Climate and Health Vulnerability Assessment CLIMATE AND HEALTH VULNERABILITY ASSESS- MENT ETHIOPIA ETHIOPIA CLIMATE INVESTMENT FUNDS © 2024 International Bank for Reconstruction and Development/The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory, or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. 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ETHIOPIA Climate and Health Vulnerability Assessment CLIMATE INVESTMENT FUNDS CONTENTS ACKNOWLEDGMENTS................................................................................................................. vii LIST OF ABBREVIATIONS........................................................................................................... viii EXECUTIVE SUMMARY.................................................................................................................. 1 Climatology ............................................................................................................................................................ 1 Climate-Related Health Risks ............................................................................................................................. 1 Adaptive Capacity of the Health Systems....................................................................................................... 2 SECTION I. INTRODUCTION..........................................................................................................5 Country Context.................................................................................................................................................... 5 Aims of this assessment and conceptual framework ....................................................................................7 SECTION II. CLIMATE CHANGE: OBSERVED TRENDS AND PROJECTIONS.........................11 Ethiopia’s geography............................................................................................................................................11 Observed and projected climatology .............................................................................................................12 Temperature ...........................................................................................................................................................13 Precipitation ............................................................................................................................................................15 Climate-related Hazards.....................................................................................................................................16 Drought.....................................................................................................................................................................16 Floods........................................................................................................................................................................ 17 Landslides ...............................................................................................................................................................18 Extreme heat...........................................................................................................................................................19 SECTION III. CLIMATE-RELATED HEALTH RISKS...................................................................... 21 Nutrition and Food Security Risks...................................................................................................................22 Vector-Borne Disease Risks.............................................................................................................................26 Water-borne and water-related diseases .....................................................................................................29 Heat related mortality and morbidity..............................................................................................................30 Air Quality..............................................................................................................................................................31 Mental Health and Wellbeing...........................................................................................................................32 SECTION IV. ADAPTIVE CAPACITY OF THE HEALTH SYSTEM..............................................37 Health system overview.................................................................................................................................... 37 Leadership and governance.............................................................................................................................39 Health workforce.................................................................................................................................................42 Health information and disease surveillance................................................................................................ 43 Essential medical products and technologies..............................................................................................45 Health service delivery......................................................................................................................................45 Financing...............................................................................................................................................................48 iv | Climate and Health Vulnerability Assessment: Ethiopia SECTION V. 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..................................................54 Component 8: Climate-informed health programs......................................................................................54 Component 9: Emergency preparedness and management....................................................................54 Component 10: Climate and health financing...............................................................................................54 REFERENCES................................................................................................................................ 55 ANNEXES....................................................................................................................................... 59 Annex A. Adaptive Capacity and Climate Change-Related Health Risks Gap Analysis ....................59 Annex B. Health Adaptation Recommendations: Menu of Options..........................................................61 Annex C. Adaptive Capacity Rapid Assessment .........................................................................................63 Annex D. Long list of recommendations .......................................................................................................66 Annex E. Methods for the estimation of mosquito suitability under RCP 8.5 in Ethiopia.................... 72 Annex F. Observed and Projected Temperature and Precipitation Changes in Ethiopia.................... 75 LIST OF FIGURES Figure 1. Population Density in Ethiopia, 2020........................................................................................................6 Figure 2. World Health Organization (WHO) operational framework for climate-resilient healthcare systems.........................................................................................................................................................8 Figure 3. Administrative boundaries of Ethiopia.....................................................................................................9 Figure 4. Physiographic regions of Ethiopia.......................................................................................................... 12 Figure 5. Observed and projected average monthly temperature and precipitation patterns in Ethiopia under SSP3-7.0.............................................................................................................................................. 14 Figure 6. Projected temperature anomaly for 2020-2039 and 2040-2059 under SSP3-7.0................... 14 Figure 7. Annual mean precipitation, observed (1991-2020).............................................................................. 16 Figure 8. Projected precipitation anomaly for 2020-2039 and 2040-2059 under SSP3-7.0....................17 Figure 9. Rainfall triggered landslide....................................................................................................................... 19 Figure 10.Stages of the food system that drive healthy and sustainable diets............................................ 22 Figure 11. Ethiopia: Acute Food Insecurity projected outcomes, December 2022-January 2023 and February-May2023 [36]...................................................................................................................................... 25 Figure 12. Malaria Risk Map, 2020........................................................................................................................... 27 Figure 13. Comparison of suitable area for malaria vector species in Ethiopia under RCP 8.5, across three epochs: 1986-2005 (historical baseline), 2020-2039, and 2040-2059............................... 27 Figure 14. Ethiopia Health Tier System....................................................................................................................37 Figure 15. WHO Health System Building Blocks ................................................................................................. 38 Contents | v Figure 16. Timeline of Ethiopia’s Climate Change Policies................................................................................ 40 Figure 17. Evaluation of Ethiopia HIS across five health sector components............................................... 44 Figure 18. Public health responses to malaria warning and required types of predictions...................... 45 Figure 19. Population distribution and location of hospitals, 2020................................................................. 46 Figure 20. WHO’s Operational Framework for Building Climate-Resilient Health Systems ..................... 51 LIST OF TABLES Table 1. Annual number of hot days (TMax >35°C), tropical nights (Tmin > 20°C), and summer days (Tmax > 25°C) in the 2030s and 2050s under SSP3-7.0 in Ethiopia and key regions.......................15 Table 2. Under 5 Child stunting, wasting and mortality rates by sub-national units...................................24 Table 3. Percent suitable habitat area, by region, for malaria vector species in Ethiopia under RCP 8.5 through mid-century....................................................................................................................................28 Table 4.Summary of the Climate Change Risks on Health Outcomes........................................................... 34 Table 5. Assessment of key climate change and health related policies.......................................................41 Table 6. Public health facilities accessed electricity and improved water sources by region, 2014...... 47 Table 7. Summary of the Health System Adaptive Capacity Gaps for Ethiopia ...........................................50 Table A1. Model parameterization and data sources for habitat characterization...................................... 72 Table A2. Copernicus Global Land Cover Layers: CG:S-LC100 Collection 2 global landcover map classifications....................................................................................................................................................... 73 vi | Climate and Health Vulnerability Assessment: Ethiopia 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 Ethiopia 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 Claire Bayntun, Christopher Boyer, Mikhael Iglesias, Adugna Woyessa, Stephen Dorey, and Tamer Rabie. The authors sincerely appreciate the valuable contributions provided by Ana Lucrecia Rivera-Rivera, Muloongo Simuzingili, Judith Namanya, April Frake, and Roman Tesfaye. 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 CHVA Climate and Health Vulnerability Assessment COPD Chronic Obstructive Pulmonary Disease CRGE Climate Resilient Green Economy CRHS Climate-resilient health system CSA Central Statistics Agency DALYs Disability-adjusted Life Years DHIS2 District Health Information System (2) EMI Ethiopian Meteorological Institute ENSO El Niño-Southern Oscillation EPA Environmental Authority EPHI Ethiopian Public Health Institute GCM General circulation models GDP Gross Domestic Product GEF Global Environmental Facility GHG Greenhouse Gas GTP II Second Growth and Transformation Plan HAP Household air pollution HEP Health Extension Programme HCF Healthcare facility INDC Intended Nationally Determined Contributions LDC Least Developed Countries NCDs Non-communicable Diseases NDC Nationally Determined Contributions NHAP National Health Adaptation Plan NTDs Neglected Tropical Diseases MoH Ministry of Health PHEM Center for Public Health Emergency Management SAM Severe Acute Malnutrition SOP Standard Operating Procedures SSP Shared Socio-economic Pathways TWG Technical Working Group UHI Urban Heat Island UNFCCC United Nations Framework Convention on Climate Change V&A Vulnerability and Adaptation VBD Vector-borne disease WaSH Water, Sanitation, and Hygiene WBG World Bank Group WHO World Health Organization WMO World Meteorological Organization viii | Climate and Health Vulnerability Assessment: Ethiopia EXECUTIVE SUMMARY Ethiopia faces significant climate-related challenges that will directly influence population health outcomes. Climate change, coupled with human-induced health stressors, exacerbates existing health burdens, and creates new health risks. Changes in temperature and precipitation patterns affect the country and burden a variety of climate-sensitive health risks while simultaneously impacting the functioning and capacity of Ethiopia’s health system. Challenges that increase Ethiopia’s vulnerability to adverse health outcomes associated with climate change include the wide range of climate hazards that affect the country due to its strong dependency on rainfed agriculture, which is susceptible to regular climatic shocks, ongoing population growth, and chronic and widespread undernutrition. CLIMATOLOGY Mean annual temperatures have been increasing, with the highest rates of warming observed in the central and highland areas and are projected to increase significantly in the eastern regions of Somali and Afar and the western region of Gambela. Precipitation, on the contrary, has been declining with significant year-to-year variations. Future projections of precipitation, however, show a slight increase in national average annual precipitation rates as short and intense rainfall events increase in frequency. Continued warming trends, however, will likely exacerbate seasonal and regional declines in rainfall, further increasing the intensity and frequency of drought events and affecting the Tigray, Afar, and Somali regions. The Afar and Somali regions, along with Gambela and Beneshangul Gumu, will also be affected by extreme heat (days at > 35°C and nights at> 20°C). High deforestation rates and increased extreme rainfall will continue to trigger soil erosion, reduce soil fertility, and increase rainfall-trigger landslides, particularly in the eastern Tigray region, along the Amhara region. CLIMATE-RELATED HEALTH RISKS Some health outcomes affected by climatic factors will be of extreme concern. The Afar, Somali, and Gambela regions are likely to experience increases in the number of hot days (TMax > 35°C) and tropical nights (>20°C) exposing roughly 13.3 million people to potentially life-threatening temperatures with implications on the health of those populations, particularly vulnerable groups such as pregnant women, children under five years of age, people over 65 years. Food insecurity, for example, will continue due to acute shocks and chronic changes in climate projections. Precipitation is projected to decrease, worsening drought and consequently affecting those who rely on rain-fed agriculture and livestock production. Many southern and south-eastern pastoral areas experienced lower-than-normal pasture and water availability, which will cause significant food and income loss. Smallholder farmers, who represent most of the rural population and produce more than 90 percent of total agricultural output, 1 will be severely impacted, especially in areas of both diseases breed in small water pools already overburdened with high undernutrition, in discarded utensils adjacent to households. such as Tigray, Afar, and Somali regions. Ethiopia Since 2013, dengue fever cases have increased has one of the highest levels of food insecurity in due to repeated outbreaks reported in eastern the world, and children (<5 years) will continue to Ethiopia, with peak high malaria prevalence be one the most affected groups. The Amhara, observed between September and November. Benishangul-Gumuz, Affar, and Dire Dawa regions Slight increases in the number of consecutive are the most affected by child stunting, whereas dry days are projected in the Somali region, wasting imposes the heaviest burden in Somali, particularly between the months of Septem- Afar, and Gambela areas. Child mortality continues ber-October, which are historically considered to be high, particularly in Addis Ababa and Afar. high malaria transmission months. Suitability for Additionally, climatic shocks and compounding malaria vectors through mid-century will remain factors, such as conflict, desert locust invasions, unchanged throughout the country as projected and the COVID-19 pandemic, continue to drive temperature increases will not exceed the thermal up food and nutrition insecurity and prices of tolerance of malaria vector species. Only in the staple foods in Ethiopia, increasing levels of Somali region, during the 2030s and 2050s, malnutrition, already affecting an estimated 18 will temperature increase limit vector survival; million people. however, hot spots will remain, particularly in Hadiya, Metekel, and South Gonder districts. Increases in the intensity of rainfall events will Extreme weather events are becoming more continue to cause flash, groundwater, and sewer frequent and intense in Ethiopia, potentially flooding, worsening hazards for human health. leading to an increased risk of elevated rates of The East Africa sub-region is projected to be the mental disorders. Moreover, research shows that worst impacted during and after El Niño events, mental health conditions attributed to extreme increasing cholera deaths, particularly in children weather events increased, impacting a larger below 15 years old. Projected increases in warm fraction of the population affected by natural temperatures, increases in intense periods of disasters. The destruction of landscape, such precipitation, and shifting patterns of rainfall as through severe flash flooding, diminishes the will increase the proliferation and persistence sense of belonging and comfort people derive of pathogens, making managing and sustained from their connectedness to the land. control of outbreaks challenging. Addis Ababa, for example, already experiences the most precipita- tion in the country, and with projected increases ADAPTIVE CAPACITY OF THE in rainfall, mean temperatures, and population, will likely experience increased episodes of HEALTH SYSTEM diarrheal diseases. More intense droughts are The Government of Ethiopia is aware of the also associated with reduced water quality and potential negative impacts of climate change and disease outbreaks. has been actively developing policies and plans to support mitigation and adaptation actions, as The lack of fresh rain during droughts prevents well as signing onto international and regional the opportunity to flush out stagnant waters. initiatives. Health is highlighted as a priority area, Because of the overlapping feature of the epide- second in number only to agriculture and climate miology of dengue fever and malaria, vectors service/disaster risk reduction, with six adaptation 2 | Climate and Health Vulnerability Assessment: Ethiopia interventions focusing on vector-borne diseases not yet implemented mental health services as (malaria), water-borne diseases (cholera), and part of integrated services. Identified barriers to adequately resourced healthcare facilities with implementation include low political commitment, safe water and sanitation and reliable electricity. shortage of resources, non-functional referral Ethiopia also has social protection policies to deal system, lack of interest from private health service with the post-recovery of disaster victims through organizations, attitudinal problems from the society establishing a community-based social security and service providers, and lack of consistent fund. At the sub-national, however, health-focused reporting system of the mental health problems. climate change adaptation planning is limited. Overall, Ethiopia has seen significant advance- The MoH has made strides to enhance its response ments in health service delivery in the last two to extreme weather events and other public health decades, resulting in improvements in several emergencies. Still, many existing health facilities health outcomes. However, access to health are not equipped with the needed equipment, services tends to disproportionately benefit those trained health professionals, and essential with greater economic means or higher levels infrastructure, such as safe and reliable water of education, despite governmental efforts to supply, electricity, means of communication, and overcome financial barriers, such as subsidiza- adequate medical storage conditions, leaving tion of more than 80 percent of the cost in public many healthcare facilities exposed to climate health facilities and community-based insurance change-related disasters. There are also issues schemes. Over the last two decades, total health with procurement, maintenance, and inventory expenditure has been low and declining, while management of medical equipment, along with out-of-pocket expenditure has been higher than a gap in testing the efficacy of generic drugs public health expenditure. Ethiopia has scaled up produced in Ethiopia due to a lack of bioequiv- a community-based health insurance program, alence centers. but risk pooling does not account for climate and health-related risks. Access to healthcare can still Simultaneously, climate change impacts the health be challenging for some areas of the country, with workforce and may affect their ability to reach thousands of people living over 150 km away the facility and be unable to respond to climate from a hospital, such as in the Oromia region. hazards. Additionally, the healthcare system lacks enough medical doctors and nurses, particularly Climate financing is low and shows a huge gap in in rural or remote areas. Current salaries of health budgeted versus actual spending. The majority of workers are low and with irregular payments. Health financing for the climate is focused on adaptation workers also lack adequate labor conditions. This activities. Ethiopia faces a huge financing gap has triggered the out-migration of skilled health to respond to climate change. Additionally, workers. Although specialty training programs climate expenditure was mainly concentrated have been developed to enhance retention in the Ministry of Agriculture and the Ministry of strategies for the nursing workforce, these have Water, Irrigation, and Energy. Although there was proved insufficient. There are no details if these an increase in climate-related expenditure by the programs integrated climate-related health risks. Ministry of Health, the expenditure on climate is There are no reports on the number of psychia- low. Ethiopia relies heavily on donor funds, yet trists, psychologists, or nurses with mental health these funds are off-budget and hard to track. training. Additionally, the Ministry of Health has Executive Summary | 3 RECOMMENDATIONS Based on climate and health systems synthesis, this document recommends the following actions to assist decision-makers with planning effective adaptation measures to address climate-related health risks: → Integrate health climate adaptation planning at all administrative levels, which includes formalizing and resourcing the National Climate Change and Health Technical Working Group led by the Ministry of Health and enhance climate-related communications for government officials and the general public. → Develop climate-related educational and training materials and implement training for healthcare workers that would allow them to understand the health impacts of climate change. → Support climate-health-related research to develop surveillance of climate-sensitive diseases, climate- informed early warning systems, and response mechanisms and guide future vulnerability adaptation assessments. → Improve healthcare accessibility to these facilities by enhancing the transportation network to ensure access to facilities during extreme weather events. → Enhance the health system resilience via the development and implementation of national building codes/permits, which would consider sustainable energy (e.g., solarization of healthcare facilities) and water supplies, storm drains and sewers, and sanitation services. → Develop regulations that support sustainable healthcare waste management and policies on key environmental health services and determinants; this could include establishing and maintaining a climate and environmental health database to support these regulations that would allow for multi- sectoral engagement and inform disease control and prevention programs ahead of potential extreme weather events. 