Climate and Health Vulnerability Assessment NEPAL CLIMATE CLIMATE INVESTMENT INVESTMENT FUNDS 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. The World Bank encourages the dissemination of its knowledge; thus this work may be reproduced, in whole or in part, for noncommercial purposes, as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Cover image: A Nepali woman makes her daily walk to the nearest river with her daughter to obtain clean water. Shutterstock/Javing Herrera. NEPAL Climate and Health Vulnerability Assessment June 2024 CLIMATE INVESTMENT FUNDS TABLE OF CONTENTS Acknowledgments................................................................................................................................................vi List of abbreviations.............................................................................................................................................vii EXECUTIVE SUMMARY...................................................................................................................1 INTRODUCTION..............................................................................................................................5 Country context..................................................................................................................................................... 5 Aims of assessment and conceptual framework............................................................................................ 6 I. CLIMATOLOGY..............................................................................................................................9 Nepal’s Geography............................................................................................................................................... 9 Observed and Projected Climatology...............................................................................................................11 Climate Hazards...................................................................................................................................................15 Key messages......................................................................................................................................................23 II. CLIMATE-RELATED HEALTH RISKS....................................................................................... 25 Nutrition risks.......................................................................................................................................................25 Vector-borne disease risks...............................................................................................................................28 Waterborne disease risks................................................................................................................................... 31 Air quality health risks........................................................................................................................................32 Mental health....................................................................................................................................................... 34 Extreme Temperature risks...............................................................................................................................35 Key messages......................................................................................................................................................36 III. ADAPTIVE CAPACITY OF THE HEALTH SYSTEM............................................................... 39 Health System Overview...................................................................................................................................39 Leadership and Governance.............................................................................................................................40 Health Workforce................................................................................................................................................ 43 Health Information Systems (HIS).................................................................................................................... 47 Essential Medical Products & Technologies.................................................................................................. 48 Service Delivery...................................................................................................................................................49 Health Financing.................................................................................................................................................52 IV. RECOMMENDATIONS.............................................................................................................57 ANNEX............................................................................................................................................ 71 REFERENCES.................................................................................................................................73 iv | Climate and Health Vulnerability Assessment: Nepal INDEX OF TABLES TTable 1. Temperature and precipitation — Monthly patterns.............................................................................11 Table 2. CMIP 6 projections under SSP3-7.0..........................................................................................................13 Table 3. CMIP 6 Ensemble Projections SSP3-7.0 by region, for the 2030s and 2050s..............................21 Table 4. Proportions of regions of Nepal suitable for dengue vector species habitat and corresponding populations........................................................................................................................................29 Table 5. Percent area of suitable malaria vector species habitat, by province, in Nepal...........................30 Table 6. Percent of roles filled in government health facilities, by province.................................................45 Table 7. Summary of the health system’s adaptive capacity gaps for Nepal.................................................54 INDEX OF FIGURES Figure 1. WHO’s Operational framework for building climate-resilient healthcare systems, comprising 10 components and their connections to the building blocks of health systems.....................7 Figure 2. Administrative boundaries of Nepal’s provinces.................................................................................. 8 Figure 3. Nepal’s agroecological zones by Province...........................................................................................10 Figure 4. Elevation map of Nepal..............................................................................................................................10 Figure 5. Projected average monthly temperature and precipitation patterns in Nepal under SSP3-7.0................................................................................................................................................................11 Figure 6. Mean temperature — Anomaly projections for the 2030s................................................................13 Figure 7. Mean temperature — Anomaly projections for the 2050s................................................................13 Figure 8. Mean precipitation — Anomaly projections for the 2030s...............................................................14 Figure 9. Mean precipitation — Anomaly projections for the 2050s...............................................................14 Figure 10. Current risk for rainfall-triggered landslide.......................................................................................... 17 Figure 11. SPEI Drought Index’s projections for the 2030s (CMIP5).................................................................18 Figure 12. SPEI Drought Index’s Projections for the 2050s (CMIP5)................................................................18 Figure 13. Days above 35 C — anomaly projections for the 2030s................................................................20 Figure 14. Days above 35 C — Anomaly projections for the 2050s.................................................................21 Figure 15. Trader-reported food insufficiency and supply decreases in 2020............................................. 27 Figure 16. Households vulnerable to food insecurity in 2020.......................................................................... 27 Figure 17. Dengue mosquito vector suitability across Nepal, under RCP8.5, from across three model time periods....................................................................................................................29 Figure 18. Comparison of Malaria mosquito vector suitability across Nepal, under RCP8.5, across three epochs: 1986–2005 (historical baseline), 2020–2039, and 2040–2059.............................31 Figure 19. WHO’s climate-resilient health system building blocks...................................................................40 Figure 20. Nepal’s health care system levels.......................................................................................................46 Figure 21. Geographical accessibility of health facilities (average travel times in minutes by motorized transport and walking)..........................................................50 Figure 22. WHO’s operational framework for climate-resilient health systems........................................... 57 Table of Contents | v ACKNOWLEDGMENTS The authors are thankful to the Climate Investment Funds (CIF) and the Climate Support Facility (CSF) for funding this work. This Climate and Health Vulnerability Assessment (CHVA) for Nepal was produced by the Health-Cli- mate, Environment and Disasters (HCED) program in the Health, Nutrition and Population (HNP) Global Practice of the World Bank, which is led by Tamer Rabie. The assessment is authored by Mikhael Iglesias, Jessica Huang, Stephen Dorey, and Tamer Rabie. The authors sincerely appreciate the valuable contributions provided by Jhabindra Bhandari, Ana Lucrecia Rivera-Rivera, Muloongo Simuzingili, April Frake and Loreta Rufo. This work benefited from the administrative support of Fatima-Ezzahra Mansouri and Julie Luvisa Bazolana, the editorial work of Kah Ying Choo, and the production of Sarah Jene Hollis. The authors are also highly grateful to the HNP management for their strong support of the HCED program and this product and would like to extend their thanks to Juan Pablo Uribe and Monique Vledder. vi | Climate and Health Vulnerability Assessment: Nepal LIST OF ABBREVIATIONS AAP Ambient Air Pollution ACRORAB Association of Community Radio Broadcasters Nepal AGDP Agricultural Gross Domestic Product AHW Auxiliary Health Worker AR6 Assessment Report 6 [of the IPCC] AQI Air Quality Index BC Black Carbon CCDR Country Climate Development Report CCKP Climate Change Knowledge Portal [World Bank] CD Communicable Disease CDC Center for Diseases Control and Prevention CHVA Climate and Health Vulnerability Assessment CHWs Community Health Workers CMIP6 Coupled Model Inter-Comparison Project Phase 6 COP Conference of the Parties COPD Chronic Obstructive Pulmonary Disease COVID-19 Coronavirus Disease 2019 CRU Climatic Research Unit [University of East Anglia, UK] CVD Cardiovascular Disease DA Department of Ayurveda DALYs Disability Adjusted Life Years DDA Department of Drug Administration DHM Department of Hydrology and Meteorology DHS Demographic and Health Survey DoHS Department of Health Services DRM Disaster Risk Management EWS Early Warning System(s) ENSO El Niño Southern Oscillation FbA Forecast-based Action FCHVs Female Community Health Volunteers FEWS Famine Early Warning System GCM General Circulation Model GDP Gross Domestic Product GFDRR Global Facility for Disaster Reduction and Recovery GIS Geographic Information System GHG Greenhouse Gas [emissions] List of Abbreviations | vii GLOFs Glacial Lake Outburst Floods HA Health Assistant HAP Household Air Pollution HDI Human Development Index HIS Health Information System(s) HRH Human Resources for Health HNP Health, Nutrition and Population [World Bank] HNAP Health National Adaptation Plan HSSP Health Sector Strategic Strategy HSS Health System Strengthening HTA Health Technology Assessment ICIMOD The International Centre for Integrated Mountain Development IHIMS Integrated Health Information Management Systems IPCC Intergovernmental Panel on Climate Change LAPA Local Adaptation Plans for Action LI-BIRD Local Initiatives for Biodiversity, Research and Development MAGICC Model for the Assessment of Greenhouse Gas Induced Climate Change MoHP Ministry of Health and Population MoFE Ministry of Forest and Environment MoPI Ministry of Physical Infrastructure MoHA Ministry of Home Affairs MO Medical Officer MOU Memorandum of Understanding MPI Multidimensional Poverty Index NAP National Adaptation Plan NAPA National Adaptation Programme of Action NBoD Nepal Burden of Disease NCD Non-Communicable Disease NDC Nationally Determined Contribution NGO Non-Governmental Organization NHRC Nepal Health Research Council NHMS Nepal National Mental Health Survey NHSS Nepal Health Sector Strategy NHTC National Health Training Center OOP Out-of-Pocket (spending on health) PET Potential Evapotranspiration PHC Primary Health Care PM2.5 Fine Particulate Matter RCP Representative Concentration Pathway SAHW Senior Auxiliary Health Worker SLCP Short-Lived Climate Pollutant viii | Climate and Health Vulnerability Assessment: Nepal SMS Short Messaging Service SPEI Standardized Precipitation Evapotranspiration Index SOPs Standard Operating Procedures SRI System of Rice Intensification SRSP Shock-Responsive Social Protection SSP Shared Socioeconomic Pathway UHC Universal Health Coverage UNDP United Nations Development Programme UNEP United Nations Environment Program UNFCCC United Nations Framework Convention on Climate Change USAID United States Agency for International Development VBD Vector-Borne Disease VIIRS Visible Infrared Imaging Radiometer Suite WASH Water Sanitation and Hygiene WBD Waterborne Disease WFP Water Food Programme WHO World Health Organization List of Abbreviations | ix EXECUTIVE SUMMARY Nepal’s diverse geoclimatic system makes it vulnerable to a myriad of climatic-related events. The combination of variable torrential rainfall patterns and heavy monsoons, both extreme heat and cold, along with steep terrain, increase the risks of floods including Glacial Lake Outburst Floods (GLOFS), landslides, droughts, and waterborne diseases (WBDs). Nepal’s communities are particularly vulnerable to climate change, as they are already hampered by poverty, being located in remote areas and operating on subsistence agriculture. Given Nepal’s high exposure and vulnerability to climate change, the World Bank, through the Health Climate and Environment Program (HCEP), is conducting a Climate and Health Vulner- ability Assessment (CHVA) in Nepal. The objective of this CHVA is to assist decision-makers with planning effective adaptation measures to deal with climate-related health risks. Where available, these measures are provided at a subnational level to assist regional health planners. The recom- mendations of this CHVA are primarily targeted at the health sector and related sectors that influence health risks from climate changes, such as disaster risk management (DRM). This CHVA begins with an analysis of observed and projected climatology data from the Climate Change Knowledge Portal (CCKP) and climate hazards to provide information on climate-related health risks: • Nepal’s changes in temperature and precipitation are not homogenous across the country’s surface area, nor are they defined consistently by altitude. There is great seasonal variability. • Temperatures have increased by 0.62°C between the period 1961-1990 and 1991-2020. Extreme temperatures, both cold and hot, occur in Nepal, with the Central Region experiencing the highest temperatures and the Mid-Western Region the coldest temperatures. By the 2050s, extreme heat temperatures will become more common, especially during warmer months (April to June), with Nepalis in the Central Region at the greatest risk. In contrast, the Terai Lowlands have been experiencing cold waves. • Precipitation changes varying widely will increase floods and landslides risks, with the Far Western Region expected to experience some of the highest increases at 12.45 percent in 2020–2039 and 16.92 percent in 2040–2059, respectively, during the months of June to August. • The risk of floods is greatest in the lower elevation and more populated provinces of the country, with the estimated population exposed to extreme floods expected to increase to nearly 370,000 by 2035–2044. Rising temperatures can impact GLOFs and snow stability, thereby contributing to avalanches and landslides. • The combination of earthquakes and extreme rainfall can lead to a six-fold increase in rainfall-trig- gered landslides during the monsoon months from June to August. 1 • Droughts are becoming more frequent during the winter months, while wildfires are increasing in the dry months preceding the monsoon season. Despite making significant advances in reducing its burden of disease over the last three decades, Nepal is still facing an increasing burden of non-communicable diseases (NCDs) that may be exacerbated by climate change. Furthermore, risks to health outcomes from climate are not evenly distributed in the population, with some groups at greater risk than others. Nutrition risks: Climate change is likely to substantially aggravate food security and nutrition outcomes in Nepal. Global estimations project that populations at risk of climate-re- lated nutritional risks will increase by up to 30 percent between 2010 and 2050. Nepal already ranks amongst the highest in the South Asia Region for stunting, which affects nearly a third of the population. Adverse climate impacts on agriculture and crop yields, particularly rice, are projected to increase, thus putting further strain on food security and nutritional outcomes. Vector-Borne Diseases (VBDs): Vector suitability ranges — in particular for mosquitoes — are highly sensitive to climate. Analyses indicate that climate will put an additional 600,000 people at risk of malaria and an additional 400,000 at risk of dengue. This is on top of an already very high burden of VBDs across the country, thereby imposing additional strain onto already stretched surveillance, control, and treatment services. Water-borne diseases (WBDs): Nepal’s extreme topography and limited access to safely managed drinking services results in a large proportion of the population being highly vulnerable to WBDs. Climate-related changes to precipitation patterns, floods, and landslide events will further exacerbate this vulnerability. Extreme temperature risks: Increases in the annual mean temperature, coupled with an increase in the intensity and frequency of heatwaves, will result in a greater number of people at risk of heat-related NCDs. Projections indicate that under a high emissions scenario (Representative Concentration Pathway [RCP]8.5), heat-related mortality would increase to around 53 deaths per 100,000 annually by the 2080s, compared with 4 deaths per 100,000 between 1961 and 1990. There have also been morbidity and mortality increases due to cold waves. Other climate-related health risks to be prioritized include air pollution and mental health. 