-RELATED AIR QUALITY DIRECT INJURIES MENTAL HEALTH NUTRITION   DISEASES (VBDS)  DISEASES (WBDS) MORBIDITY AND AND MORTALITY AND WELL-BEING  MORTALITY Emergency Promote communi- Enhance Strength- Enhance heat Implement Incorporate prepared- tyled programs on knowledge on en WASH illness preven- community climate change ness and food storage systems climate change emergency pre- tion programs awareness impacts on manage- for improved food impacts on paredness and to support the campaigns on mental health ment  security. VBDs. response plans adaptation and preparedness into community and strategies. resilience of and response programs.    Incorporate communities to before floods to climate change extreme heat. reduce mortali- information into ties and injuries. VBD control plans. Climate Strengthen the Enhance gov- Strengthen Promote funding Advocate for Increase Explore funding and health resource mobiliza- ernment and funding to and the need funding and funding to opportunities for financing  tion plan for funds partner funding support WBD for the inclusion budgeting for air support disaster mental health to support food for prevention, programs, of heat risk quality initiatives, response and research and    insecurity, emergency control, surveil- including water programs in including research, preparedness programs. responses, as well as lance, treatment testing, WBD national and sub- control, and adapta- efforts. programs, and surveillance, and national budgets. tion mechanisms. agriculture, food research to WASH programs. security, and nutrition reduce VBDs initiatives. burden.    Annexes | 71 REFERENCES 1 https://www.climatelinks.org/sites/default/files/asset/ trends-variability-historical. document/20180629_USAID-ATLAS_Climate-Risk-Profile-Tanzania.pdf. 28 Lonnie G. 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