4 | Climate and Health Vulnerability Assessment: Ethiopia SECTION I. INTRODUCTION COUNTRY CONTEXT 1. Ethiopia, located in the horn of Africa, is the second most populous country in Africa with total population estimated as roughly 110 million people. Ethiopia’s Human Development Index (HDI) value for 2019 was 0.485 [1], positioning the country in the low human development category (rank 173 out of 189). However, this figure doubled when compared to the 2000 HDI, 0.292. HDI of Ethiopia in 2018 was below the average of both the low human development group countries and countries in Sub-Saharan Africa, 0.513 and 0.547, respectively [1]. It is predom- inantly a young demographic, in which children below five years of age account for 14.6 percent of the population. Data is limited on educational attainment for the total population. Among the total urban population aged 10 years and above, 81.8 percent were found to be literate. The proportion of literate males are higher than that of the females, 89.2 percent versus 75.2 percent, respectively. Half of the literate attained elementary education (Grade 1-8) [2]. 2. Ethiopia’s population is growing rapidly with 3. Ethiopia’s gross domestic product (GDP) one of the fastest rates in the world at 3.02 grew by 6.1% in 2020 [6]. The annual GDP was percent per year. At this rate, the population US$ 107.65 billion in 2021, with unemployment will reach 210 million by 2060, doubling the at 3.1 percent of total workforce [6]. Ethiopia is current population size [3]. This is similar in 174th position among the poorest of the 196 to other projections which have suggested countries according to their GDP per capita. that the Ethiopian population is projected People living in multi-dimensional poverty in to reach 133.5 million in 2032, and 171.8 in Ethiopia is 58.5 percent [1]. Over 45 percent of 2050 [4]. Population density across the country Gross Domestic Product (GDP) and 80 percent varies substantially and depletion of natural of exports comes from agriculture, which also resources might occur as the livelihood of accounts for 83.4 percent of the labor force. most of the rural community is reliant on the The population is predominantly rural with natural environment. The central highlands nearly 80 percent living in rural areas, mainly from north to south have the highest population based on subsistence agriculture [2]. density, while the north-eastern, southern and south-eastern pastoral low land areas are less densely inhabited (Figure 1) [5]. 5 FIGURE 1. Population Density in Ethiopia, 2020 Source: Oak Ridge National Laboratory 4. Ethiopia faces significant climate-related a strong dependency on rainfed agriculture challenges that will directly influence that is susceptible to regular climatic shocks, population health outcomes. Coupled with ongoing population growth, and chronic and human-induced health stressors, climate widespread under-nutrition. change exacerbates existing health burdens as well as creating new health risks. Changes 5. Ethiopia is committed to meeting the climate in temperature and precipitation patterns challenge through both adaptation and affect the country and burden of a variety of mitigation measures. Ethiopia ratified the climate-sensitive health risks while simultane- Paris Agreement in 2017, which aims to limit ously impacting the functioning and capacity of global mean temperature increase to well Ethiopia’s health system. Compounding these below 2°C compared to pre-industrial levels challenges, climate exacerbates health and and has developed several policy frameworks economic inequalities that are not uniformly that aim to reduce the country’s vulnerability distributed, which can significantly affect to climate change related impacts, including to population health risks. Challenges that human health outcomes. Adaptation is a high increase Ethiopia’s vulnerability to adverse priority for the country due to the climate-re- health outcomes associated with climate lated hazards that already pose significant change include the wide range of climate risks. Section IV of this assessment highlights hazards that affect the country due to its the key steps adopted by the government diverse geography (e.g., floods and droughts), of Ethiopia to meet its climate change goals. 6 | Climate and Health Vulnerability Assessment: Ethiopia AIMS OF THIS ASSESSMENT AND 8. Investment in adaptation strategies to proactively address the effects of climate CONCEPTUAL FRAMEWORK change on health outcomes is critical. This 6. The objective of this Climate and Health assessment outlines climate risks to health, Vulnerability Assessment (CHVA) is to the adaptive capacities that are in place to synthesize current research evidence and deal with these risks, and recommendations review relevant government documents to meet identified gaps. The primary focus to assist decision makers with planning of this assessment is, therefore, on climate effective adaptation measures to address adaptation and resilience measures. However, climate-related health risks. Where available, as the Intergovernmental Panel on Climate these measures are provided at a sub-national Change (IPCC’s) Assessment Report Six (AR6) level to assist regional health planners. The makes clear ‘Global surface temperature recommendations of this CHVA are primarily will continue to increase until at least the aimed at Ethiopia’s Ministry of Health, but mid-century under all emissions scenarios also include other ministries whose actions considered’ [7]. Mitigation alone is no longer a can influence the health risks from climate, sufficient strategy regardless of the pace with such as disaster risk management, agriculture, which governments and communities around and natural resources and climate change. the world act. Adaptation is now as critical a part of climate action as mitigation. Therefore, 7. Adaptation priorities need to be accompanied this report focuses on adaptation measures, but by fundamental and urgent action to mitigate where possible, also includes recommenda- climate change. It is important to stress tions that reduce GHGs or facilitate decoupling how complex the climate challenge is and of emissions from progress towards human how hard it is to predict exactly how severe health goals. climate exposures facing populations will become. There are many factors that could 9. The World Health Organization’s (WHO) slightly slow or significantly speed up rates operational framework for building climate- of change including positive feedback effects resilient health systems [8] is adopted to and cascading climatological tipping points analyze the adaptive capacity to adequately which are the most worrisome. For this reason, deal with current and future identified mitigating existing greenhouse gas emissions risks. Following this framework (Figure 2) (GHGs) and developing and implementing the adaptive capacity section of this CHVA is measures to protect human health from the first structured around the six Health System changing climate is of paramount importance. Strengthening (HSS) building blocks. These Mitigation alone is no longer a sufficient strategy regardless of the pace with which governments and communities around the world act. Adaptation is now as critical a part of climate action as mitigation. Introduction | 7 FIGURE 2. World Health Organization (WHO) operational framework for climate-resilient healthcare systems [8] LIMATE RESILIENCE C hip & Heal eaders nce Workf th L verna orce Go V uln pac ation t Fin alth & A Ca apt men He ate era ity & Leadership As g d ss Clim cin bil & Governance Health se ity, an Workforce Financing P paredness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS e Service r 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 Re s il f C li m a l e 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 s tr u & Infra six categories encompass the assessment of to reduce climate-related health vulnerability capacities and gaps, now and into the future. in Ethiopia. The CHVA is based on a review The CHVA then moves on to consider the of the published literature, national statistics, 10 components of health system climate and consultations with key counterparts in resilience. government and at the Ethiopian Public Health Institute, with individuals specializing in climate 10. The CHVA follows a stepwise linear approach. and health risks. The first step characterizes the climatology in Ethiopia highlighting the observed and 11. The CHVA incorporates sub-national consid- future climate exposures relevant to health. eration for health-related climate action. The second step examines climate-related Ethiopia’s administration is classified into health risks including identifying vulnerable regional states that again sub-divide into zones populations most at risk. The final step assesses and districts, locally called Woreda (Figure 3). the adaptive capacity of the health system Woredas are the implementing organ of the identifying gaps to manage current and future Government, and are themselves comprised climate-related health risks. Together these of Kebeles, the smallest administrative unit. steps inform a series of recommendations 8 | Climate and Health Vulnerability Assessment: Ethiopia FIGURE 3. Administrative boundaries of Ethiopia Source: World Bank Cartography Unit Introduction | 9 SECTION II. CLIMATE CHANGE: OBSERVED TRENDS AND PROJECTIONS 1. This section describes observed climatic changes and projected climate trends, highlighting the priority climate-related hazards in relation to human health risks in Ethiopia. Climate information is taken from the World Bank Group’s Climate Change Knowledge Portal (CCKP) where historical, observed data is derived from the Climatic Research Unit, University of East Anglia (CRU). Climate data used in the World Bank Group’s CCKP is derived from CMIP6, the Coupled Model Inter- comparison Project, Phase 6. The CMIP efforts are overseen by the World Climate Research Program and CMIP6 is the foundational data used to present global climate change projections presented in the Sixth Assessment Report (AR6) of the Intergovernmental Panel on Climate Change (IPCC). CMIP6 relies on the Shared Socioeconomic Pathways (SSPs), which represent possible societal development and policy scenarios for meeting designated radiative forcing (W/m2) by the end of the century. Scenarios are used to represent the climate response to different plausible future societal development storylines and associated contrasting emission pathways to outline how future emissions and land use changes translate into responses in the climate system. This assessment explores observed climate conditions for the latest climatology, 1991-2020 and projected climate conditions and changes under SSP3-7.0 for the near (2030s; 2020-2039) and medium term (2050s; 2040-2059). ETHIOPIA’S GEOGRAPHY Ethiopia is cleaved into eastern and western escarpments with high and uneven plateaus 2. Ethiopia is a land locked country located and peripheral lowlands by the Great African within 3.3°N-15°N and 33°E-48°E, in the Horn Rift Valley. The topography gradually slopes of Africa. It has a land mass of 1.14 million square kilometers [9]. The country has a up from the lowland edges of Rift Valley to diverse landscape affecting its climate, ranging the eastern and western escarpments into from equatorial rainforest with high rainfall and the southern, central, western and northern humidity in the south and southwest, to the mountains [10]. Along with wide plateaus, there Afro-Alpine on the summits of the Simien and are mountains which are typically 1,500-3,000 Bale Mountains, to desert-like conditions in meters above sea-level, with some peaks over the north-east, east and south-east lowlands. 3,500 meters. Overall, Ethiopia is considered 11 largely arid, but exhibits a high variability of OBSERVED AND PROJECTED precipitation. Ethiopia has three homogeneous geographic categories - (i) north-western CLIMATOLOGY highlands and associated lowlands, (ii) south- 4. Ethiopia’s climate is strongly influenced eastern highlands and associated lowlands, by its varied topography and the seasonal and (iii) the Ethiopian Rift Valley [10]. (Figure 4). movement of the Intertropical Convergence Zone (ITCZ), which produces tropical, 3. Ethiopia’s rivers originate in the highlands subtropical, and temperate regions, each and flow outward in through an array of featuring a range of precipitation conditions deep gorges. Most notable of these is the (Figure 4, also see Annex F on observed Blue Nile, the country’s largest river. In the and projected temperature and precipita- northern half of the Great Rift Valley flows the tion changes by subnational unit). The Kolla Awash River, on which the government has or hot zone describes areas <1500 meters built several dams to generate power and in elevation, which align with the tropical irrigate major commercial plantations. The zones classified by Sayre et al. as having Awash flows east and disappears into the mean annual temperatures of 24-34°C [149]. saline lakes near the border with Djibouti. The These areas include the arid east, the Denakil Genale and Shebele rivers and their tributaries Depression, and the Blue Nile Valley, among drain the southeast, and the Omo drains the other peripheral lowlands in the south and southwest [11]. west [11]. The Weina Dega or temperate zone FIGURE 4. Physiographic regions of Ethiopia Source: Woldemariam M (1972). An introductory geography of Ethiopia. 215 Pp. Addis Ababa. 12 | Climate and Health Vulnerability Assessment: Ethiopia encompasses parts of the northwest, central, TEMPERATURE and southeastern highlands with elevations 6. Mean annual temperature in Ethiopia has 1500-2400 m, such as the capital Addis Ababa, increased by 1°C since 1960, an average Hareri, and most major cities in the highlands rate of 0.25°C per decade, with the most [11]. Sayre et al. distinguish between warm notable increases observed from July through temperate zones with mean annual tempera- September [13]. The average number of “hot” tures of 10-18°C and subtropical zones with nights (the hottest 10 percent of nights annually) mean temperatures of 18-24°C, which char- increased by 37.5 percent between 1960 and acterize many of Ethiopia’s subnational units’ 2003, while the average number of hot days mix of both temperate highlands and tropical per year increased by 20 percent [14]. At the lowlands. sub-national level, higher rates of warming have been observed in the central regions 5. Ethiopia has three rainfall seasons – Bega, and highland areas [15]. Belg, and Kiremt – that are characterized by different durations and intensities 7. Mean monthly temperatures in Ethiopia are according to region and are also subject projected to increase by 0.7°C by the 2030s, to high interannual variability. Mean annual 1.5°C by the 2050s, and 3.1°C by end of the precipitation in Ethiopia can range from less century, under a high emissions scenario than 450mm in Afar and Somali to more than (SSP3-7.0) when compared with the historic 1,150mm in Beneshangul Gumu, SNNPR, and reference period (1995-2014) [13] (Figure 5). Addis Ababa. The primary rainy season, Kiremt, This will result in corresponding increases typically occurs from mid-June to mid-Sep- in projected mean annual temperature of tember and accounts for 50–80 percent of 24.8°C by the 2030s, 24.6°C by the 2050s, annual rainfall. Parts of central and northern and 26.0°C by the end of the century with the Ethiopia (Addis Ababa, Amhara, Tigray, Afar, highest temperatures likely to be seen in the Dire Dawa, Hareri) experience a sporadic, eastern regions of Somali and Afar and the secondary wet-season, Belg, which often western region of Gambela. Moreover, annual has considerably less rainfall and occurs temperature anomalies will increase across from February to May [12]. SNNPR, Somali, Ethiopia under emissions scenario SSP3-7.0 and Oromia receive their wettest or nearly through the 2030s and 2050s, (+0.6°C to wettest month during Belg. The cooler dry +1.5°C and +1.2°C to +2.6°C, respectively) season, Bega, typically occurs from October (Figure 6). Seasonally, temperature increases to December, associated with a shift in high will spike and be felt from June to January pressure over the Red Sea. Since the ITCZ under high-emissions scenarios. Gambela is drives much of the seasonal rainfall patterns projected to experience the highest increases in Ethiopia and inter-annual variability is often in daily max temperatures, particularly in March, influenced by ENSO events, the onset and April and May, with temperatures reaching intensity of rainy seasons vary by region and 41.0°C by the 2030s and 42.1°C by the 2050s year. under emissions scenario SSP3-7.0. Climate Change: Observed Trends and Projections | 13 8. The frequency of ‘hot’ days (TMax > 35°C) to 127 nationally, under the same timeframe and tropical nights (Tmin > 20°C) will substan- and scenario, with higher increases in Afar, tially increase in projected future climates Somali, and Gambela regions (Table 1). The in Ethiopia. Annual projections indicate that most rapid increases are expected in the July, the number of ‘hot’ days for the whole country August, and September season. Moreover, the will increase from 69 by the 2030s to 87 by increase in summer days (Tmax > 25°C) are the 2050s (under SSP3-7.0), whereas tropical expected to be pronounced with the whole nights are projected to increase from 105 of the country experiencing summer days for FIGURE 5. Observed and projected average monthly temperature and precipitation patterns in Ethiopia under SSP3-7.0 140 mm 27 ˚C 120 mm 26 ˚C 25 ˚C 100 mm 24 ˚C 80 mm 23 ˚C 60 mm 22 ˚C 21 ˚C 40 mm 20 ˚C 20 mm 19 ˚C 0 mm 18 ˚C Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Precipitation (mm) Historical Ref. Period, 1995-2014 Precipitation (mm) 2020-2039 Precipitation (mm) 2040-2059 Mean Temperature (°C) Historical Ref. Period, 1995-2014 Mean Temperature (°C) 2020-2039 Mean Temperature (°C) 2040-2059 Source: World Bank Climate Change Knowledge Portal FIGURE 6. Projected temperature anomaly for 2020-2039 and 2040-2059 under SSP3-7.0 Source: World Bank Climate Change Knowledge Portal 14 | Climate and Health Vulnerability Assessment: Ethiopia TABLE 1. Annual number of hot days (TMax >35°C), tropical nights (Tmin > 20°C), and summer days (Tmax > 25°C) in the 2030s and 2050s under SSP3-7.0 in Ethiopia and key regions HISTORICAL REFERENCE PERIOD 2030s 2050s Number of Hot Days (TMax > 35°C) Ethiopia 55 69 87 Afar 89 104 124 Somali 96 126 161 Gambela 181 199 226 Number of Tropical Nights (Tmin > 20°C) Ethiopia 87 105 127 Afar 121 139 163 Somali 189 223 256 Gambela 251 280 306 Number of Summer Days (Tmax > 25°C) Ethiopia 307 317 328 Afar 341 348 352 Somali 360 362 363 Gambela 364 364 365 Source: World Bank Climate Change Knowledge Portal nearly 90% of the year by the 2050s (Table 1). [16]. For example, historically the south-cen- Dangers related to increasing heat index1 is tral region of the country has experienced a expected to be less pronounced in Ethiopia 20 percent decrease in rainfall since 1960, given low levels of atmospheric moisture, whereas the northeast and eastern regions with the number of days with a heat index only observed a decrease in rainfall during greater than 35°C ranging from 0 to 26 in Belg, a secondary rainy season. Gambela annually by the 2050s. 10. Future projections of precipitation under different climate change scenarios contain PRECIPITATION high degrees of uncertainty, due to the 9. An overall decline in annual precipitation previously described high degree of inter- has been observed in Ethiopia over the last annual variability. For example, projected three to four decades, with significant year- trends indicate continued declines in rainfall, to-year volatility (Figure 7) [13]. However, high as much as a 20 percent in spring and summer inter-annual rainfall variability makes inter- rainfall in southern and central regions in pretation of long-term trends challenging and Ethiopia, whereas other areas are projected results in variations across regions and seasons to experience increases in rainfall [13]. Under emissions scenario SSP3-7.0 the national 1 Heat Index is a measure of apparent temperature that includes the average annual precipitation will increase by influence of atmospheric moisture. High temperatures with high nearly 100mm by the 2050s when compared moisture lead to high Heat Index. Heat Index gives insight into seasonal heat risks and changing seasonal heat risks over time. with the historical reference period. In Addis Climate Change: Observed Trends and Projections | 15 FIGURE 7. Annual mean precipitation, observed (1991-2020) Source: World Bank Climate Change Knowledge Portal Ababa, which sees the most rainfall, the level extreme heat. The overall impacts of such will increase from 1364mm under the historical events in Ethiopia will not merely be attrib- reference period to 1580mm by the 2050s utable to changing environmental conditions under SSP3-7.0. It is also projected that the including changes to climatology described in proportion of heavy precipitation events will the previous section, but are compounded by increase throughout the country, especially anthropogenic causes including rapid defor- during the July to September and October estation, urbanization, and inadequate building to December rainfall periods [14]. Neverthe- regulations and housing issues. less, projected warming trends for the entire country are expected to exacerbate observed declines in rainfall, leading to increased water DROUGHT stress [13] (see section drought). 