2 | Climate and Health Vulnerability Assessment: Nepal The extent to which the health system in Nepal is prepared with the capacity to manage changes in hazards, exposure, and susceptibility will determine their resilience in coming decades. In this CHVA, Nepal’s adaptive capacity to prevent and manage climate-related health risks is examined, according to the World Health Organization’s (WHO) six health system building blocks. • Climate change risks exacerbating existing disparities in health service delivery, particularly with regard to remote regions. Nepal has made significant improvements in health coverage; however, gaps remain between policy and practice, especially at the subnational level. Full assessments of climate readiness of the health care infrastructure and workforce are needed, along with adequate contingency planning for anticipated climate-related hazards, such as heat, floods, and landslides. Minimum standards for climate-sensitive health care infrastruc- ture are required to avoid impeding the refurbishment efforts of existing healthcare facilities. • Nepal has a Health-National Adaptation Plan (H-NAP) that is incorporated within the health financing strategy of the National Health Sector Strategy (NHSS); however, a lack of resource allocations and integration with health budgets in response to climate-re- lated health risks remains a challenge. In addition, current mechanisms for risk pooling in Nepal do not account for climate-related health risks, thus putting climate-vulnera- ble groups, such as women, children, and older people, at physical and financial risk. • Despite significant improvements to the Early Warning and Reporting System (EWS) since its establishment in 1997, there is insufficient integration with health information systems and limited inclusion of climate-related information. Although EWS mechanisms do exist for several climate-related disasters, such as community-based early warning systems for floods, a more comprehensive approach is still needed for a fully climate-informed health EWS. Health information systems are not fully integrated with hydrological and meteorological (hydromet) services, and there is limited collaboration between entities across the health and environmental sectors. Recommendations include establishing a climate-smart health system to reduce climate-related health risks and improve overall health service delivery. This would prioritize (a) improving governance coordina- tion mechanisms mainly between the Ministry of Health and Population (MoHP) and the Ministry of Forest and Environment (MoFE), and also serving as a bridge between the federal and provincial and local governments; (b) harnessing public private partnerships in order to mobilize resources and strengthen health service delivery; (c) expanding health information systems to include climate-re- lated health risks and climate-related hazards; (d) developing capacity-building programs for both policymakers and practitioners, among others; along with (e) adopting a climate-smart approach in order to retrofit and strengthen the current health care infrastructure. 3 INTRODUCTION COUNTRY CONTEXT 1. Nepal’s economic and social development has continued to increase, despite challenges including major natural disasters. With a Gross Domestic Product (GDP) per capita of USD1,336.5 and a Human Development Index (HDI) ranking of 142 out of 189 countries in 2020, Nepal is a medium-development nation in the South Asia region that has experienced an HDI value increase of 55.6 percent from 0.387 to 0.602 between 1990 and 2019.1 2. The Nepali economy has been battered million people by 2050.8 Nepal’s population by multiple shocks, including the 2015 is relatively young: people under 15 represent earthquake. Before COVID-19 hit, the 28 percent of the total population9 and only economy was affected by a magnitude-7.8 6 percent of the population is over the age earthquake in 2015 that had an immediate of 65.10 As of 2021, women accounted for economic impact estimated at as much as more than 54 percent of the total population.11 USD10 billion (half of Nepal’s USD20-billion Persons of working age (15–64 years old) GDP at the time).2 The agricultural sector alone represent 66 percent of the total population.12 suffered an estimated USD283.7 million worth of damage.3 The Nepali government estimated While Nepal is one of the 10 least urbanized that in 2019, 17.4 percent of Nepalis were countries in the world (21 percent in 2021),13 considered poor under the multidimensional it also has one of the 10 fastest urbanization poverty index (MPI) — an improvement from rates globally (3.9 percent in 2021, and up 30.1 percent in 2014.4 However, starting in to 7 percent in the fastest-growing settle- 2020, the COVID-19 pandemic exacerbated ments).14,15 According to the World Population economic challenges that led to the contraction Prospects report, Nepal’s net outflow was 1.8 of the economy,5 with past marginal gains in million migrants between 2010 and 2020, poverty reduction partially undone by the making it one of the top 10 countries experi- recent shocks. encing outflow.16 3. The population of Nepal has increased since 4. Nepal’s diverse geoclimatic system makes the mid-century, with a plateau in population it vulnerable to a myriad of climatic-related growth in the 2010s. By 2020, the population events. Climate variability combines heavy of Nepal was over 29.1 million,6 with an annual monsoons, steep terrain, and both extreme growth rate of approximately 1.8 percent.7 heat and cold to place Nepal at high risk The population is projected to reach over 35 of floods, including Glacial Lake Outburst Floods (GLOFS), landslides, droughts, and 5 waterborne diseases (WBDs). Nepal’s vulnera surveillance and emergency response; (c) bility to climate hazards is characterized by: (a) environmental health measures for urban flood events that are triggered by rapid snow development; (d) promotion and conserva- and ice melts in the mountains; (b) extreme tion of water sources; (e) policy reform and torrential rainfall episodes in the foothills during strategic planning for climate-resilient health the monsoon season (June–September; (c) systems; along with (f) research, innovation, GLOFs; (d) landslides that are also triggered and development for climate-resilient by rapid snow and ice melts, along with and measures and technologies.20 extreme rainfall patterns; and (e) droughts that are becoming more frequent during the winter months. Nepal’s communities are partic- AIMS OF ASSESSMENT AND ularly vulnerable to climate change, due to CONCEPTUAL FRAMEWORK their poverty, location in remote areas, and dependence on subsistence agriculture.17 6. The objective of this Climate and Health Vulnerability Assessment (CHVA) is to assist 5. Nepal is committed to tackling climate change decision-makers with planning effective within its own borders, with strategies in adaptation measures to deal with climate-re- place to mitigate net greenhouse gas (GHG) lated health risks. Where available, these emissions and plans developed to reduce measures are provided at a subnational level the country’s vulnerability to climate change. to assist regional health planners. The recom- Nepal signed the Paris Agreement of the mendations of this CHVA are primarily targeted United Nations Framework Convention on at the health sector and related sectors that Climate Change (UNFCCC) on April 22, 2016:18 influence health risks from climate changes, it aims to limit the global mean temperature such as disaster risk management (DRM). increase to well below 2°C compared with pre-industrial levels. Nepal also submitted the 7. Adaptation priorities need to run alongside nationally determined contributions (NDCs) fundamental and urgent action to mitigate on May 10th, 201619 and the second set of climate change. It is important to stress how NDCs on December 8th, 2020. complex the climate challenge is and how hard it is to predict exactly how severe climate The NDCs outline Nepal’s commitment to exposures facing populations will become. addressing climate change within their own There are many factors that could slightly borders, in addition to planned mitigation and slow or significantly speed up rates of change, adaptation strategies to reduce the country’s including positive feedback effects, and most vulnerability to the adverse impacts of climate worrying of all, cascading climatological tipping change. Adaptation measures are developed points. For this reason, mitigating existing in their National Adaptation Plan (NAP), which greenhouse gas emissions (GHGs), along with includes an area on Health, Drinking Water, developing and implementing measures to and Sanitation. Adaptation efforts focus on protect human development from the changing (a) capacity building on climate resilience climate, is of paramount importance. for health and water sanitation and hygiene (WASH) services; (b) climate-related disease 8. Investing in adaptation strategies to proactively address the effects of climate change on health outcomes is critical. This 6 | Climate and Health Vulnerability Assessment: Nepal assessment is focused on climate risks to recommendations on reducing the carbon health and health systems, the adaptive footprint from the healthcare sector. capacities that are in place to deal with these risks, and recommendations to meet identified 9. The World Health Organization’s (WHO) gaps. The primary focus of this assessment is, operational framework for building climate- therefore, on climate adaptation and resilience resilient health systems has been adopted measures. However, as the Intergovernmental to analyse Nepal’s adaptive capacity to Panel on Climate Change’s (IPCC) Assessment adequately deal with current and future Report Six (AR6)21 makes clear, “Global surface identified risks. Following this framework temperature will continue to increase until (Figure 1), the assessment is, therefore, at least the mid-century under all emissions structured around the six health system scenarios considered.” Mitigation is no longer strengthening (HSS) building blocks. These a sufficient strategy, regardless of the pace six categories structure the assessment of with which governments and communities capacities and gaps — currently and into around the world act. Adaptation is now as the future. The framework then moves on to critical a part of climate action as mitigation. consider the 10 components of health system Therefore, although this report is focused climate resilience for the “Recommendations” on adaptation measures, it also includes section. FIGURE 1. WHO’s Operational framework for building climate-resilient healthcare systems, comprising 10 components and their connections to the building blocks of health systems. ATE RESILIENCE CLIM hip & Heal ders Workf th Lea vernance orce Go V uln pac ation t Fin alth & A Ca apt men He ate era ity & Leadership As g d ess Clim cin bil & Governance Health s ity, an Workforce Financing Preparedness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential C li o r m e h Re ima & I n f e a lt m s Medical ma d C l a lt h se te Products & h H ra Pro te a rc Technologies He - g Ma nt na ili e Env ge m ent o Res le ir o n f C li m a t e a b in D et m ental & S u st a gies ri m e lo of H n ts Techno cture e a lt h I n f r a s tr u & Source: World Health Organization, 2015, Operational Framework for Building Climate Resilient Health Systems. Introduction | 7 10. This assessment follows a stepwise linear University; Tribhuvan University; Local approach. The first step characterizes the Initiatives for Biodiversity, Research and climatology in Nepal, highlighting observed Development (LI-BIRD); The International and future climate exposures relevant to health. Centre for Integrated Mountain Development The second step examines climate-related (ICIMOD); the Nepal Health Research Council health risks, including identifying vulnerable (NHRC); WHO; and the United Nations populations most at risk. The final step assesses Environment Program (UNEP). the adaptive capacity of the health system by identifying gaps to manage current and future 11. The assessment also incorporates subnational climate-related health risks. Together, these considerations for health-related climate steps inform a series of recommendations action. For the purpose of this assessment, to reduce climate-related health vulnerability the administrative departments of Nepal were in Nepal. considered as follows. There are 7 provinces: Koshi, Madhesh, Bagmati, Gandaki, Lumbini, The assessment was based on a review of Karnali, and Sudurpaschim. (Figure 2). However, the published literature; national statistics; given that the admin- istrative departments and consultations with key counterparts in in Nepal changed in 2015, the analysis of this government. They include the Focal Point of assessment will focus mostly on the different Climate Change in the Ministry of Health and agroecological zones in the country. Population (MoHP); the Ministry of Forestry and Environment (MoFE); the Department of Hydrology and Meteorology; The Kathmandu FIGURE 2. Administrative boundaries of Nepal’s provinces. Source: Hermes Database 8 | Climate and Health Vulnerability Assessment: Nepal SECTION I. CLIMATOLOGY 12. This section describes observed climatic changes and projected climate trends, high- lighting the priority climate-related hazards in relation to human health risks in Nepal. Climate information has been taken from the World Bank Group’s Climate Change Knowledge Portal (CCKP) where historical, observed data is derived from the Uni- versity of East Anglia’s Climatic Research Unit (CRU). Observed changes in the mean annual temperature, the mean maximum temperature, the mean minimum temperature, and the precipitation presented on CCKP are derived from the CRU’s Time-Series (TS) version 4.05 gridded dataset for the 1901–2020 period. Model-based, climate projection data is derived from the Coupled Model Inter-Comparison Project Phase 6 (CMIP6). CMIP6 is a standard framework used for the analysis of coupled atmosphere-ocean general circulation models (GCMs). It provides estimates of future temperature and precipitation scenarios and serves as foundational data that is used in IPCC’s assessment reports. CMIP6 projections are shown through five shared socioeconomic pathway (SSP) scenarios that present different societal development pathways. The total radiative forcing level by 2100 (the cumulative measure of GHGs from all sources) is presented at the end of each pathway. This assessment explores projected climate changes under SSP3-7.0 for the short term (2030s; 2020-2039) and the medium term (2050s; 2040–2059). This pathway rep- resents a scenario in which countries are increasingly competitive and emissions continue to climb, doubling from current levels by 2100. 13. Climate data in this section are presented NEPAL’S GEOGRAPHY according to Nepal’s Administrative Provinces, 14. Nepal is a landlocked country of South Asia, while considering the different agro-ecological located in the Himalayas between India zones: Terai, Hills, and Mountains (Figure 3). and China. The terrain is mountainous and contains many of the world’s highest peaks, including Mount Everest (8,848 meters [m]). The country also has low-lying areas in the south, with elevations less than 100 m. At the subnational level, most of the different provinces cover different agroecological zones, characterized by higher elevations in the north and progressively lower elevations 9 as one moves southward until the Terai region melts, and rainfall) accounting for an estimated with its low-lying areas. Water and forests are 2.27 percent of the total world supply. This Nepal’s most abundant natural resources, water feeds the country’s major rivers — Koshi, with freshwater (derived from glaciers, snow Gandaki, and Karnali22 (Figure 4). FIGURE 3. Nepal’s agroecological zones by Province. Source: Adapted from: Yergeau, Marie-Eve & Boccanfuso, Dorothee & Goyette, Jonathan. (2017). Reprint of: Linking conservation and welfare: A theoretical model with application to Nepal. Journal of Environmental Economics and Management. 86. 10.1016/j.jeem.2017.09.006. FIGURE 4. Elevation map of Nepal. Source: Natural Earth, ASTER GDEM Version 3 10 | Climate and Health Vulnerability Assessment: Nepal OBSERVED AND PROJECTED mountains. Annual precipitation variability is heavily influenced by the El Niño-Southern CLIMATOLOGY Oscillation (ENSO) and the Indian Ocean Dipole. 