12. Climate change is contributing to increases in the frequency and magnitude of droughts in Ethiopia, particularly in lowland areas, CLIMATE-RELATED HAZARDS affecting the health and livelihoods of 11. Ethiopia is vulnerable to several climate-re- millions of people. On average, roughly lated hazards, many of which have already 1.5 million people are affected by drought demonstrated increases in frequency and annually [17]. Although high degrees of inter-an- intensity. The most pressing climate-related nual variability exist for precipitation trends hazards are drought, flooding, landslides, and across Ethiopia, the incidence of drought 16 | Climate and Health Vulnerability Assessment: Ethiopia has increased and the rainfall patterns from a similar variability across the country, with February to May have become increasingly changes ranging from -14.1mm to +21.2mm less predictable in central and northern areas. by the 2030s and 16.8mm to +27.4mm by the Deficits in water availability are greatest in 2050s under emissions scenario SSP3-7.0 Tigray, Afar, and Somali regions. Moreover, (Figure 8). By mid-century under SSP3-7.0 increases in sea surface temperatures in the scenario, the country as a whole will see a slight Indian Ocean influences the migration of the decrease in the annual projected number of Intertropical Convergence Zone, which can consecutive dry days, 205 compared to 203 for further increase variability in the timing and the historical reference period. Nevertheless, duration of rainfall seasons, altering traditional droughts remain one of the key drivers of food rainfall patterns and causing more frequent insecurity for the country resulting in crop drought. Water resources are also likely to damage, loss of pasture and water sources, be increasingly strained as precipitation is loss of animals, hunger, disease outbreaks, expected to increase in some parts of East asset depletions, malnutrition and migration. Africa and warmer temperatures will accelerate the rate of evapotranspiration, thus reducing the benefits of increased rainfall [13]. FLOODS 14. Flash floods and seasonal river floods are 13. The projected maximum number of becoming more frequent and widespread consecutive dry days (in which the daily in Ethiopia. Projected trends indicate that accumulated precipitation is less than through the end of the century there is a likely 1 mm) is expected to vary by region and 20 percent increase in extreme high rainfall season in Ethiopia. For example, Somali is events (20mm or more) increasing the risk of projected to see up to 81 consecutive dry days floods [13] [18]. On average, roughly 250,000 in December, January, February compared to people are exposed to flooding risk annually 44 days in September, October, November, by [17]. Riverine areas in Ethiopia are at risk of the 2030s (SSP3-7.0) whereas the Gambela seasonal flooding, especially during Kiremt will experience between 75 to 11 days season (June, July, August), including many seasonally over the same period. Projected lowland flood-prone areas that are adjacent to mean precipitation anomalies demonstrate Awash, Wabi Shebele, Baro-Akobo, Omo-Gibe FIGURE 8. Projected precipitation anomaly for 2020-2039 and 2040-2059 under SSP3-7.0 Source: World Bank Climate Change Knowledge Portal Climate Change: Observed Trends and Projections | 17 In terms of extremes, by mid-century Ethiopia is projected to experience 100-year average largest one-day and five-day precipitation events more frequently (future return periods of 51 and 54 years, respectively). River and Abay Rivers. Additionally, flash LANDSLIDES floods are common in highland areas, such 16. Landslides are responsible for loss of life as those in the Awash River basin in the Rift along with damage to infrastructure (including Valley, as well as urban areas, particularly homes, transport, energy generation, and Addis Ababa [17]. health facilities) in Ethiopia, and ongoing climate change will increase landslide risk. 15. The projected seasonal precipitation percent An average of approximately 1,000 people are change varies by region, ranging between affected by landslides annually in Ethiopia. 5-24 percent in 2020-2039 and 9-40 percent The central areas of Ethiopia (Figure 9) contain in 2040-2059 with the highest increases the highest landslide risk, particularly along occurring in Afar region. Although Addis the eastern boarder of Tigray region and Ababa is projected to see the highest increases in the maximum number of consecutive into the Amhara region. It is estimated that wet days annually. Afar will experience the around one percent of the total land area of largest change in the number of days (+9 by Ethiopia is classified as very high landslide mid-century under SSP3-7.0). Addis Ababa hazards, with highland areas (which account for will also see the greatest number of days nearly half the country and a large proportion with precipitation > 20mm (nearly nine by of the population) also highly susceptible the 2050s), whereas the largest changes in to landslides [17]. Due to the link between average largest one-day precipitation will occur landslides and heavy rainfall, the projected Beneshangul Gumu (+10 by mid-century under increases in average largest five-day precipita- SSP3-7.0). Hareri will have the highest anomaly tion events related to climate change, suggest for average largest five-day cumulative rainfall the potential for future risks in the coming (+38 days by mid-century under SSP3-7.0) decades. Changes in rainfall and temperature which presents a different flood risk where may lead to more landslide events, with rainfall areas become saturated over a number of being a primary trigger, increasing drought days. By mid-century, the national annual followed by heavy precipitation events and average largest five-day cumulative rainfall changes in vegetation can affect the likelihood is projected to exceed 131mm. In terms of of these events. Development and land use extremes, by mid-century Ethiopia is projected policies impact landslide risk as well, with to experience 100-year average largest deforestation and unmanaged and unregulated one-day and five-day precipitation events planning of the built environment exacerbating more frequently (future return periods of 51 landslides by weakening slope stability. and 54 years, respectively). 18 | Climate and Health Vulnerability Assessment: Ethiopia FIGURE 9. Rainfall triggered landslide Source: Global Facility for Disaster Reduction and Recovery (GFDRR) EXTREME HEAT the same time period and scenario, Afar, 17. Rising temperatures in Ethiopia are of Somali, Gambela, and Beneshangul Gumu increasing concern, including the increased will experience the highest increases. For frequency of extreme heat events [19]. ‘very hot’ days (Tmax > 35°C) a similar pattern Although the projected number of days with a exists. The number of tropical nights (Tmin > heat index >35°C remain low until mid-century, 20°C) will also increase with climate change in under high-emissions scenarios increases are Ethiopia, albeit with more dramatic increases. expected to begin in the 2080s, particularly in For example, by mid-century populations Gambela and Somali regions during March-May. in Gambela region will see tropical nights Moreover, under SSP3-7.0 a sharp increase for 80 percent of the year, compared to 68 in hot days (Tmax > 35°C) with acceleration percent for the historical reference period. starting by 2050 and continuing until the The increase in tropical nights is important end of the century [13]. Annually, Ethiopia for human health, especially in areas that is projected to experience an increase in regularly do not experience high temperatures the number of hot days (Tmax > 35°C) from (e.g., highland areas), because it restricts the 54 during the historical reference periods human body’s ability to cool down. to 87 by the 2050s under SSP3-7.0. Under Annually, Ethiopia is projected to experience an increase in the number of hot days (Tmax > 35°C) from 54 during the historical reference periods to 87 by the 2050s under SSP3-7.0. Climate Change: Observed Trends and Projections | 19 SUMMARY OF CLIMATOLOGY Temperature → Historically, mean annual temperature in Ethiopia has increased by 1°C since 1960, including increases in both ‘hot’ days and nights, with the highest rates of warming observed in the central regions and highland areas. → Under a high emissions scenario (SSP3-7.0) temperatures are projected to increase by 0.7°C by the 2030s, 1.5°C by the 2050s, with the highest temperatures likely to be seen in the eastern regions of Somali and Afar and the western region of Gambela Precipitation → Overall decline in annual precipitation has been observed in Ethiopia over the last three to four decades, with significant year-to-year volatility. → Future projections of precipitation under different climate change scenarios contain high degrees of uncertainty, with slight increases in national average annual precipitation rates. However, continued warming trends will likely exacerbate seasonal and regional declines in rainfall. Climate extremes → Drought: Increases in drought risk are expected in Ethiopia, with declines in water availability greatest in Tigray, Afar, and Somali regions. → Floods: Flash floods and seasonal river floods are significant risks in Ethiopia, with projected 100-year average largest one-day and five-day precipitation events projected to occur more frequently. → Landslides: Climate change may increase landslide risk, with central areas of Ethiopia, particularly along the eastern boarder of Tigray region and into the Amhara region most vulnerable. → Extreme heat: The frequency of ‘hot’ days (TMax > 35°C) and tropical nights (Tmin > 20°C) will substantially increase in projected future climates in Ethiopia, with Afar, Somali, Gambela, and Beneshangul Gumu likely to experience the highest increases. 20 | Climate and Health Vulnerability Assessment: Ethiopia SECTION III. CLIMATE-RELATED HEALTH RISKS 1. Climate change influences human health outcomes and disease in multiple ways. This section reviews evidence for the burden of current climate-related health risks in Ethiopia and projections of future risks of health outcomes due to climate change, based on the expected changes in a countries’ climate under an RCP 8.5 (high GHG emissions) scenario. This scenario represents a ‘realistic’ worst-case scenario as the “worst-case” scenario, characterized as fossil-fuel intensive, that excludes any climate mitigation policies. It has been used as a likely outcome in the absence of mitigation actions. Health risks are presented according to prioritization and are examined according to historic, current and projected risk, where information is available. Risks to health system related to climate change are covered in Section IV - Adaptive Capacity. 2. Risks to health outcomes related to climate in endemic areas, and a propensity to spread change are not evenly distributed in the because of climate change. These diseases population with some groups at greater risk tend to spread from hot (or Kolla) to adjacent than others. Climate change may exacerbate mid-highland (or Weina Dega) zones [20], health inequalities, especially among certain with the potential for re-emergence. Previous vulnerable population groups, including projections indicate more than one-thirds of the poor, rural populations, those living in Ethiopia’s total land mass is at high and very informal urban settlements, women and high risk of visceral leishmaniasis endemicity young children, the elderly, those living with [21], and above 3.2 million people live in areas pre-existing conditions and disabilities, and at risk. Meningitis outbreaks also repeatedly displaced populations. Therefore, investment occurred in Ethiopia. Although projections in adaptation and mitigation measures must specific to meningitis prevalence in the future carefully consider groups who would directly of Ethiopia’s climate is absent, as dryness benefit from or may be disadvantaged by will prevail with the rising temperature and adopted measures. environmental changes it appears risk of meningitis outbreak is highly likely. 3. Neglected tropical diseases (NTDs) are also of high importance in Ethiopia and in 4. Ethiopia’s CHVA assesses six climate- some instances may be affected by climatic related health risk categories. These include factors. In particular, Visceral Leishmaniasis, risks to (a) nutrition and food security risks, trachoma and meningitis are the common (b) vector-borne disease, (c) water-borne ones, with over 4,500 cases reported yearly and water-related disease, (d) heat-related 21 risks, (e) air quality, and (f) mental health. NUTRITION AND FOOD Risk categories were selected from literature review on climate and health risks to Ethiopia. SECURITY RISKS Each category is assessed in terms of current 5. Weather and climate are foundational and future risk, with considerations for both drivers of healthy and sustainable diets. national and sub-national peculiarities, where The mechanisms by which climate change possible. It is important to note that these affects nutrition via the food system are risk categories represent only the most profound and include acute and chronic pressing climate-related health risks to the effects on agricultural production, storage, population of Ethiopia. Other climate-related processing, distribution, and consumption health risks can include, but are not limited (Figure 10). Nutritionally secure and stable to, direct injuries and mortality associated diets depend on agricultural production, but with natural hazard events. also on the complex interactions of demand, FIGURE 10. Stages of the food system that drive healthy and sustainable diets [22] Healthy & Sustainable Diet Agriculture Storage Processing Distribution Consumption Production Unhealthy & Climate Change Post-harvest Loss Nutrient Losses Demand Culture Unsustainable Diet Land Use Mycotoxins Fortification Trade A ordable Water Use Nutrient Losses Waste Politics Accessible Waste Waste Legislation Economics Preferences Extreme Weather Nutrient Losses Nutrient Losses Legislation & Policies Waste Waste Nutritionally secure and stable diets depend on agricultural production, but also on the complex interactions of demand, economics, legislation, conflict, food waste, nutrient losses, food safety, and access. 22 | Climate and Health Vulnerability Assessment: Ethiopia economics, legislation, conflict, food waste, an estimated 45% of all deaths in under five nutrient losses, food safety, and access [22]. years of age, with most of those being in Climate variability is already contributing to low-income countries [26], a figure that was increases in global hunger and malnutrition also identified in 2011 data when aggregating [23]. While a comprehensive analysis of fetal growth restriction, stunting, wasting, and climate change’s impact on the food system deficiencies of vitamin A and zinc along with is beyond the scope of this assessment, this suboptimum breastfeeding [27]. Children with CHVA examines climate and nutrition linkages Severe Acute Malnutrition (SAM) face a risk of through a food security lens in Ethiopia as morbidity and mortality nine-to-eleven times it relates to weather and climate impacts on greater than their healthy counterparts [28]. agricultural productivity. Agricultural produc- The burden of SAM in children under five is tivity is a key determinant of food availability projected to increase in Sub-Saharan Africa and is affected by weather and climate in a from 8.1 million cases in 2014 to potentially multitude of ways, from short term shocks (e.g., 9.0 million cases by 2030 [29]. natural disasters), to longer term changes in agro-ecological conditions that can drastically 8. In Ethiopia, although there has been progress reduce yields or re-define spatio-temporal to improve nutritional outcomes, especially patterns of crop suitability. in children under five years of age, under- nutrition continues to be a priority health 6. Rain-fed agriculture is a major climate- risk. Ethiopia has one of the highest levels sensitive concern in Ethiopia, particularly of food insecurity in the world, in which with changes in rainfall pattern and intensity more than 35 percent of its total population as a result of increasing drought and flood is chronically undernourished [30] and an events. Crops are sensitive to unpredictable estimated 20.4 million people require food climate hazards such as floods and pests. support [31]. Between 2000 and 2016, under-5 The impact is most significant in communities mortality declined from 166 deaths per 1,000 which rely on subsistence and/or rain-fed live births to 67 deaths per 1,000 live births, farming and livestock production, which is representing a 60 percent decrease, in part relevant to approximately 70-80 percent of due to an enhanced focus on undernutri- the population in Ethiopia [24]. Although the tion. Nationally, 38 percent of children under country will see a slight decrease in the annual age 5 are stunted (short for their age), 10 projected number of consecutive dry days, percent are wasted (thin for their height), 24 droughts will remain one of the key drivers of percent are underweight (thin for their age), food insecurity, causing crop damage, loss of and 1 percent are overweight (heavy for their pasture and water sources, loss of animals, height). Amhara, Benishangul-Gumuz, Affar, hunger, disease outbreaks, asset depletions, and Dire Dawa are the regions that are most malnutrition and migration. affected by child stunting (41-46 percent), whereas wasting imposes the heaviest burden 7. High morbidity and mortality are immediate in Somali, Affar, and Gambela, with rates of consequences of undernutrition and results 23, 18, and 14 percent, respectively (Table 2). in a predisposition to infections, particularly This continues to affect childhood mortality, those of the gastrointestinal and respiratory with large variations across regions in Ethiopia. systems [25]. Globally, undernutrition caused For example, under-5 mortality ranges from a Climate-Related Health Risks | 23 TABLE 2. Under 5 Child stunting, wasting and mortality rates by sub-national units [32] REGIONAL STATES/CITY CHILD CHILD CHILD MORTALITY ADMINISTRATIONS STUNTING (%) WASTING (%) (PER 1000 LIVE BIRTHS) Addis Ababa 15 4 39 Diredawa 40 10 93 Benshangul-Gumuz 43 12 98 Harari 32 11 72 Afar 41 18 125 Amhara 46 10 85 Oromia 37 11 79 Gambella 24 14 88 Southern Nations, Nationalities, 39 6 88 Peoples (SNNP) Tigray 39 11 59 Somali 27 24 94 low of 39 deaths per 1,000 live births in Addis weather shocks such as drought, with large Ababa to a high of 125 deaths per 1,000 live areas of the country not being suitable for births in Afar. cultivation [34]. 9. Droughts, soil erosion, reduced water 10. Food security is a significant growing risk supply and increased crop damage worsen due to the acute shocks and chronic changes food insecurity. Increased extreme rainfall of climate projections. For example, three triggers soil erosion and reduces soil fertility, categories of the main staple food producers aggravated by prolonged drought periods. from within Ethiopia are already impacted by Soil erosion is also worsened by deforesta- the changing climate, further increasing food tion rates in Ethiopia. Moreover, droughts insecurity. Many southern and south-eastern have increased in frequency, duration, and pastoral areas experienced lower-than-normal intensity which has and will likely continue pasture and water availability, which will to impact Ethiopia’s rain-fed agriculture cause significant food and income loss as a system, potentially leading to reduced crop result. Additionally, climatic shocks as well yields, especially for smallholder farmers as compounding factors such as conflict, which represent most of the rural population desert locust invasions, and the COVID-19 and produce more than 90 percent of total pandemic continue to drive up levels of food agricultural output [33]. The five major crop and nutrition insecurity and prices of staple cereals in Ethiopia are teff, wheat, maize, foods in Ethiopia. These conditions all drove sorghum and barley, which account for roughly further declines in living conditions and dete- three-quarters of the total cultivated land. riorating food security and increased levels of However, yields are considered to be low malnutrition affecting an estimated 18 million by international comparisons, mainly due to people [35]. 24 | Climate and Health Vulnerability Assessment: Ethiopia 11. Ethiopia is currently facing five consecutive food security for both the 2030s and the drought seasons (below-average rainy 2050s. Water scarcity in Ethiopia is pivotal for seasons) in the south and southeast pastoral agriculture and livestock. Overall, there is a high regions, and households are expected to face level of uncertainty regarding projections of increased food insecurity. Nearly 2.3 million precipitation under different climate scenarios people in the Somali region face difficulty in Ethiopia, with key indicators such as accessing food. Acute malnutrition levels are maximum number of dry days (in which the categorized as Critical in the Amhara Region. daily accumulated precipitation is less than 1 (see Figure 11 with recent data and projections mm) is expected to vary by region and season. for Tigray conflict-affected areas). However, the shifts in precipitation and threat of continued drought conditions coupled with 12. Considering the observed overall decline a limited water management infrastructure, in annual precipitation and increases in the as well as a lack of development in the agri- frequency and intensity of droughts, as well cultural sector, will potentially increase the as the potential shifts in rainfall patterns vulnerability to food insecurity. In particular, under climate change, Ethiopia may continue areas that already experience a high burden to face important consequences related to of undernutrition, such as Tigray, Afar, and the replenishment of soil moisture, the avail- Somali regions will also face the greatest ability of water resources and therefore on deficits in water availability. FIGURE 11. Ethiopia: Acute Food Insecurity projected outcomes, December 2022-January 2023 and February-May 2023 [36] December 2022 — January 2023 February 2023 — May 2023 IPC v3.1 Acute Food Insecurity Phase 1: Minimal 2: Stressed 3: Crisis 4: Emergency 5: Famine Would likely be at least one phase worse without current or programmed humanitarian assistance. FEWS NET classification is IPC-compatible. IPC-compatible analysis follows key IPC protocols but does not necessarily reflect the consensus of national food security partners. Climate-Related Health Risks | 25 VECTOR-BORNE DISEASE RISKS fever and malaria, vectors of both diseases breed in small water pools in discarded utensils 13. Weather and climate are critical drivers of adjacent to households and entail transmission spatio-temporal vector-borne disease (VBD) as documented and took actions to abrupt distribution and transmission dynamics. At the outbreaks [42]. Similarly, Chikungunya large scales, climate variability causes vector outbreaks are repeatedly documented in and host ranges to change, shifting disease eastern Ethiopia [43]. Figure 12 from the distribution, seasonality, and/or facilitating Ethiopia MoH provides a spatial analysis of emergence or re-emergence of VBDs [37]. At malaria incidence for the year 2020, stratified local scales, vector abundance is a product by district [110]. of microclimates, availability of larval sites, shade for resting, sources of blood meals 15. Malaria transmission risk in Somali region and nectar, and predator density [38]. will decline in the 2030s and 2050s due to ongoing climate change, however hot 14. Climate is a critical driver of vector borne spots will remain, particularly in Hadiya, disease distribution and transmission Metekel, and South Gonder districts (Figure dynamics. Climate variability causes vector 13). Spatial models were constructed to and host ranges to expand or contract, shifting demonstrate the plausible distributions of disease distribution, seasonality, and/or Anopheles arabiensis mosquitoes according facilitating emergence or re-emergence of to environmental suitability. Here, suitable vector-borne diseases. Investigating species areas are defined as those that facilitate distribution and seasonality of vectors is the development of malaria mosquitoes valuable to understanding plausible vector- through the production and persistence of borne diseases distributions and planning oviposition sites and where temperatures do efficient, spatially targeted methods of not exceed or fall below thermal tolerances control. This assessment focuses on malaria for the species. It can be assumed that considering its importance for morbidity and where suitability for malaria vector species mortality in Ethiopia; there are more than 40 is greatest so too is malaria transmission risk species of Anopheles, however Anopheles in the absence of interventions. For further arabiensis is the principal malaria vector information on modelling methodology and (others that transmit malaria in Ethiopia are inputs see Annex E. Suitability for malaria A. funestus, A. phronesis, and A. nili, and vectors through mid-century will largely there is recent documentation of A. stephensi remain unchanged throughout the country in eastern Ethiopia [39]). The other main vector as projected temperature increases will not borne diseases in Ethiopia are dengue fever exceed the thermal tolerance of malaria vector (Aedes aegypti), chikungunya (primarily Aedes species. Only in Somali region during the aegypti and Aedes albopictus), and Yellow 2030s and 2050s, will temperature increase Fever (Aedes aegypti). Since 2013, above limit vector survival (Figure 13). Overall, the 12,000 dengue fever cases documented projected decline in suitable area for malaria due to repeated outbreaks were reported is estimated to reduce the number of people in eastern Ethiopia [40], with peak high vulnerable, however suitability for some regions malaria prevalence being observed between will remain high through the 2050s (Table 3). September to November [41]. Because of the For example, areas that are populated and overlapping feature of epidemiology of dengue 26 | Climate and Health Vulnerability Assessment: Ethiopia FIGURE 12. Malaria Risk Map, 2020 [110] FIGURE 13. Comparison of suitable area for malaria vector species in Ethiopia under RCP 8.5, across three epochs: 1986-2005 (historical baseline), 2020-2039, and 2040-2059 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 Accumulation (World Wide Fund for Nature, HydroSHEDS), Population (European Commission’s Joint Research Centre, GHSL/P2016/POP_GPW_GLOBE_V Climate-Related Health Risks | 27 TABLE 3. Percent suitable habitat area, by region, for malaria vector species in Ethiopia under RCP 8.5 through mid-century POPULATED, SUITABLE OVERALL SUITABILITY VULNERABLE POPULATION Region Historic 2030s 2050s Historic 2030s 2050s Historic 2030s 2050s Addis Ababa 85.2 85.2 85.2 99.3 99.3 99.3 3,511,125 3,511,125 3,511,125 Afar 0.5 0.4 0.2 25.1 11.8 8.2 672,763 396,715 328,389 Amhara 8.8 8.8 8.8 86.5 85.5 83.8 21,710,871 21,682,958 21,621,787 Beneshangul Gumu 2.8 2.8 2.6 56.2 50.8 37.5 987,467 963,352 888,200 Dire Dawa 13.4 12.4 13.2 100.0 97.7 96.4 454,061 454,061 453,453 Gambela 0.1 0.1 0.0 5.2 3.3 1.7 161,801 99,505 89,089 Hareri 33.1 33.1 33.1 100.0 100.0 100.0 245,872 245,872 245,872 Oromia 4.8 4.8 4.8 88.0 87.3 85.1 36,436,944 36,429,879 36,310,886 SNNPR 9.9 9.9 9.7 72.4 71.0 65.3 19,735,888 19,733,884 19,567,096 Somali 1.0 0.7 0.5 71.6 41.8 26.4 4,398,716 3,356939 2,714,751 Tigray 10.5 10.3 10.2 78.2 70.3 65.4 5,313,756 5,202,492 5,164,616 TOTAL 93,629,269 92,076,787 90,895,269 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 Accumulation (World Wide Fund for Nature, HydroSHEDS), Population (European Commission’s Joint Research Centre, GHSL/P2016/POP_GPW_GLOBE_V suitable for malaria in Addis Ababa will continue Thus, approximately, there are an additional to be roughly 85 percent resulting in approx- 6.5 million non-immune people in malaria risk imately 3.5 million people vulnerable. areas. Evidence from the Sixth Assessment Report from the Intergovernmental Panel on 16. In Ethiopia, the influences of climate Climate Change on the observed impacts and variability on malaria cases over time is projected risks for malaria state that higher well documented. Temperature and precip- temperatures and shifting patterns of rainfall itation have been highlighted as important influence the distribution and incidence of drivers of malaria epidemics, but their effects malaria in sub-Saharan Africa with high on malaria vary depending on local climate confidence. Further there is evidence that and geography [44] [45] [46] [47]. Overall, of Increasing incidence of infection with P. evidence has shown temperature is a more falciparum with higher temperatures, partic- important driver in cooler highland regions, ularly in Ethiopia. These relationships have whereas precipitation is more important in led multiple researchers to propose applying drier areas. Although occurrence of endemic climate-driven models for malaria early warning malaria is known to be limited to below 2000 in Ethiopia [52] [53] [54]. meters above sea level, malaria cases were documented in highland-fringe areas beyond 17. Drought frequently drives water storage near the altitude threshold during non-epidemic households, putting Aedes breeding sites periods [48] [49] [50]. In addition, highland near humans. There was a re-emergence of areas have seen a corresponding increase in Yellow Fever outbreaks during 2012, 2014 the altitude at which malaria transmission is and 2018 in southern Ethiopia [55]. Moreover, possible, exposing non-immune populations in during the 2000s, more frequent outbreaks of new highland areas to risk of the disease [51]. mosquito-borne diseases were recorded, which 28 | Climate and Health Vulnerability Assessment: Ethiopia was likely influenced by warming tempera- agricultural and other pollutants, as well as tures [56]. By the 2030s and 2050s, rainfall increased sediment loads in rivers - all affecting patterns and drought conditions will vary by water quality. Bacterial pathogens attach to region and season, however slight increases leafy crops under flood conditions, as well in the number of consecutive dry days are as in drought conditions [63]. Flies and other projected in Somali region, included roughly pests proliferate in flood waters, risking food 44 dry days projected between the months contamination. The flooding also results in of September-October, which are historically the geo-spatial expansion of breeding sites considered high malaria transmission months for vector-borne diseases, such as malaria, in Ethiopia [57]. chikungunya and dengue transmitted through mosquitoes, which are explored in the vector- borne diseases section. WATER-BORNE AND WATER-RELATED DISEASES 20. The 9 percent of deaths attributed to diarrhea diseases in Ethiopia [58] are an inevitable 18. In Ethiopia, diarrheal disease causes 12.8 outcome of the poor water, sanitation, and percent of disability-adjusted life years hygiene infrastructure. Out of all children (DALYs) among children under 5 years, mainly under five deaths, 13 percent are due to due to Salmonella and Shigella bacteria, and diarrheal diseases [58], such as cholera. causes 8.6 percent of total DALYs for all ages Cholera is an acute diarrheal illness caused [58]. They are caused by contamination of by infection of intestine with Vibrio cholerae, food, water, and bacteria in the environment. Climate change is increasing the magnitude usually serogroup O1. In Ethiopia, it is estimated of diarrheal diseases, with rising tempera- that about 70 million people are at risk of tures speeding up the life cycle and survival cholera. Of those, an estimated 275,221 cases of pathogens and vectors [59]. Increases in and 10,458 deaths occur annually, representing rainfall as well as average temperatures play an incidence rate of 4 cases per 1000 population a major role in the transmission of diseases [64]. The East Africa sub-region is projected [60], influencing the proliferation, transport to be the worst impacted by cholera, partic- and dissemination of infectious agents, partic- ularly during and after El Niño events [65]. It ularly through water and sanitation systems is estimated that 20,000-30,000 additional [61]. Households with unimproved water and cholera deaths attributed to climate change sanitation facilities are most at risk of increases in children below 15 years old [66]. in diarrheal diseases, with 77 percent of the variation in the occurrence of diarrhoea being 21. Spread of enteric diseases can occur through identified as being due to climatic differences direct use of the contaminated water for in Sub-Saharan countries [62]. swimming, bathing, and drinking, through the contamination of food that is farmed or 19. Common types of flooding in Ethiopia include washed using contaminated water sources, riverine and flash, with groundwater and or through person-to-person transmission. sewer-flooding also presenting hazards Projected increases in warm temperatures, to human health. Inundation of agricultural shifting patterns of rainfall, and an increase land, villages, towns, and cities contaminates in heavy precipitation events throughout fresh water with human and animal sewage, Ethiopia are ideal for the rapid prolifera- Climate-Related Health Risks | 29 tion and persistence of pathogens, making HEAT RELATED MORTALITY the management and sustained control of outbreaks challenging. For example, Addis AND MORBIDITY Ababa, which already experiences the most 23. The health risks of heat are wide ranging, precipitation in the country, will see increases including effects on mortality, heat-related in rainfall through 2050 under high-emissions injuries, mental health and well-being. Several climate scenarios. Furthermore, the water factors influence mortality and morbidity related and sanitation systems in Ethiopia have not to extreme heat events with the magnitude received sufficient investment, leaving the of impacts related to the timing, duration, population vulnerable to the transmission of and intensity of the temperature event, levels diseases such as cholera, diarrhea, dysentery, of acclimatization (an individual’s adaptive hepatitis A, and typhoid. In low-income response to a hot environment), the built countries, changes in climate are expected environment (e.g., urban heat island effect), the to influence diarrhea rates [67], however the adaptive capacity of the affected populations, extent will vary depending on climate change and resilience of infrastructure and institutions, scenarios and local factors [68]. Increased among others [70]. Health effects caused by frequency of floods in Ethiopia is expected to heat include the direct effect of heat stress, exacerbate challenges with water pollution as well as heat rash, cramps, exhaustion, and and subsequently will increase the risks of dehydration and the acute exacerbation of diarrheal diseases [69]. Although country-level pre-existing conditions including respiratory projection of climate attributable diarrheal and cardiovascular diseases, with further disease are unavailable, with projected climate risks of detrimental interactions for those change in the African region, an extra 48,000 on medications. Longer term mental health deaths will occur in children aged below 15 years, risks are also an important effect to consider. mainly due to diarrheal diseases and 33,000 In addition to the impacts on individuals, the deaths by 2030 and 2050, respectively [66]. whole population exposure that occurs with an extreme heat event can lead to significant 22. Climate change projections reveal a increases in hospitalizations putting strain significant positive trend in temperatures, on health systems [71]. which are associated with increased episodes of diarrheal diseases [68]. More intense 24. Both increases in average seasonal tempera- droughts are also associated with reduced tures and an increase in the frequency and water quality and disease outbreaks. The lack intensity of heatwave events are projected of fresh rain during droughts prevents the to increase the health risks globally in a opportunity to flush out stagnant waters. The changing climate [66] [72]. There is no water quality deteriorates as sources become specific data on the impacts of heat on health over-used, and the risk of outbreaks of disease in Ethiopia, the potential threat of elevated spreading person-to-person increases, even mortality risk still exists. Gambella and Afar away from the direct source of contamination. regions have the highest average temperature Warmer waters will contribute to increases in which institutional working adjustments in toxic algae blooms in fresh waters, and have been recommended during peak season/ associated cases of food poisoning from months (e.g., July, August, September). affected aquatic foods, resulting in outbreaks. Further, in Ethiopia, from the climate change 30 | Climate and Health Vulnerability Assessment: Ethiopia projections described in Section II, Afar, droughts, resulting in severe health impacts Somali, and Gambela regions are likely to from widespread smoke inhalation. High experience increases in the number of hot temperatures also interact with air quality, days (TMax > 35°C) and tropical nights (>20°C) affecting levels of ozone, pollutants, and by 2050 under a high emissions scenario. This aeroallergens, which in turn can result in would expose roughly 13.3 million people to acute exacerbations of chronic respiratory and potentially life-threatening temperatures and cardiovascular conditions [77]. For example, will have implications on the health of those extreme heat and high humidity trigger asthma populations, particularly vulnerable groups symptoms; and cold weather, by increasing such as pregnant women, children under five cold exposure, will increase overall respiratory years of age, people over 65 years. Moreover, infections in individuals with underlying chronic projected increases in summer days (Tmax > obstructive pulmonary disease (COPD) [78]. 25°C) are expected to be pronounced with Moreover, the changes in wind patterns and the whole of the country. increased desertification themselves increase the long-range transport of air pollutants. Under 25. Extreme heat also presents a growing occu- certain atmospheric circulation conditions, pational health risk in Ethiopia. Physical work the transport of pollutants, including aerosols, capacity can reduce when high temperatures carbon monoxide, ozone, desert dust, mold and humidity exist several months each year, spores, and pesticides, may occur over large with some global assessments calculating distances and over timescales typically of 4-6 annual loss of healthy work hours three-fold days, which can lead to adverse health impacts (from 3 percent to 18 percent) by 2100 [73]. [79]. Other contributors to poor air quality in Overall, there is a lack of reporting of heat Ethiopia include power generation, diesel related injuries, illnesses, and deaths amongst generators, and waste burning, all of which occupations in Ethiopia [74]. However, studies themselves contribute as a positive feedback from other countries indicate that workers in mechanism to climate change impacts. agriculture and construction are at a particu- larly high risk of occupational heat stress [75]. 27. In Ethiopia, air pollution is the second Climate-based indices can be used to quantify highest risk factor for driving morbidity and workdays lost to extreme heat, reflecting mortality [80]. Specifically, it is estimated that recommended heat strain thresholds [75]. air pollution in Ethiopia is responsible for 41 percent of lung cancer deaths; 47 percent of chronic obstructive pulmonary disease AIR QUALITY deaths; 25 percent of Ischaemic Heart Disease deaths; 19 percent of Diabetes deaths; and 26. The changing climate itself can influence 17 percent of Stroke deaths [81], as well as other sources of air pollution with global other outcomes such as exacerbations of mortality driven by the fossil fuel component asthma and the advancement of dementia. of PM2.5 estimated as 10.2 million per year A report by the Ministry of Health found that [76]. Changes in wind patterns and strength 1.2 million cases of acute upper respiratory lead to increased fine particulate matter, such infections (5 percent), as well as a further as atmospheric dust, desertification in some 5 percent of pneumonia cases (7 percent regions also promoting dust formation, and of total hospital admissions) may be linked increasing risks of wildfire with heat and Climate-Related Health Risks | 31 to air pollution (data from 2010/11) [82], with up to 100 µg/m3 in the urban areas, with 40 pneumonia rates highest amongst children µg/m (twice the average for the country, and under 5 years, accounting for 23 percent 8x the WHO guidelines) in suburban area at of their hospital admissions and 13 percent the same time of the year [82]. of their mortality [82]. Air pollution affects pregnant women, the developing fetus, or both, in ways analogous to tobacco smoking, MENTAL HEALTH AND WELLBEING which is a well-known risk factor for low birth 30. The association between climate change- weight and preterm birth. Other vulnerable related events and mental health can be direct groups are children under 5 years old, and or indirect, short-term, and long-term. Acute the elderly through damage and inflamma- events (such as a flood) in the short term can tion in the respiratory and cardio-vascular precipitate a psychopathological pattern similar systems in particular. to experiencing traumatic stress. Whereas exposure to extreme or prolonged weather-re- 28. In Ethiopia, the World Bank Group estimated lated impacts may result in delayed mental that the mortality rate caused by ambient impacts, such as symptoms of post-traumatic and household air pollution was 144.4 per stress in the future, or psychological impacts 100,000 population (data from 2016), this on younger generations. For example, mental compared to 169.73 regionally, and 92.43 health impacts in children can be manifested globally [83] [84]. In 2017, 7,540 deaths were as behavioural disorders. In 2011 neuropsychi- attributed to exposure to outdoor PM2.5, with a atric disorders were estimated by the WHO to further 32,800 deaths attributed to Household Air Pollution, and 533 to ozone [81]. In total account for 5.8 percent of the disease burden that is approximately 41,000 deaths, making [86], while a paper published in the same it the 3rd leading risk factor for premature year reported the mental disorders burden death, accounting for nearly 8 percent of to be 18 percent in adults and 15 percent all-cause mortality in 2017 [81]. for children [87]. Diagnostic capacity in the country is minimal, perhaps explaining the 29. The State of Global Air research group discrepancies in the published data, and lack estimate that the entire Ethiopian population of recent sources. Nonetheless, the impact of lives in areas with PM2.5 concentrations climate change and climate extreme events above the 2021 WHO Air Quality Guidelines on mental health and well-being is mediated [85] for healthy air of 5 µg/m2. They estimated by individual and community resilience. Even that in 2017 the population weighted average globally, the research on the effects of mental PM2.5 concentration was 39 μg/m. There health outcomes related to climate change has been a trend of improvement, and in lags behind research related to physical health, 2021 another group estimated the PM2.5 and the assessment presents challenges due concentration at 20.1 µg/m [82]. However, to the diversity in cultural issues and norms. smog areas of high pollution remain — available data indicates that Addis Ababa is the most 31. To assess mental health in the context of polluted city, with the dry months of January climate change, the full spectrum from mental and February having the concentrations of illnesses to psychological and social wellbeing, or ‘psychosocial health’, is considered. 2 µg/m3=micrograms per meter cubed, ie one millionth of a gram This allows for the incorporation of consider- 32 | Climate and Health Vulnerability Assessment: Ethiopia ations of wellbeing and resilience [88]. This is the population affected by natural disasters. particularly relevant in Ethiopia, where there Research suggests that this can persist up to is a background strain on the resilience of the two years after the event [92]. The destruction population due to food and income insecurity, of landscape, such as through severe flash long-term climate and conflict stresses, as well flooding, in itself diminishes the sense of as limited opportunities for psychological or belonging and comfort that people derive psychiatric assessment and diagnoses to inform from their connectedness to the land [93]. an analysis. The concept of mental health and wellbeing can thus be framed as a spectrum 34. Extreme heat also has an impact on mental of ‘psycho-social health’. This embodies the health and well-being [94] [95]. High diverse psychological and social strains of temperature can aggravate mental health climate change impacts — such as housing, symptoms, increase the risk of suicide [95], water and income insecurities, as well as and conflict [96]. More generally, research living in physically uncomfortable drought has shown that hot nights are associated or humid conditions. with insomnia [97], with consequences that included susceptibility for disease and chronic 32. Extreme weather events, such as floods, illness [98] [99] psychological and cognitive can result in direct trauma, anxiety, and functioning [100] [101] [102]. Research in other depression through personal injury, or death countries has projected levels of heat-related and injury of a close relative, damage or excess mortality for mental disorders [103]. loss of property and important community The trends between increasing temperatures services infrastructure, as well as disruption and associated mental disorder has also been to livelihood. Intense negative emotions such found in regard to self-harm and suicide rates. as terror, anger, and shock are recognized as Some findings suggest that suicide rates acute responses to natural disasters. These increased by 0.7 percent and 3.1 percent, extreme events can also result in long-lasting respectively, for a 1ºC increase in monthly psychological distress [89] [90]. average temperature [104]. There are two likely mechanisms for this: First, direct physi- 33. Mental disorders such as depression, ological effects on the brain are hypothesized anxiety, and post-traumatic stress are to influence emotional control, aggression, related to increasing climate events. Extreme and violent behaviour. This direct mechanism weather events such as floods and droughts, appears to be driving increases in suicide are becoming more frequent and intense in rates on hot days in wealthy locations like the Ethiopia, potentially leading to increased risk United States [105]. Second, high temperatures of elevated rates of mental disorders. Although generate negative economic shocks, particu- there is a lack of information on mental health larly in agriculturally dependent communities, disorders’ incidence and prevalence in Ethiopia, which is critical for the subsistence farming global figures show that 14 percent of the population in Ethiopia [106]. These economic burden of disease is attributed to mental losses have been shown to translate into health illnesses [91]. Moreover, research increased suicide risk [107]. shows that psychopathologies attributed to extreme weather events increases by 17 35. There are many factors that influence mental percent, impacting about 30-40 percent of health and wellbeing, and the nature of Climate-Related Health Risks | 33 resilience is not fully understood. For example, “significant beneficial changes in cognitive and there is the opportunity for post-traumatic emotional life beyond levels of adaptation, growth (PTG) following a climate change-re- psychological functioning, or life awareness that lated extreme weather event, as opposed occur in the aftermath of psychological traumas the trauma being inevitable. The PTG term is that challenge previously existing assumptions described by Tedeschi and Calhoun (1995) as: about self, others, and the future.” [108] TABLE 4. Summary of the Climate Change Risks on Health Outcomes HEALTH OUTCOME CURRENT RISK PROJECTED RISK Nutrition and • Ethiopia suffers from food insecurity • In the absence of adaptation, climate Food Security which has resulted in high levels of mal- change is predicted to increase the nutrition. duration of droughts, and increase the • Malnutrition is consistently the highest frequency of flooding, resulting in a contributor to total DALYs over the reduction in crop yield, aggravating food 2009-2019 period, across all ages. insecurity and increasing malnutrition. • Nearly 33 million people are suffering • Areas that already experience a high from chronic undernourishment and food burden of undernutrition, such as Tigray, insecurity. Afar, and Somali regions will also face the greatest deficits in water availability. Vector-borne • In Ethiopia, there is a risk that the vectors • All of these diseases could spread as Diseases for malaria have the opportunity to changes in precipitation and population increase their spatial and temporal distri- internal settlements provide increased bution, particularly in highland areas. habitats for breeding and opportunities • Evidence has shown temperature is a for the respective mosquito species to more important driver of malaria in cooler flourish. highland regions, whereas precipitation is • Areas that are projected to experience more important in drier areas. increases in drought conditions, such as • Outbreaks of Dengue Fever (eastern Somali, may be at additional risk of vec- regions), Chikungunya (eastern regions) tor-borne diseases. and Yellow Fever (southwestern regions) have also been recorded. Waterborne • Waterborne and water related diseases • Projected increases in warm tempera- and Water- occur throughout Ethiopia in response to tures, shifting patterns of rainfall, and an related inadequate water and sanitation systems, increase in heavy precipitation events Diseases intense precipitation, drought conditions, throughout Ethiopia will likely influence and specific water contaminants. the expanded ecosystem opportunities, • Droughts of longer duration have been the growth and transmission rates, as linked to reduced availability of fresh well as the persistence and virulence, of water, a deterioration in water quality, with pathogens. stagnation and disease outbreaks. 