15. Nepal’s climate varies considerably, both Precipitation is variable, with some central and seasonally and according to its geography. northerly pockets of the country getting more Nepal can be divided into different climate than 3,000 millimeters (mm), while the central zones by elevation — ranging from the Terai and southern plains and some high-altitude region in the south at less than 500 m above areas in the north typically receive 1,500–2,000 sea level, with a humid subtropical climate, mm and less than 1,000 mm, respectively.23 to the High Himalayan region in the north at Climate also varies drastically on a monthly over 5,000 m, with a continental subarctic basis: while intense precipitation takes place climate. Average temperatures decline from in June and July, there is almost no rain from a peak of over 24°C in the south down to November to February (Table 1). sub-zero temperatures in Nepal’s highest TABLE 1. Temperature and precipitation — Monthly patterns. JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Cooler Cooler Temperature Hot Months Months Precipitation Dry Season Long and Intense Rain Dry Season Nepal Season Winter Spring Early Summer Early Autumn Late (Ritu) (Shishir) (Basanta) Summer Monsoon (Sharad) Autumn (Grishma) (Barkha) (Hemanta) Note: The Table above was developed by the authors using data from various sources. FIGURE 5. Projected average monthly temperature and precipitation patterns in Nepal under SSP3-7.0. Source: World Bank Climate Change Knowledge Portal CLIMATOLOGY | 11 TEMPERATURE PRECIPITATION 16. Nepal has experienced a general warming 18. Average annual precipitation across Nepal trend since the 1960s. The observed average has decreased by 64.81 mm over the last annual mean temperature has increased from half century, with the most substantial 13.55°C to 14.17°C between the time periods change occurring in the Sudurpaschim. By of 1960–1991 and 1991–2020, respectively. the 1961–1990 period, the average annual Overall, the highest monthly increases precip- itation in Nepal was 1,331.17 mm, with were observed between November and most of the rainfall occurring between June December as well as between February and and September. November has historically March, with a maximum increase of 0.87°C been the driest month. At the subnational level, in March and November. These increases Bagmati experiences the largest amount of have occurred simultaneously with annual annual precipitation (1,691.79 mm), followed maximum and minimum temperature increases. by Koshi with 1,606.08 mm. At a subnational level, the Lumbini province experiences the highest temperatures, with 19. Precipitation is expected to increase by an average annual mean temperature of 20.66°C around 124.67 mm in the 2050s. While there (11.45°C–26.64°C), while Karnali has the coldest will be a higher increase in precipitation (13 temperatures, with an annual mean of 7.24°C and 15 percent) between May and June, there and a mean minimum temperature going as will be a steep decrease of 25 percent of low as -2.77°C in January. rainfall in December, by the 2050s. At the subnational level, Madhesh will experience 17. The mean annual temperature in Nepal the overall highest increase in rainfall, mostly is projected to increase by 0.73°C in the between May and June (11 and 12 percent, 2030s and by 1.48°C by the 2050s. Most respectively), but it will also experience a of this increase will be experienced in the 41-percent decrease during December by the month of December, with an increase of 0.9°C 2050s. Nationally, while the rainy season will and 1.95°C by the 2030s and 2050s, respec- have more intense rainfall, the dry season is tively, meaning that the cooler months will expected to get drier by the 2050s. A more get warmer. On the other hand, the warmer intense rainy season (June–September) would months will be experiencing temperatures also increase the risk of floods and direct above 19°C by the 2030s and above 20°C by injuries from floods or landslides, while a drier the 2050s. At the subnational level, warmer season (November–February) would affect temperatures will be in the Madhesh, with crop yields, and therefore, food security (see an annual mean temperature of 25.05°C by the next section for more information). the 2030s and 25.72°C by the 2050s, along with mean temperatures of above 30°C in May and June. Other provinces, such as Lumbini, will experience mean temperatures above 25°C from May to August, thereby increasing the exposure of populations to heat. See the section on climate hazards for a further discussion on population vulnerability to extreme temperatures. 12 | Climate and Health Vulnerability Assessment: Nepal TABLE 2. CMIP6 projections under SSP3-7.0. CMIP6 ENSEMBLE PROJECTION 2020–2039 2040–2059 Annual Mean Temperature (°C) 13.17 (+0.73°C) 13.92 (+1.48°C) Annual Precipitation (mm) 2,087.08 (+72.99 mm) 2,137.74 (+124.67 mm) Note: Bold value is the median (or 50th percentile); values in parenthesis indicate the increase in Celsius degrees. Source: World Bank Climate Change Knowledge Portal FIGURE 6. Mean temperature — Anomaly projections for the 2030s. Source: World Bank Climate Change Knowledge Portal FIGURE 7. Mean temperature — Anomaly projections for the 2050s. Source: World Bank Climate Change Knowledge Portal CLIMATOLOGY | 13 FIGURE 8. Mean precipitation — Anomaly projections for the 2030s. Source: World Bank Climate Change Knowledge Portal FIGURE 9. Mean precipitation — Anomaly projections for the 2050s. Source: World Bank Climate Change Knowledge Portal 14 | Climate and Health Vulnerability Assessment: Nepal CLIMATE HAZARDS of the worst floods took place during the monsoon season in July 1993, when over 700 20. There are several climate-related hazards people were killed in Central Nepal.26 More affecting population health in Nepal, recently, heavy rain during monsoons led to which are linked to changes in baseline river floods along the Melamchi River, killing temperatures and precipitation. The most over half a dozen people and leading to the common climate-related hazards affecting evacuation of more than 260 households in Nepal are floods, landslides, avalanches, June 2021.27,28 wildfires, droughts, and extreme temperatures (including heat and cold waves). Other climate Another concern is unseasonal heavy rain, hazards, such as extreme weather events, which can trigger floods and landslides, when pose additional risks. Although cyclones people are not prepared for such hazards. This are not as frequent as other climate-related was the case in October 2021, when the rain hazards, with a 1-percent chance of potentially killed over 100 people along the Karnali River damaging wind speeds over the next 10 years, and Mahakali River following typical summer according to the World Bank Global Facility monsoon months. 29,30 Floods in densely for Disaster Reduction and Recovery (GFDRR), populated urban areas (such as Kathmandu infrastructure damage and health risk are Valley) are of particular concern, leading to prominent due to cyclone-induced heavy costly infrastructure damage, as well as losses rains and subsequent floods. Major cyclones of lives and livelihoods. Beyond precipitation, in recent years have included Cyclone Yaas policies also contribute to flood risks due to a (2021), Cyclone Hudhud (2014), and Cyclone lack of zoning, of development planning, and Pailin (2013). The overall impacts of such of building regulations. Urban flooding risk is events in Nepal are not merely attributable categorized as “high” by the GFDRR, meaning to changing environmental conditions, for they that potentially damaging and life-threatening are compounded by anthropogenic causes, urban floods are expected to occur at least including rapid deforestation, mining, urban- once in the next 10 years.31 The construction of ization, and inadequate housing. homes on hill tops and deforestation, mining on hills, the destruction of vegetation leading to erosion, along with the buildup of waste FLOODS in drains and culverts, further compounding 21. Climate-related increases in total and extreme flood risks.32 precipitation are exacerbating flood risks in Nepal. Floods in Nepal frequently occur 22. Accelerated glacial melting and glacial during the monsoon seasons in the valleys and lake outburst floods (GLOFs) are a growing the Terai lowlands, with the rainiest months risk in Nepal. GLOFs are sudden releases being June to September, as summarized in of water from a lake fed by glacier melts.33 Table 1. Flash floods are often triggered by Nepal possesses over 2,000 glacial lakes.34 heavy or sustained rainfall, which increases While not all glacial lakes are near populated river volumes, and insufficient or blocked areas, some lakes can cause damage to drainage infrastructure.24 Between 1900 and downstream communities through floods, as 2005, it is estimated that 3.2 million people well as significant movement of sediment and died due to floods in Nepal, of whom 2.8 debris, so the country currently has efforts million were from the Terai lowlands.25 One underway to mitigate GLOFs. CLIMATOLOGY | 15 23. Nepal’s precipitation levels may increase almost every year since then, mostly linked further and become more variable, which to heavy rainfall and floods. can exacerbate flood risk. The projected precipitation percent change varies widely The relationship between climate change and across the country, Sudurpaschim is expected landslide and mudslide risks is complex due to experience some of the highest increases to several factors. While changes in rainfall during the months of May and June by 17.89 and temperature may lead to more landslide percent in 2020–2039 and 19.4 and 24.26 events, with rainfall being a primary trigger, percent in 2040–2059, during the same increasing droughts and vegetation can months. The average largest one-day precip- decrease the likelihood of these events. In itation is projected to reach more than 60 addition, the impacts of climate on landslides mm by 2040–2059, which is an indicator of can also be difficult to separate from the both flood and landslide risks (see the next impacts of earthquakes. Landslide hazards section on “landslides”). Beyond the largest in the worst-affected districts in Central and one-day precipitation, another measure to Western Nepal have increased after the 2015 consider is the five-day cumulative rainfall earthquake, with a significant number of because this represents a different risk where landslides also occurring in new locations.37 areas become saturated over a number of New research suggests that the combination of days, thereby increasing the risks of floods earthquakes and extreme rainfall can lead to a as well as landslides through the sustained six-fold increase in rainfall-triggered landslides loss of slope stability. The average largest during the monsoon months of June to August, five-day cumulative rainfall is projected to when Nepal typically experiences severe reach 300 mm in the month of in the period landslides.38 Human activity is yet another 2020-2039 and reach more than 320 mm in contributing factor. Development and land the same month by 2040–2059, which is use policies impact landslide risk as well, with an increase of more than 50 mm from the deforestation and the unmanaged planning of historical reference period (1995–2014). the built environment exacerbating landslides by weakening slope stability, with socioeco- nomic factors further increasing a community’s LANDSLIDES AND AVALANCHES vulnerability to landslides.39,40 24. Landslides are responsible for the loss of life, as well as damage to homes and While landslides have historically impacted a other infrastructure (for example, transport, larger number of homes and people in Nepal, energy, and health) in Nepal. Ongoing climate avalanches have had serious impacts on change will aggravate both landslide risk in the tourism and the communities residing in the hillsides and avalanche risk in the mountains. mountains, including the Sherpas who often Between 1972 and 2016, it is estimated that rely on mountain tourism for their livelihoods. over 5,100 people have lost their lives in over Recent deadly avalanches in Nepal occurred 3,400 recorded landslide events.35 One of in 2014, 2015, and 2021, with at least one the deadliest landslides in Nepal was the avalanche in 2014 documented to have been 2014 Jure landslide: it killed 156 people and triggered by a snowstorm. From a climate caused over NPR5 million in damage.36 There change standpoint, rising temperatures, apart have been deadly and destructive landslides from precipitation changes, can impact snow 16 | Climate and Health Vulnerability Assessment: Nepal stability, which may trigger avalanches, making midland hills, and the Terai lowlands, combined the projected mean monthly temperature with erosion from tropical weathering and increases of over 1°C in Nepal by the 2050s heavy precipitation during the rainy season, a considerable concern. also influence their vulnerability to landslide and avalanche events (Figure 10). Finally, the elevation differences in Nepal among the mountainous highlands, the FIGURE 10. Current risk for rainfall-triggered landslide. Source: Natural Earth, ASTER GDEM Version 3, and GFDRR 2020. DROUGHT in 2020–2039 or 2040–2059; however, 25. While the risk of drought is currently relatively various models have been inconsistent in low, this may increase in parts of Nepal, due estimating the change of drought hazards.41 to erratic rainfall, coupled with increasing The projected maximum number of temperatures; as such, the risk of water consecutive dry days (CMIP5) is another scarcity remains high. The annual Standard- indicator that varies across Nepal. The ized Precipitation Evapotranspiration Index drier months of November to January are (SPEI) drought index measures drought severity projected to have slight increases (<5 days) according to its intensity and duration, taking in consecutive drydays; these months already into account both precipitation and potential have a relatively high number of consecutive evapotranspiration (PET), where negative SPEI dry days, so even a slight increase can be values indicate a negative water balance and impactful. Historically, Nepal has experienced values below -2 equate to a severe drought drought events that impacted agricultural (Figures 11 and 12). CMIP6 data does not production, which took place in 1982, 1985, project Nepal to have negative SPEI values CLIMATOLOGY | 17 1991–1992, 1994, 2005–2006, 2008–2009, categorized as “high” by the GFDRR, indicating 2012, 2013, and 2015. that droughts are expected to occur once every 5 years on average, and highlighting While the drought season are expected to the need to consider the possibility of droughts increase, adequate management of sources during project planning, project design, and of water becomes essential during the construction.42 dry months. Water scarcity risk in Nepal is FIGURE 11. SPEI Drought Index’s projections for the 2030s (CMIP5). Source: Natural Earth, ASTER GDEM Version 3, and GFDRR 2020. FIGURE 12. SPEI Drought Index’s Projections for the 2050s (CMIP5). Source: Natural Earth, ASTER GDEM Version 3, and GFDRR 2020. 18 | Climate and Health Vulnerability Assessment: Nepal WILDFIRES predicting the impact of wildfires in Nepal, 26. Wildfire events are a concern in Nepal, as climate continues to change. especially for air quality, and fire risks may Despite the limited data, it is reasonable to be impacted by the projected increase in the assume that the increasing temperatures in maximum number of consecutive dry days and Nepal, coupled with the higher likelihood of the projected decrease in seasonal precipi- drought conditions, could exacerbate wildfire tation during the drier months from November risks. Wildfires have also been linked to severe to February. Historically, the wildfire season in declines in air quality in Nepal, with the Air Nepal has coincided with the drier months of Quality Index (AQI) in Kathmandu reaching March and April preceding the monsoons. In over 400 during the 2021 wildfires and leading 2021, Nepal experienced some of the country’s to school shutdowns.46 To put this figure into worst wildfires in recent decades, with 22 out context, AQI levels above 300 are categorized of 77 districts impacted.43 The visible infrared as “hazardous” — a warning of emergency imaging radiometer suite (VIIRS) satellite conditions where all members of the general detected around 41,000 thermal anomalies population are likely to experience health or hotspots in Nepal from January 1 to April 7, effects and members of sensitive groups may 2021 — which is among the highest number experience more serious health effects. observed for that time period, second only to January 1 to April 7, 2016.44 The wildfire risk in Nepal is categorized as “high” by the EXTREME TEMPERATURES GFDRR, meaning that there is a 50 percent chance of encountering weather that could 27. Nepal faces risks of both extreme heat and support a wildfire that is significant enough extreme cold. The climate of Nepal ranges to result in both life and property loss in any from subtropical to arctic, depending on the given year.45 elevation. Nepal experiences both extreme hot temperatures, with days above 35°C Wildfires can be exacerbated by climate during the warmer months (April–June), change through increases in temperature and and extreme cold temperatures, with days rainfall variability, and the literature suggests where the minimum temperatures are below that wildfire seasons may lengthen from 0°C during the colder months (November– climate change. However, it is challenging to February). Moreover, temperatures vary widely determine what proportion of the increases subnationally, with Madhesh being the warmest in the wildfire frequency and / or severity in and Karnali the coldest. Nepal can be attributable to climate change. A contributing reason is that information on 28. Extreme heat exposure will become more wildfire events in Nepal is scarce, including common through the 2050s, especially during whether individual incidents are natural or warmer months (April–June), with Nepalis in human-induced. For example, fire is often Madhesh at the greatest risk. Extreme heat used as a tool for land-clearing practices for is defined by the Centers for Disease Control agriculture in Nepal, but wildfires can also be and Prevention (CDCs) as temperatures and started by lightning from convective storms. humidity that are much higher than average Studies have not yet been published on for a particular location.47 On the average, annual mean temperature will increase by CLIMATOLOGY | 19 0.73 and 1.48 degrees during the 2030s moisture content in the air. As the body’s natural and 2050s, respectively (Table 2). Nepalis cooling mechanism is compromised, tempera- in Madhesh will be the most vulnerable to tures feel warmer and require consid- erably extreme heat conditions, with an increase of more blood circulation and respiration to lower 14 days to an estimated 61 days of tempera- core temperature. tures above 35°C annually by the 2050s. Hot days in Nepal will primarily occur from April Daytime temperature increases will be coupled to June, when more than half of each month with a large number of annual of tropical will have temperatures above 35°C. nights. In Madhesh, the number of tropical nights will increase to 212.6 in the 2050s. The impacts on heat-related morbidity and Other provinces such as Lumbini, will have a mortality are only, in part, a function of daytime projected increase in tropical nights to 136.13 temperatures, with high nighttime tempera- by the 2050s (Table 3). Seasonally, these tures and humidity also playing a significant tropical nights are projected to be concen- role. High humidity, prevents sweat from trated from May to September, with almost readily evaporating because of the high every nighttime temperature above 20°C in July, across the country. FIGURE 13. Days above 35 C — anomaly projections for the 2030s. Source: World Bank Climate Change Knowledge Portal 20 | Climate and Health Vulnerability Assessment: Nepal FIGURE 14. Days above 35 C — Anomaly projections for the 2050s. Source: World Bank Climate Change Knowledge Portal TABLE 3. CMIP 6 Ensemble Projections SSP3-7.0 by province, for the 2030s and 2050s. CMIP 6 ENSEMBLE PROJECTIONS SSP3-7.0 2020–2039 2040–2059 Lumbini Hot Days 28.21 (+3.8) 34.34 (+4.01) Tropical Nights 125.75 (+8.69) 136.13 (+19.72) Ice Days 2.02 (-0.43) 1.54 (-0.93) Gandaki Hot Days 1.41 (+0.33) 34.34 (+1.15) Tropical Nights 34.02 (+4.23) 39.58 (+10.01) Ice Days 52.28 (-7.23) 46.26 (-13.63) Koshi Hot Days 4.81 (+0.85) 6.28 (+2.26) Tropical Nights 74.18 (+7.52) 83.19 (+16.3) Ice Days 20.94 (-3.29) 17.93 (-6.31) Sudurpaschim Hot Days 11.71 (-1.82) 14.57 (+4.68) Tropical Nights 59.74 (+6.38) 69.19 (+15.47) Ice Days 17.11 (-2.7) 14.81 (-4.96) Karnali Hot Days 1.54 (+0.36) 2.29 (+1.1) Tropical Nights 18.48 (+2.8) 21.97 (+6.52) Ice Days 74.13 (-7.92) 67.7 (-14.36) CLIMATOLOGY | 21 CMIP 6 ENSEMBLE PROJECTIONS