34 | Climate and Health Vulnerability Assessment: Ethiopia HEALTH OUTCOME CURRENT RISK PROJECTED RISK Heat-related • Heat-related morbidity and mortality data • Afar, Somali, and Gambela regions are Morbidity and is still lacking in Ethiopia. likely to experience increases in the Mortality • Exposure to extreme heat may be high, number of hot days (TMax > 35°C) and especially in urban areas, with occu- tropical nights (>20°C) by 2050 under a pational health risk from heat a major high emissions scenario. concern. Air Quality and • The burden of disease due to poor air • It is challenging to project air quality Respiratory quality is the second highest contributor health risks related to climate change due Health to DALYs across all ages in Ethiopia. to the complex between air quality and • The mortality rate caused by ambient and climate change. household air pollution in Ethiopia was • Increasing temperatures can interact with 144.4 per 100,000 population in 2016, air quality affecting levels of ozone, pollut- with the whole of the population currently ants, and aeroallergens, which in turn can living in areas with PM2.5 concentrations result in acute and chronic adverse health above WHO guidelines. outcomes. • Highly populated areas, such as Addis Ababa will likely be at risk of high air pollution rates, particularly during dry months Mental Health • Information on mental health disorders’ • Increases in extreme weather events, and Well-being incidence and prevalence in Ethiopia such as floods and droughts, increase the is lacking, including associations with incidence of mental health and well-being climate change, particularly extreme concerns. weather events. Climate-Related Health Risks | 35 SECTION IV. ADAPTIVE CAPACITY OF THE HEALTH SYSTEM HEALTH SYSTEM OVERVIEW 1. The Ethiopian health system has three-tier system including primary, secondary, and tertiary levels (Figure 14). The latter is comprised of general and specialized hospitals, and the coverage of each extends to larger portions of the population. The district health office and regional health bureau are accountable to manage, coordinate and distribute supplies as well as render skill transfer. However, the Ministry of Health at the federal level is responsible for policy formulation and acts on critical matters of high-level concern, such as declaring epidemics. FIGURE 14. Ethiopia Health Tier System [109] Specialized Hospital TERTIARY LEVEL 3.5 — 5.0 Million HEALTHCARE General Hospital SECONDARY LEVEL (1 — 1.5 Million) People HEALTHCARE Primary Hospital (60,000 — 100,000) People Health Center 40,000 Health Center PRIMARY LEVEL (15,000 — 25,000) People HEALTHCARE People Health Post (3,000 — 5,000) People URBAN RURAL 37 FIGURE 15. WHO Health System Building Blocks [8] Leadership & Governance Health Workforce Financing Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential Medical Products & Technologies 2. Woreda (or district) transformation has been 4. The extent to which the health system the main scheme of enhancing the health in Ethiopia is prepared for and has the sector. This scheme began in 2015/16 as part capacity to manage changes in hazards, of the first health sector transformation plan exposure, and susceptibility, will determine (HSTP-I). Several woreda transformation related their resilience in coming decades. In this reforms have been implemented, including assessment, Ethiopia’s adaptive capacity3 the Ethiopian primary health care alliance for to prevent and manage climate-related quality (EPAQ), Woreda management standards, health risks is examined according to the and community scorecards. Performance of WHO’s six health system building blocks, the Woreda health indicators is measured as shown in Figure 15 (see also the Annex through demographic and health surveys - A for a summarized Adaptive Capacity and the DHS reports, demonstrating significant Climate Change-Related Health Risks Gap progress of Ethiopia’s health system [110]. Analysis and Annex C for an Adaptive Capacity Rapid Assessment, which inform this section). 3. The emergence of COVID-19 pandemic has It should be noted that several factors outside brought with it a focus on health and health the scope of the health sector can also drive systems, specifically the capacity to manage reductions in adaptive capacity to manage the emerging public health risks. Climate change, health risks of climate change in Ethiopia’s like COVID-19, has the potential to disrupt institutions and people. These include the and overwhelm health systems, including country’s economic challenges, changing healthcare facilities and healthcare staff. The COVID-19 situation is ever-evolving in Ethiopia 3 Adaptive capacity is defined by the IPCC as, ‘the ability of a system to adjust to climate change, moderate potential damages, take advantage with cases continuing to be documented (as of of opportunities, and cope with the consequences’ (IPCC AR5). The June 2022), contributing to additional strains related term, resilience, is the ability to prepare and plan for, absorb, recover from, and more successfully adapt to adverse events. People on the health system as well as additional and communities with strong adaptive capacity have greater resilience. This assessment makes use of the term adaptation and adaptive economic uncertainties. capacity to encompass both terms. 38 | Climate and Health Vulnerability Assessment: Ethiopia demographic patterns, and slowly improving directorates, line ministries, and development social conditions. Promotion of equity as a partners. The development of an updated cross-cutting theme for enhancing the adaptive Health National Adaptation Plan (HNAP) capacity and resilience to the health risks will aim to strengthen the TWG through the of climate change is also critical. Adaptive establishment of a MoH and Climate Change capacity is likely to be greater when access Directorate supported Steering Committee to resources within a community, nation, or for National Climate Change and Health the world is equitably distributed. Adaptation. 7. The Climate Resilient Green Economy (CRGE) LEADERSHIP AND GOVERNANCE strategy (developed in 2010) focuses on 5. The Government of Ethiopia is acutely reducing GHGs emission and using renewable aware of the potential negative impacts of energy resources as major source of energy climate change. As a result, the Government for the country. Ethiopia has also social has been actively developing polices and protection policy which deals prevention, plans to support mitigation and adaptation protection, transformation and promotion actions, as well as signing onto international including post recovering of disasters victims and regional initiatives. Ethiopia submitted its through establishing community based social updated Nationally Determined Contributions security fund. Through this fund, victims of (NDC) in 2021, which updates the Intended flooding, fire, drought, landslide and other Nationally Determined Contributions (INDC) disasters as well as aged and disabled people completed in 2015 and outlines the country’s will get support to recover from. The CRGE climate change and mitigation and adaptation is also integrated into the Second Growth commitments [111]. Health is highlighted as and Transformation Plan (GTP II) (the national a priority area, with six adaptation interven- development plan). GTP II (2016-2020) has tions described (second in number only to mainstreamed CRGE to implement its four agriculture and climate service/disaster risks pillars: modernization of agriculture, indus- reduction). The interventions focus primarily on trialization, transformation and foreign trade vector-borne diseases (malaria), water-borne development. diseases (cholera), and ensuring healthcare facilities are adequality resourced with safe 8. Ethiopia’s National Adaptation Plan (NAP-Eth) water and sanitation and reliable electricity. was submitted for endorsement by the central government in 2017. This plan 6. Under the National Framework of Climate embraces climate change adaptation through Resilient Health Sector (2014) and National the integration with national development Health Adaptation Plan to Climate Change policy frameworks, such as Climate Resilient (2018-2020) a National Climate Change and Green Economy (CRGE) strategy, the second Health Technical Working Group (TWG) was Growth and Transformation Plan (GTP II), and established to lead climate change and health sectoral climate resilience strategies and adaptation activities. The TWG uses existing regional and municipal adaptation plans. health sector institutional arrangements from Other relevant policies and strategies for national to community and household level, as climate change and health adaptation are well as includes members from relevant MoH Environmental Policy of Ethiopia, Agriculture Adaptive Capacity of the Health System | 39 and Rural Development Policy and Strategy, 9. At the sub-national level health-focused Water Resources Management Policy, Health climate change adaptation planning is limited. Sector Development Policy and Program, In Addis Ababa, there are some initiatives National Policy on Disaster Prevention and underway concentrated on the implemen- Preparedness, National Policy on Biodiver- tation of electric public transit systems and sity Conservation and Research, Science reducing air pollution. and Technology Policy, Population Policy and National Agricultural Research Policy 10. The evolution of the climate change and and Strategy. health policy landscape in Ethiopia from 1994 is summarized in Figure 16 (see also Table 5 for a snapshot assessment of climate change and health policies and plans). FIGURE 16. Timeline of Ethiopia’s Climate Change Policies [111] Submission of National (EPACC) Ethiopia Ratification Ethiopia’s Ratification of Initial National Adaptation Program of of the Constritution Kyoto Protocol Communication Programme of Adaptation on UNFCCC 1995 2005 to UNFCCC Action 2007 Cilmate Change 1994 20001 2010 Climate Climate Nationally Submission of Climate Climate Resilient Resilience Resilience Appropriate Second National Resilient & Transport Sector Strategy: Strategy: Mitigation Communication to Green Economy Strategy 2015 Water & Energy Agriculture & Actions UNFCCC 2015 Strategy 2015 2015 Forestry 2015 2010 National Health Second Growth Climate Resilience INDC converts Submission of Adaptation Plan Ratification of the & Transformation Strategy: Urban to NDC INDC to UNFCCC to Climate Paris Agreement Plan (GTPII) Development & March 2017 March 2015 Change (H-NAP) 2017 2016 Housing 2017 2017 Resource National National *Updating Ethiopia’s 10 Year Mobilization Adaptation Plan Adaptation Plan Ethiopia’s Development Strategy for Implementation (NAP-ETH) NDC (2020) Plan NAP-ETH 2020 Roadmap 2017 2020 2017 40 | Climate and Health Vulnerability Assessment: Ethiopia TABLE 5. Assessment of key climate change and health related policies RELEVANCE FOR CLIMATE CHANGE CLIMATE CHANGE AND HEALTH DATE POLICY OR PLAN AND HEALTH RISKS National (Climate Change and Health) Under- Health National Will guide operation of the strategic ap- Vector-borne diseases, wa- development Adaptation Plan II proaches for climate change and health ter-borne diseases, malnutrition, adaptation. heat stress, respiratory disease. 2018-2020 National Health Serves as implementation guidance and Vector-borne diseases, wa- Adaptation Plan to link to the Health Sector Transformation ter-borne diseases, malnutrition, Climate Change Plan for building climate resilience in heat stress, respiratory disease. the health sector. 2014 National Framework of Serves as policy guidance and provide Vector-borne diseases, wa- Climate Resilient Health road map for the realization of Health ter-borne diseases, malnutrition, Sector National Adaptation Plan. heat stress, respiratory disease. National (Climate Change) 2021 Updated Nationally Outlines health as a priority section for Vector-borne diseases, wa- Determined Contribu- adaptation. ter-borne diseases, climate-related tions (NDC) impacts on healthcare facilities. 2017 National Adaptation A framework and process for initiating Vector-borne diseases, wa- Plan (NAP-Eth) the NAP, including identification of ter-borne diseases, malnutrition, priority sectors, which include health. flooding and displacement. 2016 Growth and Provides a national vision for becoming None specified. Transformation Plan a low middle-income country by 2025, (GTP II) which includes aspects of strengthening the health sector 2015 Intended Nationally Provides initial targets for climate None specified. Determined Contribu- change mitigation and adaptation goals, tions (INDC) with impacts on human health briefly mentioned. 2015 2nd National Vulnerabilities, impacts, and adaptation Vector-borne diseases, wa- Communication to the assessment conducted for health sector. ter-borne diseases, malnutrition, UNFCCC heat stress, respiratory disease, risks related to extreme weather events. 2011 Climate Resilient Green Follows a sectoral approach to create Focused primarily on the health Economy (CRGE) a green economy to meet develop- co-benefits of climate change miti- strategy mental goals, with health included as a gation policies. sub-technical committee. National (Health) 2020-2025 Health Sector Climate change mentioned as a threat Focused on building climate Transformation Plan II to the health sector resilience, particularly for WaSH systems 2015-2020 Health Sector Climate change as a threat to human Focused primarily on building Transformation Plan health is highlighted prominently. climate resilience in health sector and prevention infectious disease outbreaks. Adaptive Capacity of the Health System | 41 HEALTH WORKFORCE 13. There are limitations in the health workforce, both in professional expertise and distri- 11. Decentralization of the health system has bution, as well as an overarching lack of improved management and overall capacity information on the awareness of climate of the health workforce in Ethiopia; however, change and health risks among health it still lacks enough medical doctors and workers. The health workforce, particularly nurses to achieve WHO guidelines. Ethiopia doctors, are more concentrated in urban faces numerous health workforce challenges, areas, mostly due to lack of basic services in including urban-rural maldistribution, lack of rural or remote areas (water, road, electricity, proper skill mix, low quality of education, poor education). By 2010 it was reported that 83 absorption capacity, rural retentions issues, percent of doctors were located in urban international out-migration, and insufficient areas [117]. Addis Ababa, for example, has a and irregular salary payments [112]. Simulta- doctor density of 2.9 per 10,000 [116]. On the neously, climate change impacts the health other hand, nurses and midwives are better workforce through mechanisms related to distributed throughout the country, having an changes in the frequency and intensity of extreme weather events that may affect a adequate ratio of nurses per 10,000 population facility or workers’ ability to reach the facility, in most of the regions. There is an uneven as well as altered patterns of climate-sensi- distribution of the health workforce across tive diseases, of which health professionals provinces, with most highly skilled profes- may not be able to respond to in a timely sionals stationed in urban areas. There is manner [113].  no data on the quantity or level of expertise on climate-related health risks in the health 12. Health workforce in Ethiopia is below workforce [117].  the WHO minimum threshold to achieve universal health coverage, 44.5 per 10,000 14. Labor conditions for health workers curtail [114]. In 2020, the country had an estimated health workforce capacity. Current salaries 1.06 medical doctors and 7.84 nurses and of health workers are low and lack adequate midwives per 10,000 population.  In total, there labor conditions, especially in rural areas where are an estimated total of 12,174 registered roads, communications, electricity and other doctors and 90,179 nurses and midwives basic services are limited or lacking. Poor [115]. Despite having a shortage of medical working conditions have triggered the out- doctors and nurses, the country has expanded migration of skilled health workers (especially its workforce by increasing the number of among medical doctors). Decentralization of Community Health Workers (42,630 by 2020 the health system has increased autonomy [115]) and Health Extension Workers (19,927 of lower administrative units in each region, by 2019 [116]). Regarding mental health, there strengthening the efficiency, accountability are no reports on the number of psychiatrists, and capacity to increase health workforce. psychologists, or nurses with mental health Although there is mention of strategic incentive training [115]. On the other hand, the Health packages for health workers, however, there Extension Program, added more than 42,000 are no details on what these packages include, health extension workers since its creation coupled with a reported lack of consistency in 2003, however, it is not clear what is the throughout the regions, health facilities, and role and training of the extension workers. among health workers [112]. Official documents 42 | Climate and Health Vulnerability Assessment: Ethiopia state that incentives have been a key topic of routine health management information (HMIS), discussion, however, it is unclear the current District Health Information System (DHIS2), status of incentive packages or labor conditions electronic community health information [112]. system (eCHIS) and public health emergency management (PHEM). National surveys are 15. Ethiopia’s efforts to increase its health also additional sources of information that use workforce, includes expansion of educational high quality tools and follow global standards. and training opportunities. Public univer- In 2021, the MOH evaluated the strengths sities that offer health-related degrees and areas of improvement for the current reached 23,000 new enrollments by 2015/16. HIS and set the aspired status for 2024 [118]. Educational institutions providing health The findings agree with a similar exercise science programs (public) also increased from conducted by the WHO in 2019 based on 5 in 2003 to 35 in 2016, having that annual the Global Digital Health Index [119]. Figure intake of medical students increased from 17 illustrates the status of HIS across five 152 in 2000 to 3,537 for the period 2015/16 components of Ethiopia’s health sector, with [112]. Specialty training programs have been key needs highlighted across all areas of developed in order to enhance retention the HIS. strategies for the nursing workforce, having programs in neonatal, surgical, pediatrics, 17. The Ethiopian Public Health Institute (EPHI) is emergency, among others. However, there proactive in surveillance of various diseases are no details if these course integrated of local and global public health significance. climate-related health risks. Moreover, the The EPHI is the technical wing of the MOH, country also has in-service training (IST) which is mandated to undertake Public Health and continuing professional development Emergency Management (PHEM) among (CPD) programs in place, aiming at improving other thematic areas in addition to research, capacities, motivation, and overall performance regional laboratory capacity building and of health professionals. These courses are training of health professionals (according to linked to career progression; however, it is revised mandate in 2014). It uses emergency not clear which areas or specific courses it operation centers during serious epidemics provides and how many health workers have and obtains health and other event information benefitted [112]. from respective health facilities on hours to days’ timescales. PHEM uses dashboard for monitoring diseases of epidemic feature, which HEALTH INFORMATION AND are mostly climate-sensitive in nature (e.g., DISEASE SURVEILLANCE malaria, cholera, meningitis, malnutrition, 16. The Ministry of Health of Ethiopia (MoH) and dengue). The frequency of reporting is identified health information systems (HIS) determined by requirements and according to as a key pillar of the health sector transfor- guidelines of the World Health Organization mation plan for 2020-2025, with the aim to and International Health Regulations (IHR) advance collection, analysis, presentation, for various diseases. For example, malaria is and dissemination of information that could reported weekly using WHO week definitions influence decision-making. The key platforms and compares previous subsequent years to for capturing information in the health sector are learn and detect outbreaks in specific adminis- Adaptive Capacity of the Health System | 43 FIGURE 17. Evaluation of Ethiopia HIS across five health sector components [120] I. HIS Leadership and Governance 5 2.47 4 3 2 V. HIS Data Quality and Use II. HIS Management and Workforce 1 3.27 2.99 0 IV. HIS Standard and Interoperability III. HIS Information and Communications 2.38 Technology (ICT) Infrastructure 2.29 trative units (district, zone, and regions). EPHI warning in Ethiopia [121]. Available sources of has had good experience in using dashboards national-level malaria surveillance data have for surveillance of COVID-19 currently and been examined to assess their suitability for Ebola in the past. Emergency Operations supporting a national malaria early warning become functional notified and detected system [122] [123] and a pathway for scaling cases require national response, such as a the EPIDEMIA project to the national level disease outbreak beyond the capacity of local has been developed [124]. Figure 18 identifies health facilities and respective regional states. public health responses to malaria warning and required types of predictions. Additionally, 18. There have been initiatives under the MoH there are on-going efforts to improve detection to use climate information to prevent climate of and response to infectious diseases, such sensitive diseases and to make necessary as training of health professionals to manage preparations to tackle the predicted the current Monkey Pox outbreak, however, disaster, or epidemic disease, with a high there remains a need for improved surveil- focus on malaria. As mentioned, the PHEM lance and diagnostics (including specialized has a dashboard for surveillance of priority training and services) to manage current and climate-sensitive diseases and gives regular future climate-sensitive health risks, such as updates to the Ministry of Health. Moreover, mental health. Overall, the center for PHEM there have been substantial efforts to oper- strives to improve the early notification and ationalize a malaria early warning system in response as well as rehabilitation of the Ethiopia. The EPIDEMIA project and associated affected community, particularly in the case tool has worked to address challenges to of internally displaced peoples (IDPs). applying climate-driven models for malaria early 44 | Climate and Health Vulnerability Assessment: Ethiopia FIGURE 18. Public health responses to malaria warning and required types of predictions [124] PUBLIC HEALTH RESPONSE TYPE OF PREDICTION NEEDED Purchase commodities in Long lead time (>6 months) to anticipation of malaria epidemics Nation allow for preparation Distribute commodities to Medium lead time (1-3 months) and Woredas at risk of epidemics Region geographically accurate to guide resource allocation Implement malaria Zone (Health O ce) Short term (<1 month) and interventions locally precise to Woreda (Health Center) target activities Kebele (Health Post) Note: Levels at the top of the pyramid are largest in geographic area and population size, but fewer in number. At lower levels, more entities encompass smaller areas and fewer people. ESSENTIAL MEDICAL PRODUCTS AND diseases, as well as improving the quality of data and surveillance systems, is believed TECHNOLOGIES to support informed decision-making by local 19. Overall, Ethiopia has a relatively high avail- health authorities. Additional information ability of medical products and supplies, on interaction of human and the natural with a product score4 of 0.51, which was environment to elucidate reservoirs and local slightly higher than the regional average transmission is required. Understanding the of 0.48 [125]. However, challenges remain, transmission cycles, including jungle (sylvatic), including lack of adequate medical storage intermediate (savannah), and urban transmis- conditions and wastage, particularly for health sion of yellow fever, guide interventions [126], center and health posts. There are also issues enabling the identification of the appropriate with procurement, maintenance, and inventory intervention designs. management of medical equipment, along with a gap in testing the efficacy of generic drugs produced in Ethiopia, due to lack of HEALTH SERVICE DELIVERY bioequivalence centers [109]. 