SSP3-7.0 2020–2039 2040–2059 Bagmati Hot Days 4.98 (+0.99) 6.94 (+2.8) Tropical Nights 76.18 (+9.58) 87.44 (+21.04) Ice Days 9.09 (-1.62) 7.73 (-3) Madhesh Hot Days 50.44 (+6.32) 60.58 (+14.24) Tropical Nights 203.72 (+7.65) 212.6 (+16.17) Ice Days 0 0 29. Exposure to extreme cold temperatures is expected to continue being a risk in Nepal, with the most profound threat experienced by populations residing in Karnali. Average annual mean minimum temperatures are projected to increase by 0.74°C in the 2030s and 1.51°C in the 2050s. These increases in temperatures will subsequently be coupled with declines in the number of Ice days, as defined by days with Maximum Temperatures falling below a threshold of 0°C. However, despite rising temperatures, the risk of extreme cold exposure will not be eliminated altogether. Populations residing in the Karnali are likely to be the most vulnerable to extreme cold conditions, where the annual number of ice days is projected to be 74.13 and 67.7 days in the 2030s and 2050s, respectively, being the highest in the country. Nationally, It is projected that ice days will be similar in the 2030s, while decreasing slightly for the 2050s with 27.37 days per year.48 22 | Climate and Health Vulnerability Assessment: Nepal KEY MESSAGES: Nepal’s changes in temperature are not homogenous across the country’s surface area, nor is it defined consistently by altitude. The country shows great seasonal variability, having cold temperatures from October to February and hot temperatures from March to September. Temperatures have increased by 0.62°C between the period 1961-1990 and 1991-2020. Extreme temperatures, both cold and hot, occur in Nepal, with Madhesh experiencing the highest temperatures and Karnali the coldest temperatures. By the 2050s, extreme heat temperatures will become more common, especially during the warmer months (April–June), with Nepalis in the Madhesh at the greatest risk. In contrast, Karnali will continue to experience ice days. Precipitation changes varying widely will increase floods and landslides risks, with Sudurpaschim expected to experience some of the highest increases at 3.25 percent in 2020–2039 and 3.03 percent in 2040–2059 during the months of June to August. The risk of floods is greatest in the lower-elevation areas and the more populated provinces of the country, with the estimated population exposed to extreme flood increasing to nearly 370,000 by 2035–2044. Furthermore, rising temperatures can impact GLOFs and snow stability, leading to avalanches and landslides. The combination of earthquakes and extreme rainfall can lead to a sixfold increase in rainfall-triggered landslides during the monsoon months of June to August. Droughts are becoming more frequent during the winter months, while wildfires are increasing in the dry months preceding the monsoon season. CLIMATOLOGY | 23 SECTION II. CLIMATE-RELATED HEALTH RISKS 30. Nepal has made significant advances in reducing its burden of disease over the last three decades, but now faces an increasing burden of non-communicable diseases (NCDs) that may be exacerbated by climate change. Life expectancy has increased from 58.4 to 71.1 years between 1990 and 2019.49 NCDs are now the leading cause of mortality, responsible for 71.1 percent of all deaths, while communicable, maternal, and neonatal disease, as well as nutritional outcomes, still account for 21.1 percent.50 This means that Nepal can be considered to be undergoing an epidemiological transition, necessitating a response to a double burden of disease.51 It is evident from the 2019 Nepal Burden of Disease (NBoD) report that NCDs are a major public health concern that could be worsened by climate change.52 31. Risks to health outcomes from climate are and well-being, and (f) extreme temperature not evenly distributed in the population, with risks. Each category is assessed, in terms of some groups at greater risk than others. The current and future risks, with considerations factors that affect a population’s vulnerability for both national and subnational peculiarities, to climate are often similar to those that affect wherever possible. It is important to note health more broadly.53 However, climate may that these risk categories represent only the exacerbate health inequalities, especially most pressing health risks to the population among certain vulnerable population groups, in Nepal. Other climate-related health risks including the poor, rural populations, those have not been included in this assessment living in informal urban settlements, women and these may incorporate, but are not limited and young children, the elderly, those living to, direct injuries and mortality associated with pre-existing conditions and disabilities, with natural hazard events. and displaced populations. Notably, remote communities in Nepal are already at high risk. Therefore, investments in adaptation and NUTRITION RISKS mitigation measures must carefully consider 33. Despite Nepal achieving the world’s fastest groups who would directly benefit from, or recorded reduction in stunting prevalence may be disadvantaged by, adopted measures. between 2001 and 2011,54 progress has stagnated in recent years, with the country 32. Nepal’s CHVA assesses five climate-related still ranked amongst the highest in the South health risk categories. These include risks Asia region for stunting, wasting, and the to (a) nutrition, (b) vector-borne disease (VBD) percentage of those severely underweight,55,56 risks, (c) waterborne disease (WBD) risk, each of which are climate-sensitive.57 Over (d) air quality health risks, (e) mental health 25 one-third (36.4 percent) of Nepal’s population 35. Food security and poor nutritional outcomes suffers from moderate or severe food insecurity, in Nepal are compounded by shifting representing a nearly 7-percent increase over climate baselines and shocks, including the last 4 years (previously 29.5 percent).58 climate- related hazards. Projected While the prevalence of undernourishment warmer tempera- tures, water deficits, and has declined significantly over the past two the increasing frequency and intensity of decades (from 23.5 percent in 2001 to 4.8 climate-related hazards are very likely to percent in 2019), recent nutrition statistics aggravate food insecurity and nutritional for children under 5 years of age (2022) deficiencies, with important geographical showed that Nepal still experiences around variations. Erratic rainfall can drastically reduce 24.8 percent of stunting, 7.7 percent of wasting, agricultural production. To that end, irrigation, and overall 18.7 of underweight.59 fertilizer application to reduce plant suscep- tibility, and the adoption of drought-resistant 34. Weather and climate are the foundational varieties are common adaptation measures drivers of healthy and sustainable diets. The under consideration in response to climate mechanisms by which climate change affects change, including in Nepal. nutrition via the food system are profound. Climate variability is already contributing 36. Impacts to cereal crop production, particularly to increases in global hunger and malnu- rice, will be an especially critical climate risk trition. While a comprehensive analysis of factor for nutrition. Agriculture in Nepal is climate change’s impact on the food system largely dependent on cereal crops: it is made is beyond the scope of this assessment, this up mostly of rice, wheat, and maize, with each CHVA examines climate and nutrition linkages contributing to 20.8, 7.14, and 2.64 percent of through a food security lens in Nepal, as it the agricultural gross domestic product (AGDP), relates to weather and climate impacts on respectively.61,62,63 Changing temperature and agricultural productivity. precipitation baselines, coupled with climate shocks (for example, droughts and floods), will Agricultural productivity is a key determinant of not only impact agricultural production and food availability and is affected by weather and yield, and in turn, price and profit, but also climate in a multitude of ways, from short-term personal consumption at a household level. shocks (for example, natural disasters) to longer-term changes in agroecological Approximately 84 percent of Nepal’s conditions that can drastically reduce yields population are subsistence farmers who or redefine spatiotemporal patterns of crop depend on producing crops for their own suitability. Furthermore, apart from agricul- consumption and income.64 Studies on the tural production, climate variability can also impact of climate change on rice production impose acute and chronic effects on agricul- in Nepal show a largely negative impact.65,66 tural storage, processing, distribution, and Production shortfalls are very likely to consumption.60 aggravate food insecurity at the household level. Quantity, both in terms of food avail- ability and calories consumed, and quality of food products play a considerable role in the nutrition outcomes for most Nepalis. Additional 26 | Climate and Health Vulnerability Assessment: Nepal FIGURE 15. Trader-reported food insufficiency and supply decreases in 2020. Source: World Food Programme FIGURE 16. Households vulnerable to food insecurity in 2020. Source: World Food Programme Climate-related health risks | 27 drivers include poor feeding practices and by traders in April 2020, as well as where there infectious diseases, such as diarrhea.67 are high numbers of households vulnerable to food insecurity. According to a United States At a household level, crop productivity and Agency for International Development (USAID) affordability are critical determinants of proper survey from 2019, households in the rural areas nutrition across Nepal. Despite agriculture of the country, where food prices tend to be contributing significantly to annual GDP (23.13 higher, are more likely to be food-insecure percent) as of 2020, Nepal does not currently than people living in urban areas.74 produce enough food to adequately supply its population and thus relies on imports.68 The average household spends over half (54 VECTOR-BORNE DISEASE RISKS percent) of its total income on food, with grain 38. Weather and climate are critical drivers of and cereals providing the foundation for the spatiotemporal vector-borne disease (VBD) majority of the Nepalese population’s diets, distribution and transmission dynamics. especially rice.69,70 The consequences of malnu- Climate variability causes vector and host trition, especially in children, are far-reaching ranges to expand or contract, shifting disease with profound implications on human and distribution, changing seasonality, and / or physical capital which can constrain a county’s facilitating the emergence or reemergence overall economic growth and development. of VBDs.75 Investigating species distribution and the seasonality of vectors is valuable for 37. In the absence of adaptation, climate understanding plausible VBD distributions change is likely to substantially aggravate and planning efficient, spatially targeted food security and nutrition outcomes in methods of control, both for the current Nepal.71 While there is uncertainty on the situation and as the climate continues to precise number of individuals in Nepal who change. The epidemiology of the majority will be at risk of food insecurity because of of VBDs is climate-sensitive; however, this climate variability, recent findings suggest initial assessment is focused on dengue and that globally, between 2010 and 2050, the malaria, given their significance to the overall population at risk could increase by up to burden of disease in Nepal and the potential 30 percent, as a result of climate change.72 for causing large-scale outbreaks among the The rise in food insecurity spurred by climate population. change will have profound effects on nutrition outcomes, particularly in the lower elevations This assessment has modeled epidemiological to the south that are already facing food data and geographic information system (GIS) insecurity. information to estimate plausible spatial distri- butions of the vectors of dengue and malaria As of April 2020, the most vulnerable to assess the risk propensity of these diseases provinces were Koshi, Madhesh, Bagmati, for different populations. The climate data used and Lumbini, with all reporting over 150,000 are sourced from the World Bank’s CCKP and households susceptible to food insecurity; modeled under RCP 8.5, using the historical affected districts are primarily concentrated reference period (1986–2005) in comparison in the south.73 The figure below shows food with the 2030s (2020–2039) and the 2050s insufficiencies and supply decreases reported 28 | Climate and Health Vulnerability Assessment: Nepal (2040–2059). Further details of this analysis in Nepal due to climate change (Table 4). are available in Annex A to this document. Dengue is transmitted by the bite of infected Aedes aegypti, and to a lesser extent, Aedes albopictus mosquitoes. Madhesh has the DENGUE highest absolute risk, independent of climate 39. It is estimated that an additional 400,000 change, and it is possible that climate change people by 2030 and 550,000 people by 2050 will further increase risk. will be living in dengue-vulnerable areas TABLE 4. Proportions of regions of Nepal suitable for dengue vector species habitat and corresponding populations. PROPORTION OF REGION BY AREA VULNERABLE SUITABLE FOR DENGUE VECTORS POPULATION OVERALL SUITABILITY POPULATED, SUITABLE ABSOLUTE VALUES DELTA Ref. Ref. Ref. Province period 2030s 2050s period 2030s 2050s period 2030s 2050s 2030s 2050s Koshi 67.45 73.60 73.60 46.20 51.15 51.15 3,315,841 3,382,784 3,382,784 66,943 66,943 Madhesh 99.38 99.38 99.38 51.28 51.28 51.28 4,034,414 4,034,414 4,034,414 - - Bagmati 74.81 80.76 83.49 28.20 30.07 30.72 3,167,238 3,222,651 3,246,108 55,413 78,870 Gandaki 35.28 45.71 48.78 22.13 29.13 31.85 1,380,503 1,650,342 1,674,295 269,839 293,792 Lumbini 90.82 91.19 91.34 52.92 53.39 53.42 3,871,841 3,881,698 3,886,066 9,857 14,225 Karnali 18.69 19.04 21.10 9.68 10.02 11.84 646,340 653,056 762,910 6,716 116,570 Sudurpaschim 40.13 40.23 40.58 20.64 20.71 20.99 1,740,974 1,741,311 1,747,581 337 6,607 Total 18,157,151 18,566,256 18,734,158 409,105 577,007 Note: The Table above was developed by the authors using data from various sources. See Annex A. FIGURE 17. Dengue mosquito vector suitability across Nepal, under RCP8.5, from across three model time periods. Note: The maps above were developed by the authors using data from various sources. See Annex A. Climate-related health risks | 29 However, the analysis conducted for this focused on the southern low-altitude regions. assessment looks at the change of vector It is expected that the distribution will creep range, and using this approach, a different northwards into progressively higher-altitude picture can be discerned. The greatest regions, as the climate changes. climate-related increases are expected in Madhesh, where over a quarter of a million more people will be at risk by 2030, rising MALARIA to almost 300,000 by 2050, accounting for 40. More than 25 million people in southern Nepal over two-thirds of the national increase in are already vulnerable to malaria each year risk due to climate change. These findings (Table 5). Malaria in Nepal is transmitted by the complement the Nepal Annual Department Anopheles fluviatilis, Anopheles maculatus, of Health Services (DoHS) Health Report for and Anopheles annularis mosquitoes. Malaria 2018/2019, which identified Koshi, Madhesh is endemic in southern Nepal,76 with modeled and Lumbini as being the national focus for results demonstrating the provinces of Koshi, dengue. This is, indeed, still the case for Madhesh, Bagmati, and Lumbini having the absolute figures, but it is important to factor highest overall suitability for malaria vectors. in the future predicted impact of climate in Madhesh will not see an increase due to its using this kind of analysis. already overwhelming suitability to malaria vectors. Koshi is not expected to see any Further analysis will attempt to explore subpro- increase in malaria vector ranges in the near vincial disaggregation in order to better term (2030s), but by the 2050s, it is projected identify the regions of focus. The map in Figure to account for the second-highest increase in 17 illustrates the subprovincial heterogeneity populations at risk. Karnali shows the greatest seen in the distribution of dengue vector overall increase, with at-risk population habitat suitability and the way in which this is numbers increasing progressively through TABLE 5. Percent area of suitable malaria vector species habitat, by province, in Nepal. PROPORTION OF REGION BY AREA VULNERABLE SUITABLE FOR DENGUE VECTORS POPULATION OVERALL SUITABILITY POPULATED, SUITABLE ABSOLUTE VALUES DELTA Ref. Ref. Ref. Province period 2030s 2050s period 2030s 2050s period 2030s 2050s 2030s 2050s Koshi 62.67 62.67 67.95 41.65 41.65 46.58 4,842,718 4,842,718 4,990,009 0 147,291 Madhesh 100.00 100.00 100.00 51.88 51.88 51.88 5,949,982 5,949,982 5,949,982 0 0 Bagmati 72.88 76.12 76.12 28.36 29.18 29.18 6,334,604 6,418,822 6,418,822 84,218 84,218 Gandaki 33.51 34.10 35.60 21.08 21.64 22.41 1,738,546 1,767,915 1,789,053 29,369 50,507 Lumbini 87.66 88.17 91.09 50.21 50.72 53.14 4,416,395 4,425,919 4,474,078 9,524 57,683 Karnali 12.41 18.01 19.05 5.88 9.05 9.05 488,893 634,326 651,354 145,433 162,461 Sudurpaschim 34.43 38.66 40.28 18.04 19.56 19.56 1,903,494 1,962494 1998183 59,000 94,689 Total 25,674,632 26,002,176 26,271,481 327,544 596,849 Note: The Table above was developed by the authors using data from various sources. See Annex A. 30 | Climate and Health Vulnerability Assessment: Nepal FIGURE 18. Comparison of Malaria mosquito vector suitability across Nepal, under RCP8.5, across three epochs: 1986–2005 (his- torical baseline), 2020–2039, and 2040–2059. Note: The maps above were developed by the authors using data from various sources. See Annex A. the 2030s and 2050s. The maps in Figure 18 WATERBORNE DISEASE RISKS illustrate the southern concentration of malaria 42. Water quality, which is in part affected by vector suitability. Similar to dengue vectors, it climate related hazards such as floods or is expected that this concentration will creep landslides, has been associated with an northwards into progressively higher-altitude increased incidence of waterborne diseases regions, as the climate progressively changes. (WBDs). Nepal faces an important burden 41. In the absence of coordinated control of WBDs, particularly due to their impact measures, ongoing climate change is likely to on children under 5 years of age. Current increase malaria vector ranges across Nepal, drivers of WBDs throughout the country are thereby placing nearly 600,000 additional attributable to many factors, including the people at risk (Table 5). Overall suitability sources, quality, and quantity of drinking water, at the national scale will increase from 51 sanitation facilities, and hygiene practices,77 percent during the historical reference period each of which can be negatively affected by to 53 percent in the 2030s and 55 percent climate-related factors, in particular, floods in the 2050s. Besides Madhesh, all other and landslides. provinces will also experience an increase in Diarrhea is a key WBD affecting Nepali children. overall vector suitability in the 2030s, 2050s, Nepal has been registering a downward trend or during both periods. While Madhesh, in cases of diarrhea in children under 5 years Lumbini, Bagmati, and Koshi will remain the of age, from 12 percent in 2006 to 10.4 percent most vulnerable to malaria, it is important in 2022.78 Rates were slightly higher in urban to note the increases in the provinces with areas with 11.1 percent, and rural areas with 9.1 less historic exposure to malaria infection. In percent. The highest rates were found in the Karnali, nearly a doubling of populated area Bagmati Province in 202279. Additionally, most is projected through the 2050s, thus placing of diarrheal cases were reported between May an additional 162,000 people at risk. and October.80 On the other hand, enteric infections have also seen a decreasing trend Climate-related health risks | 31 in the burden of disease, going from 4,610.11 with landslide hazards in the worst-affected DALYs in 1999 to 1,075.82 DALYs in 2019. While districts increasing after the 2015 earthquake.85 the burden of disease from enteric infections Due to the varying elevations of the country have decreased, it still results in 22.6 deaths and the high disparity of safe water coverage, per 100,000 population (by 2019). it is estimated that a large percentage of the population is vulnerable and could be 43. Water sources, waste, and sanitation services are at greater risk in the future to WBD risk, as a at risk of climate hazards, thereby increasing result of changing climate patterns.86 waterborne and water-related diseases in the country. The majority of households had 45. Climate change projections will have a access to improved sources of drinking water different impact on Nepali communities, (98 percent, without major differences between depending on their current vulnerability rural and urban areas -96.4 and 98.8 respec- due to remoteness, poverty, and access tively) by 2022. Likewise, around 92 percent to WASH services, with wide differences of households were reported to have access between and within provinces. In this sense, to improved sanitation,81 increasing from 83.8 diarrheal disease incidence is higher in the percent in 2016.82 Subnational vulnerability mountainous region when compared to differences between regions and districts lowland areas. Research suggests that the depend mostly on remoteness and agro- risk of diarrhea increases by approximately ecological zones (see Fig 3). 5.05 percent per 1°C-rise in the average temperature in mountainous regions compared Subnational impact differences would with non-mountainous areas in Nepal.87 Overall, determine level of risk and vulnerability, for 60 percent of diarrheal cases in Nepal, occur example, the Terai region, which is projected from May to October, which correspond to to be affected mostly by droughts and high the rainy season. Considering that the rainy temperatures, would also impact access to season is projected to increase its rainfall safe water sources, increasing the risk of patterns, while temperatures will continue to WBDs.83 increase throughout the country, waterborne and water-related diseases could increase 44. Areas experiencing increased precipitation, concomitantly, as WASH services would be floods, and landslide events, with limited affected by climate-related hazards. access to safely managed drinking services, will likely experience greater vulnerability to WBDs in Nepal. The Red Cross has reported AIR QUALITY HEALTH RISKS that all provinces are at risk of landslides, 46. Ambient air pollution (AAP) and household floods, or both. The risk of floods is greatest air pollution (HAP) pose a risk to the health in the lower-elevation areas and the more of people in Nepal. Exposure to urban air populated provinces of the country, with the pollution, as well as smoke from indoor estimated population exposed to extreme flood cooking, wildfires, and dust storms, can increasing to nearly 370,000 by 2035–2044.84 adversely affect health. The inhalation of fine At the median level of elevation, there is a particulate matter 2.5 micrometers or smaller risk of both floods and landslides, due to (PM2.5) and other toxins, which can enter the the greater concentration of hills and valleys, deeper sections of the lungs and bloodstream, 32 | Climate and Health Vulnerability Assessment: Nepal has contributed to the development of severe intensity, geographic proximity, and length chronic health conditions. People who are of the wildfire season in Nepal, worsening particularly vulnerable to particulate air wildfire-induced air pollution. Additionally, pollutants include those with asthma, chronic increasing temperatures and atmospheric obstructive pulmonary diseases (COPDs), carbon dioxide can extend the allergy season children, and those with close exposure to due to their impact on plant phonologies, and the sources of air pollution, such as women while this is not well documented in Nepal, when cooking with biomass and firefighters recent research elsewhere has shown that addressing wildfires. According to the World poor air quality is significantly associated with Bank Development Indicators, the age-stan- the risk of autoimmune diseases.91,92 Predicted dardized mortality rate attributed to ambient air quality deterioration is linked to the risk and household air pollution was 193.80 deaths of autoimmune diseases, such as connective per 100,000 in 2016,88 and nearly 100 percent tissue disorder, inflammatory bowel diseases, of the population was estimated to be exposed and rheumatoid arthritis. to levels exceeding WHO guideline values for PM2.5 air pollution in 2017, with little decline 48. The Indo-Gangetic Plain (IGP) areas of since 2010.89 the Terai region are a global hotspot for AAP, including from black carbon (BC) — a 47. Climate change exacerbates AAP and HAP short-lived climate pollutant (SLCP).93 Studies risks to human health. The State of Global in other countries in the region, such as India, Air 2020 report shows that Nepal is among have shown a strong association of black the top 10 countries with the highest outdoor carbon aerosol and cardiovascular disease PM2.5 levels and an annual average of 83.1 mortality (CVD). The IGP, which includes the micrograms per cubic meter of PM2.5.90 In Terai region in Nepal, has been found to be urban areas, increased temperatures can result a global hot spot of atmospheric pollutants, in “heat island” effects — characterized by showing large concentrations of BC aerosols an increased risk of smog formation, where during winter. Research has found that around polluted air (mainly with high levels of ozone 60 million people live over BC hotspots along and particulate matter) stagnates, thereby the IGP, with approximately 400,000 annual impacting health acutely and chronically deaths estimated to be attributable to BC through damage to the cardiovascular and exposure.94 respiratory systems. 49. Indoor air pollution is another concern in Ambient air quality is also impacted by smoke Nepal, with the World Bank estimating from wildfires, which typically occur during the that only 35 percent of the population drier months of March and April before the had access to clean fuels and technologies monsoons in Nepal. The country saw one for cooking in 2020.95 The 2017 Biomass of the worst wildfire seasons in 2021, and Energy Strategy found that nearly 77 percent projected increases in temperatures and risks of Nepal’s energy is supplied by traditional of wildfires could lead to the deterioration of biomass energy and recommended switching air quality, especially when combined with households to clean cooking technologies high wind speeds and prolonged droughts. by 2022.96 Precipitation pattern changes in Droughts can increase the frequency, Nepal can indirectly influence air quality health Climate-related health risks | 33 outcomes via exposure to indoor biomass air 51. To assess mental health in the context of pollution. Exposure to biomass air pollution climate change, the full spectrum from can change during the monsoon months in mental “illnesses to psychological and Nepal, when cooking must be done indoors social well-being,” or “psychosocial health,” in rooms that may have poor or no ventilation. is considered, thereby allowing for the incor- Further, during heavy rain, there is limited poration of considerations of well-being and access to dry wood for fuel, and wet firewood resilience.98 This is particularly relevant in is not only harder to burn but also produces Nepal, where there is background strain on more smoke, thereby increasing air pollution. the resilience of the population, coupled However, some households in Nepal are able with limited opportunities for psychological to switch from using wood to another fuel or psychiatric assessment and diagnoses. source, such as gas, during the monsoon; though more costly, gas is a cleaner burning The concept of mental health and well-being fuel with reduced indoor air pollution risk. The can thus be framed as a spectrum of “psycho- projected changes in precipitation frequency, social health.” It embodies the diverse as well as the timing of rainfall events, are psychological and social strains of climate relevant to cooking and subsequent exposure change impacts, such as housing, water to indoor biomass air pollution. and income insecurities, as well as living in physically uncomfortable drought or humid conditions. In this sense, the mental health MENTAL HEALTH and overall well-being of Nepalis are affected by contextual factors that can culminate in 50. The association between climate change-re- curtailing the cognitive energy for developing lated events and mental health can be direct the coping mechanisms to deal with contextual or indirect, short-term, and long-term. stressors, namely, climate-related hazards. Acute events (such as a flood or cyclones) in the short term can precipitate a psycho- 52. The impact of climate change and climate pathological pattern similar to experiencing extreme events on mental health and traumatic stress, whereas exposure to extreme well-being is mediated by individual and or prolonged weather-related impacts may community resilience. Although there has result in delayed mental impacts, such as been increasing public awareness on the symptoms of post-traumatic stress in the relevance of mental health among Nepali future or psychological impacts on younger communities, there is still a long history of generations. The 2019/2020 Nepal National using traditional healing methods to treat Mental Health Survey (NMHS) highlighted mental health and well-being issues, which that 10 percent of Nepali adults reported are typically performed by community or any mental disorder along their lifespan, with religious leaders. In this sense, they would be 4.3 percent experiencing a current mental the key community members to contribute to illness. In particular, major depressive disorder the development of individual and collective showed a prevalence of 3.6 percent, being coping mechanisms for addressing climate-re- higher than the prevalence in the South Asia lated mental health and well-being disorders.99 region (2.6 percent).97 34 | Climate and Health Vulnerability Assessment: Nepal 53. The climate change’s impact on rural well-being. Health effects caused by heat, communities, and their access to water, can include the direct effect of heat stress, heat increase anxiety and stress levels among rash, cramps, exhaustion, dehydration, and the women involved in subsistence farming.100 acute exacerbation of pre-existing conditions In this sense, climate change impacts on including respiratory and cardiovascular mental health and well-being are mediated diseases. Longer-term mental health risks by social and contextual factors, namely, are also an important effect to consider. In poverty conditions, water insecurity, sudden addition to the impacts on individuals, the loss of property, personal or family diseases, whole-of-population exposure, which occurs or illness, among others. Households who with an extreme heat event, can lead to experience these cumulative shocks are less significant increases in hospitalizations able to develop coping mechanisms that can imposing a strain on health systems.105 build on structural and social support, therefore worsening their well-being and possibilities 56. Projections of increasing mean and extreme of improving their livelihoods.101,102 temperatures, especially in the Terai region, would increase the mortality rate 54. It is challenging to project mental health in the population segment of those aged outcomes related to climate change. In Nepal, 65 years old and above. Considering the there is a need for improved surveillance temperature projections under the high- and diagnostics, as well as specialist training emissions scenario (developed in the previous and services, to meet the mental health and section), it is estimated that around 53 out well-being needs of the population. Projections of 100,000 deaths would be attributable to for the impact of climate change on mental heat by 2080.106 Moreover, the overall rise of health would need to encompass the overall mean temperatures, and the increase in the vulnerability of livelihoods, communities’ number of days with extreme temperatures, resiliency, and individual coping mechanisms. would also lead to an increase in heat-related Research in other countries103 have projected morbidities. levels of heat-related excess mortality for mental disorders. These estimates may not 57. A perverse effect of the changing climate transfer directly to the context of Nepal; has been the precipitation of cold waves as a however, the trends between increasing phenomenon, resulting in adverse respiratory temperatures and associated mental disorders health effects. Cold waves are characterized have been found with regard to self-harm by a rapid drop in temperature (10°–15°C) and suicide rates. Moreover, other findings during the winter season. The cold increases suggest that suicide rates increased between health risks, such as viral flu, coughs, “cold 0.7 percent and 3.1 percent, for a 1°C-increase in diarrhea,” fever, and respiratory diseases the monthly average temperature.104 common during the cold season in general. It is estimated that during the period from 2001 to 2010, around 1,793 people have been EXTREME TEMPERATURE RISKS affected by cold waves, leading to a possible 376 deaths.107,108 55. The health risks of extreme heat are wide- ranging, including effects on mortality, heat-related injuries, mental health, and Climate-related health risks | 35 KEY MESSAGES NUTRITION → Nepal ranks amongst the highest in the South Asia Region for stunting (24.8 RISKS percent), wasting (7.7 percent), and underweight (18.7 percent), among children under 5 years of age, with each of these conditions being climate-sensitive. → Over one-third (36.4 percent) of Nepal’s population suffers from moderate or severe food insecurity, which has been increasing in recent years, and is expected to worsen with climate impacts on agriculture. → The provinces that are the most vulnerable to food insecurity include Koshi, Madhesh, Bagmati, and Lumbini, with each reporting over 150,000 vulnerable households; affected households are concentrated in districts in the south. WATERBORNE → Water sources, as well as waste and sanitation services, are at risk of DISEASES climate hazards, thereby the risks of increasing waterborne and water-re- lated diseases in the country. Around 98 percent of the population is reported to have access to improved sanitation. → Areas experiencing increased precipitation, floods, and landslide events with limited access to safely managed drinking services, will likely experience greater vulnerability to WBDs in Nepal. → Diarrhea increases by approximately 5.05 percent per 1°C-rise in the average temperature in mountainous regions compared with non-moun- tainous areas. Overall, 60 percent of diarrheal cases in Nepal, occur from May to October, which correspond to the rainy season. VECTOR-BORNE → It is estimated that an additional 400,000 people by 2030 and 550,000 DISEASE people by 2050 will be living in dengue-vulnerable areas in Nepal, due to climate change. → Around 25 million people in Nepal are already at risk of malaria. In the absence of coordinated control measures, ongoing climate change is likely to increase malaria vector ranges across Nepal, placing nearly 600,000 additional people at risk. 36 | Climate and Health Vulnerability Assessment: Nepal AIR QUALITY → The State of Global Air 2020 report shows that Nepal is among the top HEALTH RISKS 10 countries with the highest outdoor PM2.5 levels — at an annual average of 83.1 micrograms per cubic meter of PM2.5. → Indoor air pollution is another concern in Nepal, with the World Bank estimating that only 31 percent of the population had access to clean fuels and technologies for cooking in 2019. MENTAL → Acute events (such as a flood or cyclones) in the short term can precipitate HEALTH a psychopathological pattern similar to experiencing traumatic stress. Exposure to extreme or prolonged weather-related impacts may result in delayed mental impacts, such as symptoms of posttraumatic stress in the future or psychological impacts on younger generations. → Climate change’s impact on rural communities, and their access to water, can increase anxiety and stress levels among women involved in subsistence farming. Projections for the impact of climate change on mental health would need to encompass the overall vulnerability of livelihoods, the communities’ resiliency, and individual coping mechanisms. EXTREME → Nepal experiences both extreme heat and cold, thereby increasing risks TEMPERATURE for human health. RISKS → Extreme heat is projected to increase in both the 2030s and 2050s, especially in the Terai region. It is expected that heat-related mortality will increase to 53 out of 100,000 by 2080. → Cold waves increase health risks, predominantly as a result of respiratory diseases. Climate-related health risks | 37 SECTION III. ADAPTIVE CAPACITY OF THE HEALTH SYSTEM HEALTH SYSTEM OVERVIEW 58. Nepal has made significant improvements in health coverage, but there remain gaps between policy and practice, especially at the subnational level. The public health system in Nepal is decentralized, backed by a mix of public, private, and non-governmental organizations (NGOs). Moving from a centralized structure has allowed Nepal to employ greater management at more levels, leading to a greater availability of services and coverage at the community level. 