21. Overall, Ethiopia has seen significant 20. Building local institutional capacity, partic- advancements in health service delivery in the ularly advanced laboratory techniques last two decades, resulting in improvements for detection and reporting of arbo-viral in several health outcomes [127]. Never- theless, access to health services tends to 4 A score composed of indicators that include readiness of diagnostics disproportionately benefit those with greater and essential medicines, density of pharmacy professionals, and rate of blood donation. economic means or higher levels of education, Adaptive Capacity of the Health System | 45 despite governmental efforts to overcome areas of the country, with thousands of people financial barriers, such as subsidization of more living over 150 km away from a hospital, such than 80 percent of the cost in public health as in Oromia region (Figure 19). Further, many facilities and community-based insurance existing health facilities are not equipped with schemes [124]. the needed resources such as equipment, trained health professionals and essential 22. In most areas of Ethiopia, health facilities infrastructure, such as safe and reliable water (health posts, health centers and hospitals) supply, electricity, means of communication, were built in accordance with the conven- thus leaving many healthcare facilities exposed tional standards for developing countries to climate change related disasters, including [128]. This helps with preventing and managing flooding causalities, drought induced diseases, existing and future diseases burden. Access epidemic climate-sensitive diseases (e.g., to basic health care (measured by access to diarrhea, meningitis, malaria). Many of the a Health Center) reached 96.1 percent in 2017 public health facilities in Ethiopia still struggle with the construction of new health centers and with access to electricity and improved water upgrading previous health posts and clinics sources, with several regions with below 50 to health centers [128]. However, access to percent access for health posts, health centers, healthcare can still be a challenge for some and hospitals (Table 6). FIGURE 19. Population distribution and location of hospitals, 2020 Source: Oak Ridge National Laboratory 46 | Climate and Health Vulnerability Assessment: Ethiopia TABLE 6. Public health facilities accessed electricity and improved water sources by region, 2014 [128] ACCESS TO REGULAR ACCESS TO IMPROVED ELECTRICITY (%) WATER SOURCES (%) REGION HEALTH POSTS HEALTH CENTERS HEALTH POSTS HEALTH CENTERS AND HOSPITALS AND HOSPITALS Tigray 44 64 40 86 Afar 50 70 55 45 Amhara 54 45 63 79 Oromia 18 49 39 74 Somali 15 78 40 48 Benishangul Gumuz 10 47 52 76 SNNP 24 50 39 72 Gambella 15 68 67 77 Harari 24 63 52 94 Addis Ababa N/A 60 N/A 97 Dire Dawa 42 82 65 96 *Red indicates under 50% of healthcare facilities. 23. The Ethiopian Health Extension Programme and lack of consistent reporting system of (HEP) (the country’s flagship for health service the mental health problems [130]. delivery) was designed to serve as a bridge to convey primary health services at community 24. The MoH has made strides to enhance the level. The HEP has 16 packages and majority health sector’s response to extreme weather of them deal with disease prevention and events, such as floods and drought, as well health promotion interventions. The HEP has as other public health emergencies. One obtained remarkable achievements such as important strategy has been the establishment increased institutional delivery, increased family of the Public Health Emergency Management planning utilization, increased latrine coverage, Center, which coordinates and assists all decreased malaria incidence, and decreased efforts to improve the preparedness of the HIV incidence [129]. It was reported in 2021 health sector to prevent or reduce the public that the Ministry of Health in Ethiopia has not health consequences of outbreaks of diseases, yet implemented mental health services as including malnutrition, natural disasters, part of integrated services, but it intends to industrial or technological accidents, displace- do so having included these services into ment of populations, civil unrest, conflicts or their health extension package. Barriers were acts of terrorism and any other emergency identified, such as low political commitment, or disaster situations [127]. Additionally, the shortage of resources, non-functional referral National Policy and Strategy for Disaster Risk system, lack of interest from private health Management (2013) outlines the framework for service organizations, attitudinal problems implementation of multi-sectoral, multi-hazard from both the society and service providers, disaster management systems. The role of the Adaptive Capacity of the Health System | 47 MoH is primarily centered on food shortage expenditure as a percentage of GDP has also induced malnutrition affecting children and declined from 4.37 percent in 2000 to 3.24 mothers and also other human epidemics percent in 2019 [135]. Household out-of-pocket associated with disasters [131]. (OOP) expenditure in Ethiopia is one of the highest in the world [136]. OOP expenditure is high at approximately 37.88 percent of current FINANCING health expenditure, [135] higher than the recommended WHO threshold of 20 percent 25. Ethiopia has in place a Health Care Financing [134]. This has increased from 35.96 percent in Strategy to enhance the countries public 2000 and was highest in 2010 (46.54 percent finance efforts in the health sector. In 1998, of current health expenditure) [135]. Addition- health financing reform was introduced by the ally, as a percentage of current expenditure, Federal Ministry of Health when it developed OOP expenditure (37.88 percent) was higher a Health Care Finance Strategy to increase than domestic general government health resource mobilization, improve efficiency in expenditure (22.7 percent) in 2019 [135]. The the allocation of these resources, [132] and high OOP expenditure has negative conse- promote the sustainability of financing for quences for poorer households. Approximately, health [133]. The strategy highlighted the need 46 percent of rural households faced high for cost sharing to support the government in healthcare expenditure accounting for 10 financing health [133]. Ethiopia’s most recent percent of their total expenditure, while 94 strategy, the National Health Care Financing percent were moved further into extreme Strategy, 2015 - 2035, prioritizes the reduction poverty [136]. Nonetheless, the government has of out-of-pocket expenditure using health partnered with the private sector to enhance insurance schemes and introduced no fees the efficiency of the health system as part of for key services [134]. The National Health its health finance strategy [134]. Accounts is used to monitor the finance strategy. 27. Ethiopia has scaled up a community-based health insurance program, but risk pooling 26. Over the last two decades, total health does not seem to account for climate and expenditure has been low and declining health related risks. A country’s health finance while out-of-pocket expenditure has been system such as health insurance schemes higher than public health expenditure. influences the level of risk pooling. In 2008, Health financing in Ethiopia is mainly Ethiopia developed a health insurance strategy through government, private, and household to support the development of social health expenditure. The country’s public health insurance (SHI) for the formal sector and expenditure has remained below the community-based health insurance (CBHI) recommended share of 15 percent of the total for the informal [137]. As of 2014, the legal budget required to strengthen health systems aspects of the SHI were being initiated (according to the Abuja declaration) and is while the CBHI was being piloted [137]. The below the sub-Saharan average. Although CBHI benefit package includes curative and current health expenditure per capita has health services for families [138]. Following increased from 5.38 percent in 2000 to 26.74 the success of the pilot CBHI, it has been percent in 2019, [135] the health sector in the scaled up to 350 woredas, such that 14.5 country remains under resourced. Health 48 | Climate and Health Vulnerability Assessment: Ethiopia million people had health insurance in 2017 is low. Although, there was an increase in [138]. Although Ethiopia has in place a CBHI, it climate-related expenditure by the Ministry of relies on heavy premium payments which are Health since 2008, financing by the ministry 70 percent of its revenue [139]. Increasing the was only 6 percent of total climate expenditure risk pool can enhance the financial sustain- in 2011/12 [141]. ability of the CBHI [140]. 30. Ethiopia is heavily reliant on donor funds, 28. Climate financing in Ethiopia is low and yet these funds are off-budget and hard shows a huge gap in budgeted versus actual to track. Federal capital expenditure is spending. The majority of financing for climate heavily reliant on donor finance. In 2017/18, is focused on adaptation activities (87 percent) it accounted for 85 percent of the federal compared to mitigation (13 percent) [141]. capital health expenditure [134]. However, Between 2008 and 2012, the share of climate health resources received from donors are expenditure as a percentage of government usually off-budget making it a challenge to track expenditure ranged from 11 percent to 20.2 these resources [134]. With regards to climate percent, representing a 1.8 percent and 2.3 financing, Ethiopia has received substantial percent share of GDP, respectively [141]. During resources from the Official Development the same period, finance credibility was poor Assistance (ODA) and donors, approximately as the difference between the budget and US$ 3.5 billion in 2011 [141]. The World Bank, actual expenditure on climate was as low as African Development Bank, the United States 25 percent of actual expenditure as a share and the UK are biggest providers of finance of what was budgeted [141]. for climate change in Ethiopia [142]. The Green Climate Fund supported Ethiopia with 29. Ethiopia faces a huge financing gap to US$ 265 million and a total of more than respond to climate change. For instance, US$ 799 million was received from the Global the Climate Resilient Green Economy strategy Environment Facility as of 2021 [143]. Donor requires US$ 7.5 billion a year for the country to financing is also heavily focused on climate respond to climate change, yet the government adaptation (64 percent) in Ethiopia [144]. budgets approximately US$ 440 million a However, despite receiving some support for year for climate change [141]. Additionally, climate change from donors (approximately climate expenditure was mainly concen- 20 percent of funding from donors in 2011/12), trated in the Ministry of Agriculture and the there is still a huge financing gap to meet Ministry of Water, Irrigation and Energy [141]. intended goals [141]. The Ministry of Health expenditure on climate Ethiopia faces a huge financing gap to respond to climate change. For instance, the Climate Resilient Green Economy strategy requires US$ 7.5 billion a year for the country to respond to climate change, yet the government budgets approximately US$ 440 million a year for climate change. Adaptive Capacity of the Health System | 49 TABLE 7. Summary of the Health System Adaptive Capacity Gaps for Ethiopia BUILDING BLOCK SUMMARY OF GAPS IN ADAPTIVE CAPACITY Leadership and • Prioritization of climate change and health risks and adaptation options in Governance national policies and plans is high. • Coordination mechanisms (e.g., National Climate Change and Health Technical Working Group) could be strengthened to facilitate cross-sector action on climate change. • Implementation of climate change and health policies and plans, particularly at sub-national levels, has been slow and fragmented. Health Workforce • The health sector faces an imbalance in the number, skill mix and deployment of health workforce, including large urban-rural disparities. • A systematic approach for capacity development of health workforce in climate change, including development and integration of training materials is absent. • Knowledge, technical capacity, and resources of the health workforce to prevent and manage current and future climate-change related health risks remains unknown. Health Information and • Health information and surveillance systems are currently not integrated and do Disease Surveillance not include climate/weather data or other environmental factors. Systems • A climate-informed early warning system for malaria has been piloted, but scale and national operationalization has not been completed. • Data collection and analysis of climate-sensitive diseases at, district, and facility levels remains a challenge. Essential Medical • Management and storage of medical products and supplies is lacking, particularly Products and in rural health centers and posts. Technologies • Laboratory capacities and other health technologies in Ethiopia also need further assessment to better understand the ability to manage current and projected climate-sensitive diseases. Health Service • Many healthcare facilities lack essential services, including safe water and sanita- Delivery tions systems, and reliable electricity. • Climate-resilient healthcare facility and health infrastructure assessments are lacking, including adequate coordination across sectors to ensure climate risks are being incorporated into infrastructure planning. • Climate change and associated impacts are not mainstreamed into the opera- tions of health programs at all levels. • Baseline information is lacking on key environmental determinants of health. Health Financing • Financing gaps exist to adequately respond to climate change impacts in the health sector, including budget versus spending. • Risk pooling does not account for climate change-related health risks. • Budgets within the health sector, including for climate change adaptation planning need to clarify amounts and the incorporation of climate change risks. 50 | Climate and Health Vulnerability Assessment: Ethiopia SECTION V. RECOMMENDATIONS TO ENHANCE HEALTH SYSTEM RESILIENCE TO CLIMATE CHANGE 1. This section outlines a set of recommendations to enhance health system resil- ience and adaptation to climate change, including potential health interventions and strategies. The recommended options are based on an assessment of both the magnitude of the current and projected climate-related health risks and the existing gaps in adaptive capacity to manage and/or prevent these risks. This section is organized using the 10 components of climate-resilient health systems (Figure 20) and drawing from consultations and review of all relevant governmental policies, as well as the World Bank HNP Climate and Health Guidance Note. See Annex B for a summarized menu of health adaptation recommendations across key health risks and Annex D for an extended list of recommendations for building a climate-resilient health system across the identified climate change-related health risks. FIGURE 20. WHO’s Operational Framework for Building Climate-Resilient Health Systems [8] ATE RESILIENCE CLIM hip & Heal ders Workf th Lea vernance orce Go V uln pac ation t Fin alth & A Ca apt men He ate era ity & Leadership As g d ess Clim cin bil & Governance Health s ity, an Workforce Financing P paredness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS e Service r 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 Res le ir o n f C li m a t e b in a D et m ental & S u st a gies ri m e o lo n ts n of H Te c h t ur e e a lt h r a s tr u c & Inf 51 COMPONENT 1: LEADERSHIP planners, using workshops and policy briefs, to use climate information to inform design of AND GOVERNANCE health sector programs and enhance day to Options to strengthen leadership and governance day service delivery as well as during and after include: extreme weather events, such as flooding. → Integrate health into national and sub-na- tional level climate adaptation planning with priorities being the finalization of the Health COMPONENT 2: HEALTH WORKFORCE National Adaptation Plan (HNAP), next iteration Options to strengthen the health workforce include: of the National Adaptation Plan (NAP-Eth), as well as the next round of NDCs. This should → Develop educational and awareness raising include detailed descriptions of priority materials and implement training for healthcare climate change-related risks, health sector workers to better understand the health adaptation options, and opportunities to link impacts of climate change, including the with non-health sectors. It will also be important utilization of train the trainer (ToT) models. to link with the National Framework for Climate This may include capacity building activities, Services, of which Ethiopia is currently at the such as targeted training for health personnel planning and costing phase [145]. to manage changes in vector-borne disease (especially malaria) and food insecurity/ → Support the formalization and resourcing of the National Climate Change and Health under-nutrition, particularly as sub-national Technical Working Group, led by the Ministry levels, as well as how to conduct epidemio- of Health, including establishment of regular logical analyses of climate-sensitive diseases meetings and increased involvement across and vulnerability and adaptation assessments. sectors to facilitate effective implementation of policies, strategies, and plans. This may include signing a memorandum of under- COMPONENT 3: standing between the Ministry of Health and VULNERABILITY, CAPACITY AND other key stakeholders at the national level, ADAPTATION ASSESSMENT including other sectors such as agriculture, planning and development, and transportation, Options to strengthen vulnerability, capacity and as well as clarification of the focal point on adaptation assessments include: climate change and health in MoH to better → Utilize modeling techniques, including climate, facilitate coordination across sectors and disease, and economic scenarios to guide departments. future vulnerability adaptation assessments. → Advance / develop contextualized commu- This could integrate outputs from tools currently nication tools climate-related health risk and under development by the World Bank advocacy at all levels including the senior including the Climate and Health Economic officials and politicians as well as the general Valuation Tool (CHEVT) as well as others. public at higher risk. This may also include These tools would make use of information sensitizing health sector policy makers and collected in this and other CHVAs. 52 | Climate and Health Vulnerability Assessment: Ethiopia COMPONENT 4: INTEGRATED RISK COMPONENT 6: CLIMATE-RESILIENT MONITORING AND EARLY WARNING AND SUSTAINABLE TECHNOLOGIES Options to strengthen integrated risk monitoring AND INFRASTRUCTURE and early warning systems include: Options to strengthen the climate resilience of → Support expanded, enhanced, and electronic health technologies and infrastructure include: coverage of health surveillance for climate-sen- → Develop and implement national building sitive diseases, for example in terms of codes/permits for healthcare facilities, including geographic, population, and seasonal retrofitting, refurbishing, and maintaining aspects. This would include linking with existing health infrastructure. Importantly this environmental/meteorological monitoring should include the incorporation of climate structures to develop climate-informed early risk projections into these codes/permits warning systems and response mechanisms. for examples to include siting and construc- For example, this could build on efforts to tion, functioning and operation, energy and develop a climate-informed early warning water supplies, storm drains and sewers, and system for malaria. sanitation services of health care facilities, as well as a focus on improving the transpor- tation network to ensure access to facilities COMPONENT 5: HEALTH AND during extreme weather events. CLIMATE RESEARCH Actions have also been identified that will Options to strengthen climate and health research contribute to enhanced sustainability and reduced include: greenhouse gas emissions in the health sector → Supporting research priorities for specific such as: climate-related health risks, including studies → Assess the carbon footprint of Ethiopia’s on climate-resilient and nutritious crops, health sector. assessing extreme heat impacts among workers and interventions to improve occupa- → Prioritize sustainability in selection of health tional health, analysis of water demands under system procurement strategies procedures different climate scenarios, and assessing the and products, this would include focus on influence of frequency, timing, and magnitude incorporation of low-carbon, energy efficient of rainfall on VBDs, as well as the concomitant technologies, such as photovoltaic cells, role between VBDs and under-nutrition in solar-powered machinery, vaccine chains vulnerable populations given high rates of and water pumps. food insecurity. → Promote modern energy cooking solutions (MECS) such as low emission cookstoves to reduce solid fuel use and household air pollution. → Develop regulations that support sustainable healthcare waste management (e.g., shifting from medical waste incineration and promoting recycling of non-hazardous waste at facility levels where possible). Recommendations to Enhance Health System Resilience to Climate Change | 53 COMPONENT 7: COMPONENT 9: EMERGENCY MANAGEMENT OF ENVIRONMENTAL PREPAREDNESS AND MANAGEMENT DETERMINANTS OF HEALTH Options to strengthen emergency preparedness Options to strengthen the management of envi- and management for climate change related ronmental determinants of health include: disasters include: → Develop improved national regulations and → Establish seasonal and sub-seasonal climate policies on key environmental health services outlooks (Ministry of Health in collaboration and determinants (e.g., drinking water, air with Ethiopian Meteorological Institute) to quality, food system, housing, transport, inform disease control / prevention programs energy, and waste management). This could ahead of potential extreme weather events, and include the establishment and maintenance of facilitate multisectoral engagement with first-re- a climate and environmental health database sponders, disaster management authorities, to support development of national regulations community-based groups, to conduct outreach on the management of environmental health and awareness regarding climate-sensitive services (e.g., water supply, sanitation, and diseases. air quality) and perhaps leveraging opportu- nities to engage the World Meteorological Organization Africa headquarters located in COMPONENT 10: CLIMATE AND Addis Ababa. HEALTH FINANCING Options to strengthen climate and health financing include: COMPONENT 8: CLIMATE-INFORMED → Ensure strategic purchasing (e.g., increasing HEALTH PROGRAMS equitable distribution of resources) includes Options to strengthen climate-informed health climate considerations [146]. This should be programs include: tailored to include climate considerations → Strengthen primary health care and existing across the national and sub-national levels. programs through actions to ensure these The impact of climate on utilization of resources systems have improved adaptive capacity, needs to be factored into provincial and district including knowledge and resources to manage health investment plans to build climate current and future climate change-related resilience at sub-national levels and support risks. Activities may include revised public continued investment in poverty reduction, health program standard operating procedures health equity promotion, and increased (SOPs) to incorporate responses to climate access to essential services. 