59. The country has made efforts in decentral- 60. The emergence of the COVID-19 pandemic izing health care delivery by strengthening has brought with it a focus on health and the service response at the district level. health systems, specifically the capacity to Moreover, policies and strategy planning manage emerging public health risks. Climate documents highlight the pivotal role that change, as the COVID-19 pandemic has done, communities can play as key stakeholders has the potential to disrupt and overwhelm and actors so as to increase the access health systems, including healthcare facilities and quality of health service delivery. The and healthcare staff. This is especially important governance structure has also integrated local in settings that may already have weak health and Indigenous knowledge, particularly from systems, including leadership challenges, a Ayurveda, thereby furthering projects and lack of resources, and / or limited capacity. programs that improve service delivery. Finally, efforts in building cross-sectoral partnerships 61. The extent to which the health system in have been key in main policies and guidelines Nepal has the capacity to be prepared for in the health sector; however, it is not clear managing changes in hazards, exposure, and how these efforts are being implemented and susceptibility will determine their resilience how the Ministry of Health and Population in the coming decades. In this assessment, (MoHP) has been furthering cross-sectoral Nepal’s adaptive capacity109 to prevent and projects, such as climate-related health ones. manage climate-related health risks is examined Nonetheless, despite the expansion of health according to WHO’s six health system building services around the country and the adoption blocks, as shown in Figure 19 (see also Annex B of bottom-up programs, improvements in the for the “Adaptive Capacity Rapid Assessment” quality of health have lagged. and the summarized “Adaptive Capacity and Climate Change-Related Health Risks Gap Analysis” that informs this section). 39 FIGURE 19. WHO’s climate-resilient health system building blocks. Leadership & Governance Health Workforce Financing Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential Medical Products & Technologies Source: World Health Organization, 2015, Operational Framework for Building Climate Resilient Health Systems. It should be noted that several factors outside to climate change and health, there is a special the scope of the health sector can also drive emphasis on community engagement and reductions in adaptive capacity to manage capacity building at local levels (including the the health risks of climate change in Nepal’s use of community-based volunteers), which is institutions and people. These include the important for addressing subnational needs. country’s economic challenges, the changing For example, MoHP works closely with district- demographic patterns, and slowly improving level stakeholders to develop operational social conditions. The promotion of equity, plans that ensure bottom-up approaches for as a cross-cutting theme for enhancing the key health programs. adaptive capacity and resilience to the health risks of climate change, is also critical. Adaptive The evolution of the climate change and capacity is likely to be robust, when access to health policy landscape in Nepal can be resources within a community, nation, or the summarized as follows: world is equitably distributed. • 2010 — National Adaptation Programme of Action (NAPA). This document is the product LEADERSHIP AND GOVERNANCE of the commitment of the country after the seventh session of the Conference of the 62. The Government of Nepal is aware of the Parties (COP). It highlights the relevance of current and potential negative impacts of climate change’s impact on public health, climate change on health and its health focusing mostly on VBDs and WBDs. It also system. As a result, the government has integrates the impacts on other areas that been actively developing policies and plans concomitantly affect the health system, such to support mitigation and adaptation actions. as water and agriculture. Among the sector policies and plans relevant 40 | Climate and Health Vulnerability Assessment: Nepal Regarding adaptation strategies and efforts, current burden of disease and goals for the document underlines (a) the relevance the next five years. It acknowledges the of research to improve evidence-based impact of climate change on shifting trends deci- sion-making processes; (b) the pivotal on the burden of disease and the direct role of communities as key actors in a impact of climate-re- lated disasters on climate-re- lated emergency response; (c) injuries and death rate. However, it also the focus of research on disease outbreaks underscores the lack of knowledge and and emergency responses; (d) programs on research for determining the health vul- VBDs, WBDs, and food-borne diseases; and nerabilities to climate-related phenomena (e) the strengthening of the early warning and related risks.112 and surveillance systems in order to integrate climate change and health data.110 • 2016 — Nepal’s first National Determined Contribution (NDC). Although the first NDC • 2011 — Local Adaptation Plans for Action submission mentions adaptation efforts (LAPA). This framework highlights the im- and initiatives, it does not provide details portance of engaging with communities regarding the adaptation of the health for integrating climate adaptation and re- care sector. The document focuses on silience into local and national planning building resilience and knowledge man- and adopting a bottom-up approach. This agement, signposting to the NAPAs for approach is aimed at ensuring a more further details.113 inclusive, responsive, and flexible orga- nization in order to further adaptation and • 2017 — Health National Adaptation Plan resilience efforts. (HNAP) 2017–2021. It provides details on risks and vulnerabilities from different The LAPA highlights different strategies and districts and regions, highlighting the activities for ensuring the implementation main climate-related health risks in the of the bottom-up approach: (a) identify country, namely, extreme weather-relat- vulnerable communities, villages, and ed health impacts such as heat waves municipalities, along with their adaptation and cold waves; VBDs including malaria opportunities; (b) prioritize adaptation and dengue; and diarrheal diseases. The actions for communities; (C) prepare document also underlines the differences adaptation plans for action that integrate between agroecological zones, identifying it into local and national plans; (d) mobilize the risk of floods in the Terai region and resources and services delivery agents for the risk of GLOFs and landslides in the the imple- mentation of adaptation efforts; mountains, for example. (e) conduct monitoring and evaluation studies in order to ensure effective imple- Based on the risks and vulnerabilities mentation; and (g) identify cost-effective of climate change for health, the HNAP interventions that can be scaled up for incor- prioritizes (a) raising public awareness poration into local and national planning.111 about climate change’s impact on health; (b) generating evidence through research and • 2015 — Nepal Health Sector Strategy, studies efforts; (c) reducing morbidity and 2015–2020. The NHSS highlights the mortality related to communicable diseases ADAPTIVE CAPACITY OF THE HEALTH SYSTEM | 41 (CDs) (for example, VBDs, WBDs, along one. This document also outlines a section with airborne and foodborne diseases); on climate change, highlighting the im- (d) managing the direct impact of extreme portance of increasing adaptive capacity, weather events; and (e) incorporating health implementing clean energies to further in all policies and adopting a multi-sectoral mitigation efforts, as well as accessing in- cooperation.114 The document also provides ternational finance and technologies in specific targets for each objective and order to strengthen adaptation and miti- corresponding implemen- tation arrange- gation projects.116 While it acknowledges ments. the role of climate change and its impact on health and the country’s health system, • 2019 — Climate Change Policy (updated the document does not provide strategies policy from 2011). The country is committed to address these impacts. to integrating climate change into its main goals and strategies. Regarding climate • 2020 – Second National Determined change and health, the policy framework Contri- bution (NDC). The second com- focuses on building preparedness and pre- munication to the UNFCCC focuses mostly vention mechanisms to avoid outbreaks on mitigation opportunities and efforts in from vector- borne and other communicable Nepal. Although it mentions the adapta- diseases. It also highlights the key role of tion component within the NDCs, it only water management and the importance touches upon the thematic areas that are of having access to drinking water. Lastly, being taken into consideration for furthering it underlines the importance of the man- programs and interventions, and for building agement of hazardous waste in order to adaptation. Within those areas, health, prevent the contamination of water sources drinking water, and sanitation are outlined. or exposure to waste.115 However, it does The document also mentions cross-cutting not provide details on the implementation areas for all the thematic areas, namely, and coordination mechanisms that would (a) gender equality and social inclusion, ensure the development of projects and (b) awareness and capacity building, (c) programs to strengthen the health system research and technology development, and further adaptation efforts. and (d) climate finance. The thematic areas, including health, are signposted for the • 2020 — The 15th Plan (Fiscal Year NAPs, which are scheduled to be updated 2019/2020– 2023/2024). This document every 10 years.117 addresses the long-term planning for the country, covering a wide range of areas, • 2021 — Third National Determined Contri- including macroeco- nomics, governance, bution (NDC). The last communication as well as specific policy frameworks and to the UNFCCC is a thorough document guidelines. Regarding health, the health that deep-dives into different sectors guidelines focus mostly on health service for mitigation and adaptation strategies. delivery and increasing the access and Regarding health, it provides extensive quality of the health system, with the aim information on how climate change is of transforming the profit-orientation of impacting health, with a focus on VBDs and the health system into a service-oriented diarrheal diseases.Adaptation measures to 42 | Climate and Health Vulnerability Assessment: Nepal reduce vulnerabil- ities highlight the need are not well integrated into local-level planning to do the following: (a) raise awareness, (b) initiatives. Regions that are highly vulnerable increase research to generate evidence, to climate-related hazards, such as the Terai (c)reduce the morbidity and mortality of region, would require tailored programs and infectious diseases, (d) manage the risks strategic planning in order to address the of extreme weather events, and (e) ensure compounded effect of different climate hazards a multi-sectoral response to further health and climate-related health risks (for example, in all policies.118 floods, heat, and WBDs). • Forthcoming — 2022 NHSS & the new 65. The World Bank’s Country Climate HNAP Development Report (CCDR)119 for Nepal is a policy guideline for building efforts, 63. Nepal has made substantial efforts in both in mitigation and adaptation strategies, furthering health into their policies and including climate change impacts on strategies to address climate change. health. The CCDR for Nepal adopts an all-of- Although health has been identified in the government perspective of climate change, policy landscape as a key area for furthering highlighting the just and green transitions, adaptation to climate change measures, there as well as providing macroeconomic and are few policies in the health sector addressing selected sectoral recommendations to climate change as a challenge or priority in support the country in responding to the strategic planning. Despite the existence of climate challenge and protecting economic different coordination mechanisms, such as development. Sectoral recommendations the technical working groups for health and include the following: (a) establishing an climate change or a climate change focal integrated and collaborative framework to point in MoHP, there appears to be limited different areas such as water, agriculture, and engagement, financing, and implementation forests; (b) strengthening Nepal’s hydropower of programs from MoHP. The level of participa- capacities for an energy transition; (c) tion of these coordination mechanisms or the enhancing urbanization and environmental extent of their decision-making involvement quality in order to increase resilience and is unclear; it is also uncertain whether they improve health outcomes, and (d) strength- are dependent on specific budget lines for ening Nepal’s low-carbon, resilient roads to advancing climate and health actions. Policy improve connectivity, economic growth, and makers have demonstrated an awareness of services. Overall, having a just and green the health impacts of climate change; however, transition in the country is expected improve the engagement of MoHP with its climate health co-benefits120 from adjusting to climate change, DRM, and agriculture counterparts change. is still ambiguous. 64. At the subnational level, the development of HEALTH WORKFORCE policies and plans to address climate-related 66. Nepal has an emerging crisis in health health risks is lacking. Although MoHP has human resources, as identified by the developed local-level strategic plans, climate Human Resources for Health Strategic Plan, change and health in these subnational plans 2011–2015.121 Nepal is one of the 57 Human ADAPTIVE CAPACITY OF THE HEALTH SYSTEM | 43 Resources for Health (HRH) crisis countries climate-sensitive diseases, to which health identified by the WHO, where the health worker professionals may not be able to respond, in to population density is below the critical a timely manner.127 threshold of 2.3 per 1,000 people needed to provide the basic health services.122,123 67. Nepal has a shortage of healthcare personnel. Nepal faces numerous health workforce In 2019, Nepal had 8 physicians per 10,000 challenges, which have been exacerbated population, and 33 nurses and midwives during the COVID-19 pandemic. They include per 10,000 population — slightly below the insufficient staffing levels, urban-rural mald- WHO minimum threshold of 44.5 healthcare istribution, the lack of proper skill mix, limited workers per 10,000 to achieve universal health education access, poor absorption capacity, coverage.128 In 2014, the specialist surgical rural retention issues, international outmi- workforce was only 3 per 100,000 population.129 gration, lack of community support, and low There is limited data on the availability of salary payments.124 The MoHP has developed medical pathologists and laboratory scientists a National Human Resources for Health (HRH) and environmental and occupational health Strategy 2021–2030 that addresses the health and hygiene professionals, who play a vital workforce challenges and envisions ensuring role in reducing climate change-related health the equitable distribution and availability of risks. Regarding the mental health workforce, quality health workforce in order to advance a study found 200 practicing psychiatrists in universal health coverage. Nepal in 2021 — a substantial increase from 39 in 2008, but there are still vacancies in To reach more people who live in rural mental health worker posts in the government and remote settings in Nepal, it is critically healthcare system.130 important to increase the training and support of community health workers (CHWs). In the As seen in Table 6, several healthcare worker Nepali CHW workforce, a female community posts in government health facilities have health volunteers (FCHVs) program that was vacancies that remain unfilled, particularly in started in 1988 has since expanded to provide certain provinces like Sudurpaschim, often maternal and child health services on a large due to limited human resources and non-pref- scale.125 In 2017, it was estimated that there erences to work in remote areas.131 These are 52,000 FCHVs who contribute to health shortages are worsened by the outmigration education, counseling, outreach, and resource of medical doctors and nurses, due to a lack of distribution as part-time unpaid workers.126 adequate labor conditions and training oppor- Overall, there is still limited data availability on tunities. Previous research estimates that 16 the health workforce in Nepal, particularly for percent of registered doctors may be working unsalaried workers and private sector workers. or studying outside of Nepal.132 Climate change can impact the health 68. There are limitations in the professional workforce through mechanisms related to expertise and distribution of the health changes in the frequency and intensity of workforce, and an overarching lack of extreme weather events that may affect information on the awareness of climate a facility or the workers’ ability to reach change and health risks among health the facility, apart from altering patterns of personnel. The health workforce, particularly 44 | Climate and Health Vulnerability Assessment: Nepal doctors and nurses, are more concentrated in Nepalis receive their health services at the the urban areas. There is an uneven distribution community level.134 of the health workforce across provinces, with most of the highly skilled professionals found There is limited data on the quantity or level in large hospitals and administrative offices in of expertise on climate-related health risks in Kathmandu Valley. In contrast, CHWs are better the health workforce. This issue is important, distributed in more rural regions, but there as climate change can exacerbate the health is currently a lack of clinical supervision for impacts of having significant disparities in trained non-specialist providers.133 The skilled the roles and types of health professionals health workforce distribution is important to at subnational levels, including substantial consider because more than 90 percent of urban-rural divides. TABLE 6. Percent of roles filled in government health facilities, by province. NATIONAL PROVINCE KOSHI MADHESH BAGMATI GANDAKI LUMBINI KARNALI SUDURPASCHIM AVG. Medical Doctor - General 64.3 63.6 61.5 63.6 50.0 33.3 40.0 56.5 Practitioner (MDGP) Medical Officer 57.5 47.2 62.7 59.8 48.2 63.9 34.4 55.9 (MO) Nurse 75.9 71.1 70.2 74.1 70.5 67.7 75.1 72.1 Paramedic and Other Including Health Assistant (HA), Auxiliary Health Worker (AHW), Senior 75.1 77.5 63.8 83.1 77.8 69.1 78.4 74.3 Auxiliary Health Worker (SAHW), Public Health Inspector, Lab- oratory Technologist / Officer / Technician / Assistant, Radiographer, Dark Room Assistant Source: MoHP’s data on health services availability and readiness in the seven provinces of Nepal in 2018. 69. Labor conditions for health workers curtail for retaining human capital within the health health workforce capacity. Many unsalaried system in Nepal and the broader region. workers have limited training and / or are Moreover, education limitations including the lower-skilled, and there is a need for more shortage of faculty and teaching resources regulations to include their education or role further contribute to the shortage of qualified within the health workforce. Although there health professionals,135 thereby increasing have been efforts to increase salaries for the risks of health challenges, such as maternal formal workforce, this remains a challenge mortality. ADAPTIVE CAPACITY OF THE HEALTH SYSTEM | 45 Within the context of climate change, an 70. Nepal’s health education system lacks a unsalaried health workforce, coupled with the national plan to prioritize climate change lack of a unified health training curriculum on and health, and it is uncertain whether the climate, can deepen the disparities and gaps health workforce is receiving education in workforce distribution and roles. Moreover, on climate change’s impact on health and the reliance on private initiatives or NGOs for health systems. Health workforce training health service delivery, without strengthening monitoring is centralized through the National and articulating efforts with the public sector, Health Training Center (NHTC), which was could increase vulnerabilities for the health developed under MOHP to oversee all health workforce in a changing climate. training for DoHS, the Department of Drug Administration (DDA), and the Department FIGURE 20. Nepal’s health care system levels. LEVEL TYPE OF FACILITY Federal General Hospital (300 plus beds) Specialized Hospital (min 100 beds) Teaching Hospital (Academy and others) Central Ayurveda Hospital Provincial General Hospital (25-300 beds) Provincial Ayurveda Hospital Provincial Ayurveda Chikitsalaya/ Ayurveda Health Centre Local Basic Hospital (5, 10, 15 beds) Basic Health Service Centres • Primary Health Care Centers • Health Posts • Community Health Unit • Urban Health Center Ayurveda Dispensaries (Aushadhalaya) Source: Public Health Service Regulation, 2020 46 | Climate and Health Vulnerability Assessment: Nepal of Ayurveda (DA).136 However, information is HEALTH INFORMATION SYSTEMS (HIS) limited regarding the integration of climate 73. Surveillance, reporting, and early warning change impacts on health as part of the health systems (EWS) in Nepal, which are robust and workforce training. free to access, provide relevant information 71. Nepal’s workforce has limited knowledge, on current diseases, management, and technical capacity, and resources to prevent infrastructure. However, the current strategy and manage current and future climate-re- planning document is from 2007, and there lated health risks. There is an absence of have been no updated guidelines or progress a systematic approach for developing the monitoring. The main sources of information capacity of the health workforce in integrating are (a) the census, (b) vital registration, (c) the climate change with emergency prepared- Demographic and Health Survey (DHS) and ness and response. Climate change has not the Nepal Living Standard Survey (carried been prioritized in human resource planning out every 5 years), (d) rapid assessments, (e) mechanisms. Although climate change policies Sentinel Reporting that uses a representative in Nepal mention climate change impacts on sample of hospitals in order to surveil specific health, there are just a few programs and diseases, (f) research, (g) disease surveillance, (h) human resource management information, policies integrating climate-related risks (i) financial management information, ( j) physical into the development of health workforce assets management information, (k) logistics capacities, such as the Kathmandu University management information, (l) health service School of Medical Sciences, are starting to information, (m) drug information network, incorporate climate-related courses into health and (n) Ayurveda Reporting.137 curricula and training programs. Additionally, there is a lack of assessments to establish 74. Disease surveillance systems monitor several a baseline understanding, knowledge, and communicable and non-communicable technical needs of the health workforce in diseases, with an early warning and response relation to climate change. system put in place for three vaccine-pre- ventable diseases and three VBDs. Among 72. Overall, the health sector faces an imbalance the diseases under the surveillance system in the number, capacities, deployment of are (a) acute flaccid paralysis, (b) measles, (c) the health workforce, as well as inadequate neonatal tetanus, (d) malaria (falciparum), (e) resource allocations across the different Kalazar, (f) Japanese encephalitis, (g) cholera, levels of health care, when compared with and (h) any other unusual occurrence of a global minimum thresholds. Improving disease.138 In 2020, Nepal reported having workforce capacity would strengthen job 118 health facilities with an integrated surveil- satisfaction, human resources retention, lance system. The information collected from salaries, work environment, and resource the different facilities is provided weekly to allocations. a centralized platform that is integrated with the management information system.139 ADAPTIVE CAPACITY OF THE HEALTH SYSTEM | 47 75. The Department of Hydrology and Mete- health early warning and reporting system. orological Services collects daily data on Health management, facilities, workforce, and weather and climate, in order to disseminate surveillance information systems do not suffi- and support water resource management, ciently include climate/weather data or other agriculture, and energy. The department is a environmental factors. MoHP has recently key stakeholder in providing information on developed a strategic roadmap (2021–2030) weather and climate forecasts. It collects and for strengthening National Integrated Health publishes daily (24/7) data on temperature Information Management Systems (IHIMS) that and precipitation, as well as information on aims to harmonize different health information the monsoon season onset and withdrawal, systems and advance eHealth architecture for which is key for agricultural production. The ensuring availability and use of quality health department also monitors long-range forecasts, data and information for decision making. such as the El Niño/La Niña phenomenon. This data also feeds into the World Meteorological Organization and the EWS, especially for floods, ESSENTIAL MEDICAL PRODUCTS & which are common during the monsoon season. TECHNOLOGIES Nepal’s wider EWS exists for climate-related disasters, such as floods. However, there isn’t 77. The strong monitoring and evaluation of a comprehensive climate-informed health expired and stock essential medicines can approach: health management, facilities, help improve access in Nepal. A 2018 study workforce, and surveillance information found the availability of essential medicines to systems do not sufficiently include climate / be 92 percent, with the percentage of expired weather data or other environmental factors. medicines at 8.4 percent in district warehouses; however, it recommended stronger monitoring 76. The early warning and reporting system has and evaluation to ensure access in peripheral made significant improvements since its and rural health facilities.141 Moreover, the data establishment in 1997, having community- is limited, making it challenging to assess and based early warning systems for floods in plan for adequate drug stocks and allocate place. Regarding climate-related events, the resources to health facilities. first early warning and reporting system for floods was established in 2002, and improved Factors influencing the availability of medical in 2007 by adopting digital methods, such as supplies in Nepal include a variety of interre- push notifications and radio, to communicate lated issues,142 ranging from simple to complex expected flood hazards. The early warning problems involving different levels and cadres and reporting system employs local disaster of workers within the medical supply chain, management committees, which receive which necessitates a coordinated approach training in risk reduction and emergency between the government and partner stake- response in case of floods, and volunteer to holders. Under-resourced hospitals and work as part of the warning and emergency healthcare facilities (including preventive, response system.140 While aspects of Nepal’s primary health care facilities, and critical care) wider early warning and reporting system exist are ill-equipped, characterized by limited for climate-related disasters, such as floods, access to health technologies,143 stock-outs there isn’t a comprehensive climate-informed of medicines and supplies,144 and a lack of management of health system needs. The 48 | Climate and Health Vulnerability Assessment: Nepal gaps and vulnerabilities in equipment and where low-quality health care can result in supplies would exacerbate the impact of poor health outcomes. Despite progress from climate-related health risks; and therefore, the establishment of the primary health care reliable stockpiles of essential medicines (PHC) service in 1978, by using a network of and emergency supplies (particularly in rural mostly peripheral district and distal health posts areas) are needed to adequately prepare for and sub-health posts to reach communities, extreme weather events. remote rural areas in Nepal have seen little or slow change in access to key elements 78. Laboratory capabilities in Nepal face several of health coverage.147 Health care in these challenges in several areas, including testing areas are still affected by weaknesses in the services, the transport of specimens, quality following areas: (a) health facilities (often due management, and regulations.145 These to geographic reasons and lack of transpor- challenges are further exacerbated by poor tation); (b) availability of basic and specialized supply chains, thereby resulting in a lack of services; (c) affordability concerns due to high basic needs (for example, water and electricity) out-of-pocket (OOP) expenditures; and (d) and contributing to stock-outs of laboratory quality of care.148 reagents, consumables, and equipment. Additional shocks and stressors related At the same time, Nepal has demonstrated to climate change have the potential to an ability to increase its laboratory capabil- exacerbate existing issues and barriers ities under certain high-demand scenarios. to quality health service delivery. During For example, over 100 laboratories were climate-related emergencies such as floods, established to conduct RT-PCR tests during the access to health services and health workers COVID-19 pandemic, and this investment will can be particularly difficult due to damaged help to improve disease surveillance overall infrastructure and transport services, in the future.146 interrupted power and refrigeration, and other negative impacts.149 The lack of access Laboratory capacities and other health tech- to health services and information has been nologies in Nepal need further assessment shown to increase household vulnerability to to better understand the country’s ability to health risks in flood-prone areas. manage current and projected climate-sen- sitive diseases. This could include the 80. There are vast disparities in the accessible fundamental strengthening of its laboratory resources and support at the different types capabilities to ensure access to essential of health facilities.150 For example, more medicines, testing, and equipment. centralized urban facilities have specialized staff, medicines, equipment, and services, which are not available at many rural facilities. SERVICE DELIVERY There are also differences between public 79. Nepal faces several barriers that impede and private healthcare facilities. Some public access to health services, which can be facilities face common challenges, such as exacerbated by climate change. Achieving being understaffed, understocked, and lacking adequate delivery of quality of health services in adequate infrastructure. Rural access to and care is a recurrent challenge in Nepal, healthcare infrastructure is also complexified ADAPTIVE CAPACITY OF THE HEALTH SYSTEM | 49 FIGURE 21. Geographical accessibility of health facilities (average travel times in minutes by motorized transport and walking). Source: BMJ Global Health 2021. Equityof geographical access topublic health facilities in Nepal. 50 | Climate and Health Vulnerability Assessment: Nepal by a lack of transportation and health facilities were destroyed or severely damaged.154 The within a 5-mile radius. Figure 21 illustrates health sector can improve the coordination of some of the disparities in geographical DRM and climate change adaptation efforts in accessibility to health facilities, with lower order to reduce interruptions in health service accessibility in the northern mountain areas, delivery caused by climate hazards and natural as compared with the central and southern disasters in the future. Terai belt.151 Another study in 2015 found significant discrepancies between urban 82. Climate change impacts a wide range of (85.9 percent) and rural areas (59 percent) health program areas that are important for in the percentage of Nepali households with service delivery (including CDs, maternal access to health facilities within 30 minutes.152 and child health, and nutrition), making it As facilities are not near every community, vital to be incorporated into all levels of the distance increases for the patients to get health planning. Nepal’s 2019 Climate Change to other communities’ healthcare facilities. Policy, which was updated from 2011, does Greater distances may result in a decreased include commitments to integrate climate utilization of healthcare facilities, although change into the country’s main goals and there are other factors that may play a larger strategies. However, climate change and role in detracting from healthcare usage and its associated impacts have not yet been health outcomes (such as education, socio- mainstreamed into the operations of health economic status, and access to resources).153 programs at all levels. A coordinated approach is lacking in addressing climate-sensitive 81. The health infrastructure in Nepal is impacted epidemics and disease outbreaks, as well as by several climate-related hazards, most other climate-related health risks at multiple notably floods and landslides. Floods and levels and with multiple stakeholders. The landslides are unlikely to recede given current COVID-19 pandemic revealed gaps in health projections (according to the GFDRR), with system preparedness, including physical infra- potential damage to health infrastructure, structure limitations, lack of skilled personnel, including healthcare facilities, especially in and other resource constraints. These 155 the remote areas, likely to occur in a changing gaps in health system preparedness could climate. lead to poor health outcomes in the face of climate-related health risks. The Red Cross Climate-resilient health infrastructure in Nepal has been working on anticipatory guidelines and assessments are still in the measures, including forecast-based action process of being developed to build resilience (FbA) and shock-responsive social protection and strengthen health facilities and technol- (SRSP), for risks such as floods and extreme ogies for climate-related events, as there is a temperatures, in order to improve service need for adequate coordination across sectors delivery and reduce disaster burden . 156 to ensure that climate risks are being incor- porated into health infrastructure planning. 83. Climate change impacts other determinants Building resilience is crucial, as the health of health in Nepal (including water quality infrastructure was overwhelmed in the wake and quantity, air quality, nutrition and food of the 2015 earthquake, where over 90 percent security, waste management, and housing), of the health facilities in the affected areas which need to be monitored and addressed ADAPTIVE CAPACITY OF THE HEALTH SYSTEM | 51 in all health policies and regulations. More percent from Corporations, and 2.6 from baseline information can be collected on key others. Moreover, the general government environmental determinants of health where current health expenditure is distributed data is currently limited. Existing environmental between pharmaceuticals and medical goods quality standards and environmental health with 37.4 percent, curative care with 33.4 strategies have not been updated, with many percent, preventive care with 11 percent, other of the emerging health issues related to climate health care services with 9.2 percent, ancillary change. Additionally, most health plans do services with 4.6 percent, and administration not specifically address how to prepare for with 4.5 percent.157 the ways in which climate change will affect implementation. 85. Nepal’s relies significantly on out-of-pocket (OOP) payments. Out of the total expenditure in health care, more than half come from HEALTH FINANCING OOP expenditures (54.2 percent), while nearly 30 percent comes from government 84. Although there have been improvements schemes.158 High OOP expenditures, put in national investments on health, Nepal pressure to household’s budget, increasing still has not achieved universal health risks for pushing families to poverty.159 This coverage (UHC). Government expenditure, picture may be further aggravated by climate as a percentage of GDP in health, has slightly change putting more strain on individuals and decrease since 2015/2016. However, it is still households in Nepal, especially those most above the threshold of the recommended vulnerable to climate impacts.160 5-percent spending in order to progress towards UHC. Nepal went from a current 86. Climate change’s impact on health is incor- health expenditure as percentage of its GDP porated within the health financing strategy of 6.3 in 2016 to 5.2 in 2020. in the NHSS II. While the NHSS acknowl- edges the impact of climate change on the In terms of per capita health expenditure, burden of disease and the service delivery Nepal’s government has increased gradually, and health infrastructure, there are no evident going from USD 11.3 in 2015/2016 to USD allocations from the MoHP that are dedicated 20.2 in 2019/2020. The inadequate health to addressing climate change’s impact on expenditure has been coupled with an health and the health system. Additionally, increase in the health sector budget, which risk pooling mechanisms do not account for has more than doubled from 2015/2016 to climate exposures or vulnerabilities. 