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Health mental health and interventions warning system WASH climate-resil- impacts of extreme needs improving, for food security scale up is lacking. ient infrastructure. heat mentioned including link with and nutrition are Sub-national inter- in climate change climate-related lacking. ventions lacking. or health sector disasters, and policies or improved care planning, although for mental health no interventions issues. highlighted. Health Climate change not Training linking Baseline un- MoH staff have not Specialist training Workforce incorporated into climate / weather derstanding of completed training and services training models variables to VBD, WASH and climate on identifica- needed for mental across programs particularly epide- relationship and tion and clinical health. miology and the interventions is responses for use of climate / needed, including extreme heat. weather data at building from sun-national levels. Health Further assessment Improving basic Climate data not MoH does not No baseline data information needed to under- surveillance for integrated into HIS. record heat-attrib- on mental health and disease stand relation- VBD needed and No risk assess- utable mortality. No related to climate surveillance ships between further integration ment for WBD and mapping of urban change. Further system climatic factors of climate / mete- climate change. hot spots to identify exploration of com- and nutrition / food orological data for No EWS for wa- at-risk popula- munity-centered insecurity - building early warning. ter-borne diseases. tions. No EWS for resilience building from WFP surveys. extreme heat. and targeting vulnerable popula- tions needed. Essential No baseline Laboratory, testing, Distribution of Healthcare fa- Need for need for medical information on and control essential med- cilities have not improved surveil- products, equipment / med- capabilities need ications (e.g., been assessed to lance and diag- technologies, ication related to to continue to be vaccines) are determine potential nostics for mental and under-nutrition, strengthened for lacking in rural / risks related to health. infrastructure including new tech- effective malaria remote areas. extreme heat, and nologies related response and elim- cooling measures to sustainable ination. have not been agriculture. implemented. 59 HEALTH SYSTEM SELECTED CLIMATE CHANGE-RELATED HEALTH RISKS BUILDING FOOD SECURITY AND VECTOR-BORNE WATER-BORNE AND HEAT-RELATED MENTAL HEALTH BLOCKS NUTRITION DISEASE WATER-RELATED MORBIDITY AND AND WELL-BEING DISEASES MORTALITY Health service Strengthening Climate change Lacking baseline There are no Assessment and delivery nutrition programs not incorporat- information on extreme heat treatment of mental in remote, rural ed into standard safe WASH in programs in NDoH health and well-be- areas needed, operating proce- healthcare facilities – extreme heat not ing not included in particularly before, dures for VBD. and interventions included in DRM health services. during, and after Community-based needed to improve plans / operations. drought. interventions / resilience to awareness building climate change. can include link between VBD and climate change. Financing Climate-smart ag- Surveillance Distribution of Extreme heat not Increases in riculture systems, of malaria and funds for improved prioritized in health resources allocated including water dengue need in- WASH, especially sector budget to mental health harvesting and irri- vestment as well as in rural areas is planning. within MoH gation to manage additional analysis needed. needed. rainfall variability of VBD risk asso- needed. ciated with climate change. 60 | Climate and Health Vulnerability Assessment: Ethiopia ANNEX B. HEALTH ADAPTATION RECOMMENDATIONS: MENU OF OPTIONS COMPONENT FOOD SECURITY AND VECTOR-BORNE WATER RELATED HEAT-RELATED MENTAL HEALTH NUTRITION DISEASE DISEASES MORBIDITY AND AND WELL-BEING MORTALITY Component 1: Incorporation of Establishment of a Promotion of Develop and Development of Leadership and climate change multi-institutional climate-resilient implement national a national mental Governance risks into food steering committee water safety heat health policy health strategy and security and to monitor scale-up planning. and city-level plans. action plan. nutrition strategic and make key plans, including implementation sustainable agricul- decisions for ture efforts. climate-informed early warning system. Component2: Incorporation of Training at sub- Awareness raising Conduct heat- Training for Health educational national levels to for health workers health training for community health workforce materials on enhance capacity climate change health workers. workers on mental climate change of epidemiological impact on WASH Ensure occupation- health awareness impacts on food analysis, as well and WBD. al heat exposures and interventions, security and as knowledge of are managed. especially following nutrition into health climate change-re- extreme weather worker training. lated factors. events. Component 3: Vulnerability District and Vulnerability Conduct assess- Further exploration Vulnerability, assessment of community level assessment to ment for high-risk of impact of climate capacity and nutrition to climate assessments to water shortages, groups at city-level, change on mental adaptation as- change. Assess- better under- rainfall extremes, including informal health, as well as sessment ment of nutrition stand local risks unpredictable river settlements community-based benefits of climate- related to VBD and flows, and baseline and incorporate resilience building smart agricultural capacity to manage WASH coverage in economic analyses. interventions. interventions. outbreaks. healthcare facilities Component 4: Development Scale and opera- Integration of Heatwave alert Develop mental Integrated risk and inclusion of tionalization up of climate/weather systems for urban health surveillance monitoring and long-term strate- climate-informed information with and rural popula- system. early warning gies for nutrition early warning WBD surveillance tions. interventions into system for malaria systems to forecast drought early outbreaks. warning system Component 5: Analysis of Conduct additional Modeling water Studies to further Studies on mental Health and long-term effects of climate change security/demand explore impacts of health impact of climate research food insecurity modeling studies projection under extreme heat on climate change on health and to estimate malaria different climate health systems, and potential economy. risk projections and scenarios and including urban community- inform adaptation impact on WBD. heat island level interventions. decisions. mapping. Component 6: Improved drainage Improve laboratory Improved WASH Space cooling in Support develop- Climate-resilient systems in crop capabilities for systems in health- healthcare facilities ment of mental and sustainable fields at risk to testing and care facilities to to prevent over- health centers to technologies floods. Exploration diagnosis of withstand extreme heating and protect support distribution and infrastruc- of smart-agriculture endemic as weather events IT and equipment. of services in rural ture and crop diversifi- well as novel (e.g., drainage areas. Energy efficient or cation practices. and remerging systems and passive measures diseases. Develop healthcare waste of cooling to a list of essential management). reduce energy medicines needs costs. for VBD outbreaks. Annexes | 61 COMPONENT FOOD SECURITY AND VECTOR-BORNE WATER RELATED HEAT-RELATED MENTAL HEALTH NUTRITION DISEASE DISEASES MORBIDITY AND AND WELL-BEING MORTALITY Component 7: Community-led Community Improve household Housing standards Engagement with Management of efforts to map food awareness water security and urban planning communities environmental insecurity campaigns and sanitation (built environment) to assess and determinants of and inform to increase practices. to reduce heat improve mental health interventions awareness of risks and improve health and well- (e.g., gardening climate sensitivity water security. being, including programs) to of VBD and engage Occupational reducing stigma improve the vulnerable groups health manage- and building food system in a on outbreak pre- ment. awareness. changing climate. vention. Component 8: Interventions Incorporation of SOPs for drinking Ensure heat risks Mental health Climate- involving the climate change water and sani- are incorporat- program informed health establishment of information into tation provision. ed into maternal developed in MoH. programs gardens or food VBD prevention Public awareness- health guidance, growing opportu- and outbreak raising campaigns guidance for NCD nities. Community response SOPs. are conducted on (e.g., diabetes man- mediated delivery hygiene, particular- agement). of nutrition ly handwashing. services including screening. Component 9: Food production Inclusion of VBD Develop WASH- Extreme heat Mental health Emergency pre- and distribution disease outbreaks focused included into impacts related to paredness and chain is reinforced into disaster risk emergency pre- disaster risk man- extreme weather management to withstand management paredness and agement opera- events incorpo- impacts from plans at national, response plans, tions. rated into disaster extreme weather regional, district, including stockpil- risk management events. and community ing and distribution planning. levels. plan for supplies (e.g., purifiers, safe water storage) Component 10: Investments in Formation of Allocate resources Financing of sus- Strengthened Climate and dissemination of proposals for to build climate- tainable cities/cool resource allocation health financing crop varieties and external donors to resilient WASH cities that address for improved breeds adapted to support improved district level heat risks. mental health changing climatic control of VBD, par- operation plans. services. Other interventions condition. ticularly malaria . related to heat- health responses (e.g., cool roofs). 62 | Climate and Health Vulnerability Assessment: Ethiopia ANNEX C. ADAPTIVE CAPACITY RAPID ASSESSMENT This information represents an initial review and will need to be confirmed with additional engagement with the stakeholders). LEADERSHIP AND GOVERNANCE Questions Assessment Yes Partial No N/A 1.1: Does the country have a national climate change and health plan / strategy? 1.2: Is health mentioned as a priority in the Nationally Determined Contributions (NDCs)? 1.3: Is there a designated focal point responsible for health and climate change in their ministry of health? 1.4: Is there a multi-sectoral technical working group/committee focused on climate change and health? 1.5: Does the MoH actively participate in climate change coordination and/or working groups? 1.6: Is there a MOU between the MoH and key climate change related Ministries / De- partments (e.g., Environment, Meteorological Services, Agriculture, Water)? 1.7: Are decision-makers (both within MoH and outside) aware of climate change and health risks and potential adaptation options? 1.8: Does relevant information related to climate change and health risks and adapta- tion reach key stakeholders across sectors? 1.9: Is climate change included in health plans at sub-national levels? HEALTH WORKFORCE Questions Assessment Yes Partial No N/A 2.1: Are there dedicated full-time staff devoted to climate change and health? 2.2: Are the number of healthcare workers above 4.5 per 1000? 2.3: Are health workers adequately distributed between urban and rural areas? 2.4: Is the health workforce aware of the health risks of climate change? 2.5: Are there capacity building programmes focused on climate change and health within the Ministry of Health? 2.6: Have MoH staff received training on climate change and health in the last two years? 2.7: Does the health workforce have the technical capacity to interpret and utilize climate change information (e.g., scenarios, projections, forecasts) to inform planning / decision-making? 2.8: Is climate change and health included in the educational curriculum (e.g., schools of public health, medicine, nursing)? 2.9: Are context or country specific climate change and health training / educational materials for the health workforce? Annexes | 63 HEALTH INFORMATION AND DISEASE SURVEILLANCE SYSTEM Questions Assessment Yes Partial No N/A 3.1: Has the country completed a climate change and health vulnerability and adapta- tion or risk assessment? 3.2. Do surveillance systems exist for climate-sensitive diseases (e.g., heat related illnesses, VBD, WBD)? 3.3: Does the country have a centralized monitoring system for climate-related diseases? 3.4: Do health surveillance systems integrate meteorological and/or environmental information? 3.5: Are there efforts from the MoH to utilize national climate / meteorological informa- tion? 3.6: Does the country have a climate-informed early warning system for any health risks? 3.7: Are there early warning systems in place for climate change related extreme events / hazards? (e.g., flooding, drought, storms)? 3.8: Does the Ministry of Health coordinate with disaster/hazard focused early warning systems? ESSENTIAL MEDICAL PRODUCTS, TECHNOLOGIES, AND INFRASTRUCTURE Questions Assessment Yes Partial No N/A 4.1 Has the country’s healthcare facilities been assessed for climate resilience? 4.2 Are health facilities accessible for rural communities? 4.3: Do healthcare facilities implement measures to remove mosquito breeding sites? 4.4: Have healthcare facilities employed adaptive measures to protect against climate change related hazards (e.g., flood walls or drainage systems)? 4.5: Does the national laboratory have the capacity to conduct diagnostic tests for climate-sensitive diseases? 4.6: Are building codes for healthcare facilities to protect against climate change related hazards in place and enforced? 4.7: Have healthcare facilities implemented ‘greening’ activities (e.g., tree planting, cooling designs)? 4.8: Are there efforts to incorporate long-term planning (e.g., urban design) to reduce climate change and health impacts? 4.9: Are health facilities adequately equipped to prepare for and respond to climate change related hazards (e.g., stockpile of medical/emergency supplies)? 64 | Climate and Health Vulnerability Assessment: Ethiopia HEALTH SERVICE DELIVERY Questions Assessment Yes Partial No N/A 5.1: Has the country enacted legislation mandating universal healthcare coverage? 5.2: Are there climate change specific health programmes underway in the country? 5.3 Does health service delivery have contingency measures for extreme weather events e.g., floods, storms, heatwaves)? 5.4: Does current public health planning consider climate change information (e.g., scenarios, projections, forecasts)? 5.5: Has the MoH implemented any climate-health awareness campaigns to increase public awareness? 5.6: Is there access to safe WASH for over 80 percent of the country? 5.7: Do over 80 percent of healthcare facilities have access to safe WASH and health- care waste removal / storage? 5.8: Have multi-hazard risk assessments been conducted in the country? 5.9: If conducted, do multi-hazard risk assessments include potential health risks? FINANCING Questions Assessment Yes Partial No N/A 6.1: Is the Ministry of Health currently receiving international funds to support climate change and health work? 6.2: Is there dedicated funding within the MoH for climate change and health activities? 6.3: Is the health expenditure percentage of GDP above WHO recommendation? 6.4: Is the national health budget dependent on donors or foreign aid? 6.5: Are there climate considerations in the national health budget? Annexes | 65 ANNEX D. LONG LIST OF National (Health sector) RECOMMENDATIONS • Finalize Health National Adaptation Plan (HNAP) which should incorporate all available evidence and senior endorsement to facilitate COMPONENT 1: LEADERSHIP AND GOVERNANCE implementation. This should also be closely Options to strengthen leadership and governance aligned with the National Adaptation Plan, include: serving as the health component of the NAP National (Climate Change) to facilitate integration and enable multi-sec- • Integrate health into national level climate toral approaches to be implemented. adaptation planning with a priority being the • Systematically integrate adaptation activities iteration of the National Adaptation Plan, as to respond to identified climate-related health well as the next round of NDCs. This should risks when updating the Health Sector Trans- include detailed descriptions of priority climate formation Plan II (2020-2025), as well as work change-related risks, health sector adaptation to incorporate stronger climate and health options, and opportunities to link with non- actions into at-risk programs, such as food health sectors, as well as utilize the National security, nutrition, WaSH, malaria and other Framework for Climate Services. climate-sensitive diseases. • Utilize the National Climate Change and Health • Clarify the unit / focal point on climate change Technical Working Group, led by the Ministry and health in MoH to better facilitate coordi- of Health to increase engagement through nation across sectors and departments. the formalization, including regular meetings • Develop and deliver climate and health related and increased involvement across sectors to workshops and national policy briefs aimed at facilitate effective implementation of policies, senior health sector policymakers, as well as strategies, and plans. This may include signing with other key sectors, to advocate and develop a memorandum of understanding between the climate and health policies and plans at the Ministry of Health and other key stakeholders national level. This may include sensitizing at the national level, including other sectors health sector policy makers and planners to such as agriculture, planning and development, use climate information to inform design of and transportation. health sector programs and enhance day to • Advance / develop contextualized commu- day service delivery as well as during and after nication tools climate-related health risk and extreme weather events, such as flooding. advocacy at all levels including the senior officials and politicians as well as the general Sub-national public at higher risk. This may also include • Develop sub-national adaptation plans, increasing awareness among policymakers including at Woreda (district) and city-levels and the private sector about the impact of for climate change and health to enable pri- climate change on health, and the environ- oritization of adaptation needs and ensure mental determinants of health. allocation of sufficient financial resources for implementation. 66 | Climate and Health Vulnerability Assessment: Ethiopia COMPONENT 2: HEALTH WORKFORCE at least every five years. This could include Options to strengthen the health workforce include: further exploration of impacts and adaptation at sub-national levels, including evaluation of • Conduct a workforce climate and health needs adaptation interventions, as well as reviewing and knowledge assessments to integrate the climate resilience of current healthcare climate change-related impacts into workforce infrastructure, such as impacts from extreme planning. This would include considerations weather events such as flooding (flash and of the size of the health workforce, the skill riverine). mixes and the geographical distributions of personnel needed to meet expected health • Utilize modeling techniques, including climate, needs (e.g., addressing urban-rural disparities). disease, and economic scenarios to guide future vulnerability adaptation assessments. • Create a national curriculum that integrates This could integrate outputs from tools currently climate-related health threats into medical and under development by the World Bank including nursing schools as well as for all other health the Climate and Health Economic Valuation professionals to ensure the health workforce Tool (CHEVT) as well as others. These tools for tomorrow have the knowledge and skills would make use of information collected in to deliver health care in a changing climate. this and other CHVAs. • Develop educational and awareness raising • Review the extent to which current health in- materials and implement training for healthcare formation systems incorporate meteorological workers to better understand the health impacts variables for climate-sensitive diseases, notably of climate change, including the utilization of malaria and other vector-borne diseases. train the trainer (ToT) models. This may include capacity building activities, such as targeted training for health personnel to manage COMPONENT 4: INTEGRATED RISK MONITORING changes in vector-borne disease (especially AND EARLY WARNING malaria) and food insecurity/under-nutrition, Options to strengthen integrated risk monitoring particularly as sub-national levels, as well as and early warning systems include: how to conduct epidemiological analyses of climate-sensitive diseases and vulnerability • Support expanded, enhanced, and electronic and adaptation assessments. coverage of health surveillance for climate-sen- sitive diseases, for example in terms of geo- graphic, population, and seasonal aspects. COMPONENT 3: VULNERABILITY, CAPACITY AND This would include linking with environmental/ ADAPTATION ASSESSMENT meteorological monitoring structures to develop Options to strengthen vulnerability, capacity and climate-informed early warning systems and adaptation assessments include: response mechanisms. For example, this could build on efforts to develop a climate-informed • Continue to conduct climate change and health early warning system for malaria. vulnerability and adaptation assessments to capture new information and engage stake- • Support hospitals to update their admis- holders, including conducting more advanced sions and emergency case records to track analyses, and prioritization of adaptation in- heat-related morbidity and mortality, as well terventions. Assessments should be repeated as other climate-sensitive diseases, starting Annexes | 67 with Afar, Somali, and Gambela regions, which → modelling studies to quantitative current are projected to experience increased in heat and projected burden of climate-sensitive index and tropical nights. diseases; • Develop/improve/expand early warning systems → economic analyses to better understand for extreme weather events, such as heatwaves healthcare costs related to climate change; and flooding, to better integrate and dissem- → the quantification of health co-benefits of inate health information (e.g., vector-borne climate change mitigation actions; and water-related disease outbreaks following → operational research to test and evaluate flooding events) and link with disaster risk the implementation of evidence-based management and other key stakeholders. interventions, such as targeted resource • Review extent to which human, animal and deployment for extreme weather events; plant disease surveillance systems are in- and tegrated and incorporate climate factors to → development and testing of contextualized ensure a One Health approach is utilized and climate change and health risk commu- strengthened. nication materials and dissemination • Collect information to establish and central- approaches. ize agreed baselines for monitoring vulnera- • Additionally, research priorities for specific ble populations/regions and existing or new climate-related health risks may include health-related human resource, technical and studies on climate-resilient and nutritious health services delivery capacity, to be linked crops, assessing extreme heat impacts among with the national climate change and health workers and interventions to improve occupa- action plan (e.g., HNAP). tional health, analysis of water demands under different climate scenarios, and assessing the • Support the identification and/or development influence of frequency, timing, and magnitude of indicators to measure climate change and of rainfall on VBDs, as well as the concomi- health impact and response capacity to be tant role between VBDs and under-nutrition integrated into national and sub-national mon- in vulnerable populations given high rates of itoring systems. This would also support future food insecurity. climate change and health vulnerability and adaptation assessments. COMPONENT 6: CLIMATE-RESILIENT AND SUSTAINABLE TECHNOLOGIES AND COMPONENT 5: HEALTH AND CLIMATE INFRASTRUCTURE RESEARCH Options to strengthen the climate resilience of Options to strengthen climate and health research health technologies and infrastructure include: include: • Conduct an assessment of the climate vul- • Continue to develop research partnerships nerability of current health infrastructure in (e.g., national and international academic in- Ethiopia, including closely linked systems (e.g., stitutions) to conduct studies and projects on transportation, energy, and water and sanitation key climate change and health topics, such as: systems and infrastructure). This could include agreeing on a minimum threshold for health 68 | Climate and Health Vulnerability Assessment: Ethiopia care infrastructure and build from plans to cooling, medical cold chains and ensure sus- conduct an assessment of healthcare facilities tainable refrigerant technologies are used. using the WHO guidance on climate resilient These measures should follow a hierarchy of and environmentally sustainable in Ethiopia. interventions starting from passive measures such as building design and vegetative shading • Assess current laboratory capacities to through to more active technologies such as diagnose current and future climate-related powered air conditioning as a secondary option. diseases, particularly emerging and reemerging communicable diseases, such as vector-borne • Development of structures to integrate health diseases (e.g., dengue and chikungunya), as and climate considerations into urban design well as NCD burdens. to reduce the threat of urban heat islands with a focus on informal settlements. This could • Develop and implement national building involve strengthening health impact assess- codes/permits for healthcare facilities, including ments through specific initiatives such as retrofitting, refurbishing, and maintaining continued support for urban tree planting in existing health infrastructure. Importantly this cities, cool roof interventions (e.g., painting should include the incorporation of climate roofs white). risk projections into these codes/permits for examples to include siting and construction, Actions have also been identified that will functioning and operation, energy and water contribute to enhanced sustainability and reduced supplies, storm drains and sewers, and sani- greenhouse gas emissions in the health sector tation services of health care facilities, as well such as: as a focus on improving the transportation network to ensure access to facilities during • Assess the carbon footprint of Ethiopia’s health extreme weather events. sector. • Support the integration of new and innovative • Prioritize sustainability in selection of health technologies to monitor environmental change system procurement strategies procedures (e.g., satellite imagery) to inform measures that and products, this would include focus on in- will improve the performance of the health corporation of low-carbon, energy efficient system, for example to direct support local technologies, such as photovoltaic cells, so- health capacity planning to respond to an- lar-powered machinery, vaccine chains and ticipated increases in water-related diseases water pumps. and food insecurity due to climate change. • Promote modern energy cooking solutions Other examples would relate to drought and (MECS) such as low emission cookstoves nutrition, precipitation, heat, humidity and to reduce solid fuel use and household air VBDs, as well as mapping air quality impact pollution on health outcomes. Mental health services should also need to be considered. • Develop regulations that support sustainable healthcare waste management (e.g., shifting • Introduce sustainable cooling measures (e.g., from medical waste incineration and promoting painting roofs white, increasing natural venti- recycling of non-hazardous waste at facility lation, integrating solar and biomass energy levels where possible). sources) for health care facilities and laborato- ries, which enhance energy efficiency, space Annexes | 69 COMPONENT 7: MANAGEMENT OF COMPONENT 8: ENVIRONMENTAL DETERMINANTS OF HEALTH CLIMATE-INFORMED HEALTH PROGRAMS Options to strengthen the management of envi- Options to strengthen climate-informed health ronmental determinants of health include: programs include: • Develop improved national regulations and • Use mainstream and social media, to spread policies on key environmental health services awareness and issue warnings related to pre- and determinants (e.g., drinking water, air ventive measures to improve population health quality, food system, housing, transport, literacy related to climate sensitive health risks. energy, and waste management). This could • Engage community groups (focusing on youth include the establishment and maintenance of and women’s groups) to support dialogue a climate and environmental health database and development of prospective climate and to support development of national regulations health programs and policy options as well as to manage environmental health services (e.g., integration into the planning and support of water supply, sanitation, food safety, etc.). health promotion programs directed towards cli- • Map areas using unsafe drinking water and mate-related health threats. This could include unimproved sanitation facilities, and assess mobilizing communities to better adapt to the service delivery gaps, and investment in health consequences of climate change, as improved drinking water, sanitation, and sewage well as other impacts. infrastructure to improve water quality and • Strengthen primary health care and existing reduce climate-driven exposures. programs through actions to ensure these • Establish an improved centralized healthcare systems have improved adaptive capacity, and medical waste management system that including knowledge and resources to manage can withstand the impacts of extreme weather current and future climate change-related risks. events. Activities may include revised public health program standard operating procedures • Support community led efforts to improve san- (SOPs) to incorporate responses to climate itation practices and controls to prevent water risks and delivery of interventions, as well as and foodborne diseases, as well as communi- mainstreaming of climate change risks into cate the potential climate change-related risks. relevant policies and operational plans for • Increase support and integration with non- vector-borne disease, water-related disease, health sector (e.g., energy, agriculture, fisheries, and nutrition programs. industry, water supply and sanitation, transport, and urban and rural planning) focused interven- tions. This could include, for example, promotion COMPONENT 9: EMERGENCY PREPAREDNESS of sustainable and climate-smart agricultural AND MANAGEMENT practices by smallholder farmers, appropriate Options to strengthen emergency preparedness modelling tools to assist strategic planning of and management for climate change related water resources under climate change, and/or disasters include: technical guidelines that incorporate climate • Establish a national risk register that includes change to increase supportive supervision, climate change related risks and if necessary, monitoring and testing of potable water and implement a process of national risk assessment sanitation services. 70 | Climate and Health Vulnerability Assessment: Ethiopia to enable the prioritization of climate-relat- • Establish a budget line item at the national level ed health risks alongside other national level to finance critical preparedness activities and threats. adaptation interventions. • Enhance contingency planning for deploy- • Initiate pooling health funds to cover climate-re- ment and response (at national, regional, and lated health risks. This could include consideration district levels) for acute climate shocks, such as of a pre-payment mechanism providing financial flooding and consequent disease outbreaks, protection for climate-related health impacts as well as longer-term climate stressors such through the pooling of resources. as drought. This should include integrating • Ensure strategic purchasing (e.g., increasing climate-related health considerations into equitable distribution of resources) includes district-level and community-level disaster climate considerations5. This should be tailored to management plans to support stakeholders include climate considerations across the national in organizing activities relating to the pre- and sub-national levels. The impact of climate on paredness of emergency responses, as well utilization of resources needs to be factored into as stockpiling and distribution plans to support provincial and district health investment plans to disaster response supplies (e.g., water purifiers build climate resilience at sub-national levels and and safe water storage containers). support continued investment in poverty reduction, health equity promotion, and increased access to • Establish seasonal and sub-seasonal climate essential services. This should also incorporate outlooks (Ministry of Health in collaboration with mitigation activities such as solarization of health Ethiopian Meteorological Institute) to inform facilities. disease control / prevention programs ahead of potential extreme weather events, and fa- • Explore financial benefits of health co-benefits cilitate multisectoral engagement with first-re- of climate action. The economic benefits of sponders, disaster management authorities, mobilization of financial resources in Ethiopia community-based groups, to conduct outreach aim to support the health sector in assessing the and awareness regarding climate-sensitive co-benefits of climate action in other health-de- diseases. termining sectors and to identify climate actions that bring greatest benefits to health. • Conduct scenario-based simulation exercises with sub-national health workers to enhance • Seek international and external donor funding planning and response to health emergen- opportunities and mechanisms. This can include the Green Climate Fund, Global Environment cies that are outside the range of historical Facility, Adaptation Fund for dissemination experience. towards health-based adaptation measures, controlling climate-sensitive diseases, research COMPONENT 10: projects, and mitigation projects, including na- CLIMATE AND HEALTH FINANCING tionally determined contributions. Additionally, there should be efforts to improve engagement Ultimately establishing the below recommen- from the health sector with on-going and/or dations seeks to reach a ‘climate-smart’ UHC planned climate change adaptation projects. approach through the lens of health financing, in line with government priorities. Options to 5 WHO. Promoting Strategic Purchasing. Accessed at https://www.who. strengthen climate and health financing include: int/activities/making-purchasing-more-strategic Annexes | 71 ANNEX E. METHODS FOR THE ESTIMATION OF MOSQUITO SUITABILITY UNDER RCP 8.5 IN ETHIOPIA MODEL CONSTRUCTION Spatio-temporal distributions of Anopheles gambiae s.l. mosquitoes was determined using a raster- based suitability model constructed in Google Earth Engine by adapting methodology presented by Frake et al. [146] . This methodology uses abiotic variables specific to the thermal tolerances of vector species and biotic variables that give consideration to 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 temperatures do not exceed or fall below thermal tolerances. Parameter thresholds for all input variables were selected based on literature review of An. gambiae s.l. habitat: Temperature, Landcover, Precipitation, Flow Accumulation, and Water Resources (Table A1). Thresholds were then used to create binary maps for each predictor (i.e., 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 Ethiopia’s historic malaria transmission period: September-November. Population vulnerability was demonstrated by spatially overlaying suitability maps for malaria mosquitoes in Ethiopia with population data from the Global Human Settlement Layers (2015) to calculate the number of people 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 1000m: this analysis is performed at the landscape, not micro-scale level. Microscale variations in climatological and land use and land cover can and do affect species actual distributions. TABLE A1. Model parameterization and data sources for habitat characterization INDICATOR DATA PRODUCT SPATIAL THRESHOLD SOURCE RESOLUTION Temperature NASA NEX-GDDP 0.25 degrees An. gambiae s.s. Min: 18°C Max: 34°C Land Cover Copernicus Proba-V-C3 100 m See Annex Table 2* Global Land Service Water JRC GSW1_0 30 m >0 percent water Resources occurrence Flow Accumu- WWF HydroSHEDS 500 m lation Population JRC GHSL/P2016/POP_GPW_GLOBE_V1 72 | Climate and Health Vulnerability Assessment: Ethiopia 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 in aquatic or adult stages. Bayoh and Lindsay [147] demonstrated that the upper and lower thresholds for An. gambiae s.s. aquatic development were 18°C and 34°C, respectively. Minimum and maximum temperature thresholds for this analysis were set to 18°C and 34°C. 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 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.l. mosquitoes, class descriptions were compared to habitat preferences of the species according to literature review. An. gambiae mosquito habitats are char- acterized by open, sunlit pools which may be associated with human activity including agriculture which may facilitate water pooling. In this analysis, M-form and S-form An. gambiae s.s.(now known as An. coluzzi and An. gambiae s.s., respectively) mosquitoes habitat preferences were considered. An. coluzzi show preference for forested areas, greater sunlight exposure, higher water vapor pressure, and lower temperatures and evapotranspiration. S-forms prefer dry savannah and deciduous forest. 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 (Table A2). TABLE A2. Copernicus Global Land Cover Layers: CG:S-LC100 Collection 2 global landcover map classifications. 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 Yes any defined main stem being less than 5 m tall. The shrub foliage can be either evergreen or deciduous. 30 Herbaceous vegetation. Plants without persistent stem or shoots above Yes ground and lacking definite firm structure. Tree and shrub cover is less than 10 %. 40 Cultivated and managed vegetation / agriculture. Lands covered with Yes temporary crops followed by harvest and a bare soil period (e.g., 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 man-made structures. Yes 60 Bare / sparse vegetation. Lands with exposed soil, sand, or rocks and never Yes has more than 10 % vegetated cover during any time of the year. 70 Snow and ice. Lands under snow or ice cover throughout the year. No Annexes | 73 CLASS CLASS DESCRIPTION SUITABLE AN. VALUE GAMBIAE S.L. LAND COVER 80 Permanent water bodies. Lakes, reservoirs, and rivers. Can be either fresh or No salt-water bodies. 90 Herbaceous wetland. Lands with a permanent mixture of water and herba- Yes ceous or woody vegetation. The vegetation can be present in either salt, brackish, or fresh water. 100 Moss and lichen. No 111 Closed forest, evergreen needle leaf. Tree canopy >70 %, almost all needle Yes leaf trees remain green all year. Canopy is never without green foliage. 112 Closed forest, evergreen broad leaf. Tree canopy >70 %, almost all broadleaf Yes trees remain green year round. Canopy is never without green foliage. 113 Closed forest, deciduous needle leaf. Tree canopy >70 %, consists of seasonal Yes needle leaf 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 Yes broadleaf tree 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- Yes mixed of shrubs 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- Yes mixed of shrubs 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 Yes layer- mixed of 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 broad leaf. Top layer- trees 15-70 % and second layer- Yes mixed of shrubs and grassland, consists of seasonal broadleaf tree communi- ties 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 fresh or salt-water bodies. No Precipitation Water is fundamental to mosquito larvae development. To estimate areas likely to become inundated annual average precipitation was calculated from the Climate Hazards Group InfraRed Precipitation and Station Data (CHIRPS v2.0). Likewise, flow accumulation was derived from HydroSHEDS Flow Accumulation product to determine the natural drainage from a given pixel to adjacent, downslope pixel to determine 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 water bodies by 250-m to approximate water rich soils that would support larval development. 74 | Climate and Health Vulnerability Assessment: Ethiopia ANNEX F. OBSERVED AND PROJECTED TEMPERATURE AND PRECIPITATION CHANGES IN ETHIOPIA Observed (Reference Period 1991-2020) and Projected (2040-2059 Anomaly from 1995-2014 Baseline) Temperature and Precipitation Changes in Ethiopia by Subnational Unit CLIMATIC-TOPOGRAPHIC OBSERVED WARMEST OBSERVED WETTEST PROJECTED ANOMALY SEASON OF LARGEST REGION (SUBNATIONAL (TOP) AND COOLEST (TOP) AND DRIEST (CHANGE) IN TEMP. AND PROJECTED CHANGE UNIT) (BOTTOM) MONTH (BOTTOM) MONTH PRECIP. CONDITIONS IN TEMP. AND PRECIP. FOR 2040-2059 CONDITIONS FOR 2040-2059 Tropical Dry (Kolla) June (25C-38C) Aug (96mm) +35.07 (10.26, 53.09) Spring Months Northeast Rift Valley – Hot Days Annually Awash Valley, Denakil Depression (Afar) Jan (18C-30C) Dec (9mm) +42.01 (10.73, 67.66) Spring Months Trop. Nights Annually Annual (359mm) +47.40mm (-155.17mm, Summer Months 283.94mm) Seasonally (Kiremt) Southeast Lowlands Apr (21C-33C) Apr (102mm) +64.95 (32.46, 97.46) Spring Months – Genale and Shebele Hot Days Annually Plains (Somali) Dec (17C-32C) Jan (4mm) +66.94 (30.50, 90.89) Winter Months Trop. Nights Annually Annual (435mm) +34.08mm (-135.83mm, Fall Months (Kiremt) 174.66mm) Seasonally Tropical Moist (Kolla Mar (23C-37C) Aug (187mm) +44.35 (-7.73, 84.88) Fall Months Elevation) Hot Days Annually West Lowlands – Baro Jan (11mm) +54.91 (4.87, 82.33) Winter Months Lowlands (Gambela) Trop. Nights Annually Aug (21C-31C) Annual (1103mm) +69.00mm Fall Months (Kiremt) (-223.68mm, 333.78mm) Seasonally Northwest Lowlands Apr (21C-36C) Aug (293mm) +36.88 (11.14, 65.62) Spring Months – Angereb Lowlands Hot Days Annually (Beneshangul Gumu) Aug (18C-28C) Jan (1mm) +71.42 (21.99, 105.03) Summer Months Trop. Nights Annually Annual (1262mm) +58.15mm (-172.63mm, Fall Months (Kiremt) 284.72mm) Seasonally Subtrop. Dry (Major May (18C-32C) Aug (187mm) +25.06 (11.12, 45.66) Spring Months Tigray Cities and Hot Days Annually Hareri in Weina Dega) North Highlands Jan (12C-28C) Jan (3mm) +36.16 (8.60, 62.00) Spring Months – Tigrian Plateau Trop. Nights Annually (Tigray) Annual (601mm) +26.48mm (-212.01mm, Summer Months 346.78mm) Seasonally (Kiremt) East Highlands – June (22C-34C) Aug (129mm) +28.31 (8.03, 47.14) Hot Spring Months Hararghe Plateau Days Annually (Dire Dawa) Dec (13C-29C) Dec (8mm) +19.11 (2.29, 62.66) Spring Months Trop. Nights Annually Annual (640mm) +34.57mm (-135.83mm, Summer Months 168.30mm) Seasonally (Kiremt) Annexes | 75 CLIMATIC-TOPOGRAPHIC OBSERVED WARMEST OBSERVED WETTEST PROJECTED ANOMALY SEASON OF LARGEST REGION (SUBNATIONAL (TOP) AND COOLEST (TOP) AND DRIEST (CHANGE) IN TEMP. AND PROJECTED CHANGE UNIT) (BOTTOM) MONTH (BOTTOM) MONTH PRECIP. CONDITIONS IN TEMP. AND PRECIP. FOR 2040-2059 CONDITIONS FOR 2040-2059 East Highlands – June (17C-29C) Aug (141mm) +20.65 (8.35, 27.45) Winter Months Hararghe Plateau Summer Days Annually (Hareri) Dec (8C-27C) Dec (10mm) +14.40 (1.75, 32.00) Spring Months Trop. Nights Annually Annual (829mm) +30.49mm Summer Months (-105.40mm, 131.67mm) (Kiremt) Seasonally Subtrop. Moist (Major Apr (15C-30C) Aug (307mm) +38.80 (12.76, 63.37) Fall Months Cities in Weina Dega) Summer Days Annually North Central Massif Dec (10C-27C) Dec (10mm) +18.02 (2.41, 34.42) Spring Months (Amhara) Trop. Nights Annually Annual (1138mm) +51.36mm Summer Months (-268.89mm, (Kiremt) 417.37mm) Seasonally Southwest Lowlands Mar (16C-31C) May (152mm) +32.44 (6.92, 53.83) Spring Months and Highlands Hot Days Annually (SNNPR) Dec (13C-29C) Jan (30mm) +38.36 (6.03, 59.34) Spring Months Trop. Nights Annually Annual (1165mm) +29.93mm (-35.60mm, Winter Months (Bega) 153.53mm) Seasonally Subtrop. Moist and Apr (16C-29C) Aug (159mm) +34.02 (13.28, 52.54) Fall Months Temperate Moist Summer Days Annually (Mostly Weina Dega) Central West, Central Dec (12C-27C) Dec (18mm) +25.76 (7.53, 43.56) Spring Months East Highlands – Trop. Nights Annually Shewa Plateau, Annual (1105mm) +37.11mm (-152.74mm, Fall Months (Kiremt) Arsi-Sidama-Bale 260.07mm) Seasonally Massif (Oromia) Temperate Moist Apr (12C-26C) Aug (275mm) +62.45 (29.22, Fall Months (Weina Dega) 93.62) Summer Days Annually Central Highlands – Dec (7C-24C) Dec (9mm) +0.00 (0.00, 0.11) -- Shewa Plateau (Addis Trop. Nights Annually Ababa) Annual (1161mm) +37.97mm (-116.06mm, Spring Months (Belg) 188.09mm) Seasonally Note: Temperature ranges in parentheses for the warmest and coolest months indicate the average minimum and maximum for 1991-2020. This reference period also applies to the annual and monthly observed precipitation amounts. Projected midcentury temperature and precipitation anomalies correspond with the SSP3-7.0 ensemble and 1995-2014 reference period. Parentheses indicate 10th and 90th percentile values, respectively. “Hot Days Annually” have maximum daily temperatures >35°C, “Tropical Nights Annually” have minimum daily temperatures >20°C, “Summer Days Annually” have daily maximum temperatures >25°C, and precipitation anomalies correspond with the largest projected volume seasonally, not annually, indicated in the far-right column. Red bolded values indicate notable outliers or relative extremes. 76 | Climate and Health Vulnerability Assessment: Ethiopia Annexes | 77 JANUARY 2024 CLIMATE INVESTMENT FUNDS 78 | Climate and Health Vulnerability Assessment: Ethiopia