2020/2021. Moreover, the share of the health sector budget against the national budget has While there is a lack of integration of climate increased by 6 percentage points between change in health budget and resource 2017/2018 and 2020/2021. allocation, it is important to point out that the basic services health service package does By 2020, the health care expenditure comes account for health risks that are influenced from different sources, with 54.2 percent by climate-related hazards, such as malnu- coming from revenues from households, 30.1 trition, enteric diseases, malaria, depression percent from government domestic revenue, and anxiety, postnatal care and screening, and 9.3 percent from direct foreign transfers, 3.8 52 | Climate and Health Vulnerability Assessment: Nepal laboratory services for VBDs such as malaria. risk- pooling mechanisms, it is not clear if it However, it is noticeable that NCDs, such as is accounting for climate-related risks. cardiovascular and respiratory illnesses, which are climate-related, are not included in the 89. Climate change mitigation and adaptation basic services, free of cost.161 options in the health sector have not been adequately promoted as cost-effective 87. Health financing progress toward UHC options. Arguments for implementing climate has been affected by the 2015 earthquake, change mitigation policies often focus on the and most recently, by COVID-19, which has perceived short-term financial costs. However, required large investments for recovery. The these cost assessments are lacking; moreover, 2015 earthquake impacted health facilities, they rarely account for the health co-benefits with a total of 446 public and 16 private health of these policies, in terms of strengthening the facilities destroyed and a total of 765 partially resilience and outcomes for human health, damaged. This amounted to losses totaling while also reducing costs for the health sector. NPR7.54 billion, representing around 15 percent Therefore, additional studies are needed to of the total health budget of 2016 (in 2016/2017, quantify the longer-term cost savings through the health budget was NPR49.8 billion). On the health co-benefits of climate change the other hand, by FY2020/2021, there was adaptation and mitigation policies in Nepal. an allocation of NPR6.1 billion for COVID-19. It is unclear whether resources have been allocated to address climate shocks, such as heat and cold waves, floods, or landslides.162 The National Health Financing Strategy (2021– 2030) aims to expand fiscal space in the health sector, with an increase in the investment in the health sector. About 10 percent of the provincial and local governments’ budgets will be allocated to the health sector to help address the health emergencies or pandemics. 88. Building resilient health systems for climate change requires budget allocations as an integrated component in the overall planning of a national health plan. Although there is a multi-sectoral approach and an integration of climate change in the strategic planning for the health sector, there is a lack of guidelines for integrating a climate-resilient approach for specific climate-related health risks, such as food insecurity and malnutrition, as well as heat-related morbidity and mortality, which are necessary to inform rationalized resource allocation. Moreover, while Nepal adopts ADAPTIVE CAPACITY OF THE HEALTH SYSTEM | 53 TABLE 7. Summary of the health system’s adaptive capacity gaps for Nepal. HEALTH SYSTEM’S SUMMARY OF GAPS IN BUILDING BLOCK ADAPTIVE CAPACITY • There is a lack of policies and strategic planning at the local and community levels to address climate-related health risks. Climate Leadership and Governance change and health actions remain at the national level, with little engagement of districts and local communities and support for them. • Nepal is one of the 57 HRH crisis countries identified by the WHO, with 8 phy- sicians per 10,000 population and 33 nurses / midwives per 10,000 population. These numbers are below the recommended minimum thresholds for achieving UHC and climate resilience. • There is an uneven distribution of the skilled health workforce. Health Workforce Since more than 90 percent of Nepalis receive their health services at the community level, this leaves certain communities more vulnerable to climate-related health risks than others. • Nepal’s workforce has limited knowledge, technical capacity, and resources to prevent and manage current and future climate-relat- ed health risks. • Although Nepal’s wider EWS exists for climate-related disasters, such as floods, there is no comprehensive climate-informed Health Information and Disease health EWS. Health management, facilities, workforce, and sur- Surveillance Systems veillance information systems do not incorporate climate/weather data or other environmental factors, as key variables that could affect the prevalence of diseases. • The gaps in equipment and supplies, along with the correspond- ing vulnerabilities, exacerbate the impact of climate-related health risks. Thus, reliable stockpiles of essential medicines and emergency supplies (particularly in rural areas) are needed to Essential Medical Products adequately prepare for extreme weather events. and Technologies • Laboratory capabilities in Nepal are characterized by several challenges in the following areas, including testing services, the transport of specimens, quality management, and regulations. The national network of laboratories needs to be strengthened to respond to climate-sensitive diseases. 54 | Climate and Health Vulnerability Assessment: Nepal HEALTH SYSTEM’S SUMMARY OF GAPS IN BUILDING BLOCK ADAPTIVE CAPACITY • The health infrastructure in Nepal is impacted by several cli- mate-related hazards, most notably floods and landslides. There are vast disparities in the resources and support that are acces- sible at the different types of health facilities, which affects the Health Service Delivery country’s ability to respond to climate change impacts effectively. • Climate change impacts and environmental determinants of health have not yet been incorporated into all levels of health planning. • There are no evident budget allocations from MoHP that are dedicated to ad- dressing climate change’s impact on health and the health system. • Risk pooling in Nepal does not account for climate vulnerability Financing differences among different population groups. • Guidelines for integrating the climate-resilient approach for health care and public health systems are not available to inform ratio- nalized resource allocation. ADAPTIVE CAPACITY OF THE HEALTH SYSTEM | 55 SECTION IV. RECOMMENDATIONS 90. This section outlines a set of recommendations to enhance health system resil- ience and adaptation to climate change, including potential health interventions and strategies that can be put in place. The recommended options are based on an assessment of both the magnitude of the current and projected climate-related health risks, the existing gaps in adaptive capacity to manage and/or prevent these risks, and the feasibility to develop them in the short and medium terms. This section is organized, using the 10 components of climate-resilient health systems (Figure 22), and drawing from the consultations and the review of all relevant governmen- tal policies, as well as the World Bank’s Health, Nutrition and Population (HNP) Climate and Health Guidance Note. See Annex D for a summary of recommen- dations for building a climate-resilient health system across the identified climate change-related health risks. Further details on the stakeholders’ involvement for the recommendations are in Annex E. FIGURE 22. WHO’s operational framework for climate-resilient health systems. 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 Preparedness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential C li r m e h Re ima & I n f a lt s Medical ma d C l a lt h se te o Products & h He ra m Pro te a rc Technologies He - g Ma nt na ili e Env ge m ent o Res le ir o n f C li m a t e a b in D et m ental & S u st a gies ri m e lo of H n ts Techno cture e a lt h s tr u & Infra Source: World Health Organization, 2015, Operational Framework for Building Climate Resilient Health Systems. RECOMMENDATIONS | 57 a. Increase and strengthen collaboration among change and health-related vulnerabilities at the national government, the subnational the provincial and local levels. (This recommen- regions, communities, and the civil society. dation falls under Component 10 — Climate and Health Financing.) Strengthen the current multi-sectoral platform on climate change, involving MoFE and MoHP, e. Develop a capacity-building program that by positioning climate change impacts on builds on the National Human Resources for health as a key priority in the strategic planning. Health Strategy (2021–2030), including the The multi-sectoral platforms need to develop development of national technical guidelines the terms of reference to ensure that the for climate-related health risks. The capac- composition of these platforms aligns to the ity-building program would benefit different climate-related health needs that the platform levels, such as the following: is set up to respond to. (This recommendation falls under Component 1 — Leadership and • Cross-sectoral and national government Governance.) level: Officials from MoHP and other min- istries would acquire skills on strategies, b. The multi-sectoral platform, which already policy, and planning to account for cli- exists at the federal and provincial levels, mate-related health risks. could be expanded to the local level. This could include developing an updated LAPA in • Local governments: They would need to order to ensure implementation mechanisms strengthen their knowledge on climate at the local level for responding to climate-re- hazards and climate-related health risks, lated health risks. (This recommendation so they can ensure the adequate imple- falls under Component 1 — Leadership and mentation of strategies and policies tailored Governance.) to their climate-related vulnerabilities. c. A public private partnership approach could be • Academia and research departments: harnessed to make available further resources They could incorporate the guidelines as for a climate-sensitive health system, with priorities for their research agendas and the priority given to (a) service delivery interven- climate-related health risks into the curricula tions directed at responding to climate-related of the univer- sities’ medical schools and health risks, (b) climate- smart health infra- nursing course. structure, and (c) medical waste management. (This recommendation falls under Component • Overall health workforce of CHWs, 10 — Climate and Health Financing.) FCHVs, physicians, and nurses: They need d. Review the current basic health service to integrate climate-related health risks package to ensure that it covers key into their work. (This recommendation falls climate-related health risks. This would include under Component 2 — Health Workforce, the effective implementation of a national and Component 3 — Vulnerability, Capacity health financing strategy (2021–2030) to and Adaptation Assessment.) expand the fiscal space in the health sector at all levels. More specifically, options and provisions for increased domestic resources need to be explored to address climate 58 | Climate and Health Vulnerability Assessment: Nepal f. Strengthen communication networks recommendation falls under Component 4 — between the Department of Hydrology and Integrated Risk, Monitoring, & Early Warning.) Meteorology (DHM), MoHP, and communities at risk of extreme weather events. While DHM h. Harness the linkage between MoHP and the possesses the information needed to provide Ministry of Physical Infrastructure (MoPI) at-risk communities with the advanced warning to ensure the adoption of a climate-smart of extreme climate events, warning messages approach to health care infrastructure. often do not reach at-risk communities with Coordination between MoHP and MoPI could sufficient time for adequate preparation. A prioritize retrofitting and climate-proofing pilot is thus currently underway to notify current health facilities at the federal and communities of floods and extreme tempera- provincial levels, accounting for the specific tures via a short messaging service (SMS). climate-related hazards that could affect the infrastructure. This would also include Options for strengthening the communication locking in budgets to increase prepared- may include (a) expanding push notifications ness and responses to extreme weather to mobile users in anticipation of meteorolog- events, emergency plans for hospitals, and ical events that could present health risks; (b) integrated management information systems coordinating with rural broadcasting stations for MoHP, in order to prevent and plan strategic through the Association of Community Radio purchasing accordingly to specific climate-re- Broadcasters Nepal (ACORAB) to relay warning lated hazards. (This recommendation falls messages to listeners — a system that has under Component 6 — Climate-Resilient & been used to reach rural households with Sustainable Technologies and Infrastructure, information during the COVID-19 lockdowns; and Component 9 — Emergency Prepared- (c) improving the coordination and reporting ness and Management.) mechanisms between DHM and the focal points in MoHP and the Ministry of Home i. Conduct a review of climate-readiness in Affairs (MoHA) in response to climate and the current health care system, adopting other natural disasters. (This recommendation a DRM for health networks approach. This falls under Component 4 — Integrated Risk, would include conducting health technology Monitoring, & Early Warning.) assessments (HTAs) to understand the value of adaptation measures in the health sector, g. Integrate climate-related health risks into the creating a national register for climate-related existent HIS in order to establish integrated health risks with seasonal climate outlooks climate-informed disease surveillance. This to inform health sector programming, and could include the development of an implemen- enhancing contingency planning for acute tation guideline that ensures a coordination climate shocks at all administrative levels. and reporting mechanism among the Epidemi- This would align with the current Nepal Health ology and Disease Control Division of DoHS at Sector Strategy Plan (2022–2030). (This the federal level and the provincial and local recommendation falls under Component 6 — levels. This would build on current efforts in Climate-Resilient & Sustainable Technologies MoHP, which will be aligned with the Nepal and Infrastructure.) Health Sector Strategy Plan (2022–2030). (This RECOMMENDATIONS | 59 ANNEXES ANNEX A. METHODS FOR ESTIMATING MOSQUITO SUITABILITY UNDER RCP8.5 IN NEPAL To demonstrate the plausible spatial distributions of In addition, this methodology does not incorporate the vectors of dengue and malaria, spatial models sociodemographic factors, which can play an were constructed to assess the risk propensity appreciable role in facilitating or curtailing vector of these diseases. Climate data are taken from breeding risk. To opine on the population at risk the historical reference period (1986–2005), of these VBDs, suitable areas were spatially the 2030s, and the 2050s. The epidemiology overlaid with population data from the Global of VBDs is directly influenced by environmental Human Settlement Layers (2015) to calculate the factors that facilitate vector development and population residing in suitable areas, by region. survival. It is important to recognize that spatial Population data are held constant in all models, modeling results are limited by the input data’s in the absence of spatial population projection spatial resolutions and the parameterization of information. As such, these results should be taken predictor variables, as demonstrated from the as a conservative estimation of the areas of Nepal literature review, including laboratory studies. presenting suitable conditions for vector breeding and suitable conditions for vector breeding where Here, results are largely a function of minimum humans are present (that is, populated areas). and maximum temperatures (that is, the thermal tolerances of vector species), as well as land use and land cover (that is, species habitat preference characteristics) whose input data’s spatial resolutions are 25 km and 100 m, respectively. These resolutions provide large, not fine-scale estimations of suitable breeding areas. Annexes | 61 ANNEX B. ASSUMPTIONS OF FUTURE GLOBAL CLIMATE CHANGE Predicting the future climate of any country Looking to the future, 20-year time periods are requires several assumptions to be made about used as a consequence of the accelerating pace the direction of the future global climate. Climate of change of global climate and to be able to information was acquired from the World Bank analyze climate-related threats over a sufficiently Group’s Climate Change Knowledge Portal proximate timescale. (CCKP). Observed climate data for 1901–2020 was presented at a spatial resolution of 50 km x 50 • 2030s: This is a 20-year period from 2020 km. The model-based climate projection data was to 2039, with 2030 as the chronological derived from the Coupled Model Intercomparison mid-point. This can be seen to represent the Project Phase 6 (CMIP6), with projections shown immediate coming years to which countries through five shared socio-economic pathways and their governments need to respond with (SSPs). utmost urgency. • 2050s: This is a 20-year period from 2040 to This assessment explores projected climate 2059, with 2050 as the chronological mid- change under SSP3-7.0 for the short (2030s; point. This can be seen to represent a me- 2020–2039) and medium (2050s; 2040–2059) dium-term period, still well within the lifetime terms. The SSP3-7.0 is a high-greenhouse gas of current populations over which countries (GHG) emissions scenario in which countries are and governments have sufficient time to make increasingly competitive and emissions continue profound changes in preparation for expected to climb, doubling from the current levels by 2100. threats. This assessment uses future time periods that can be compared with the baseline and for which assumptions or models can be used to predict changes in future climate-related disease burdens. The World Bank’s Climate and Health Vulner- ability Assessments (CHVAs) use two 20-year time periods: together, they cover the next four decades to show imminent climatic changes and medium-term climatic changes in a given country. The baseline period covers 30 years (1990–2020): this has conventionally been the length of time over which climatic conditions are measured to reduce noise from annual or other cyclical variations. 62 | Climate and Health Vulnerability Assessment: Nepal ANNEX C. ADAPTIVE CAPACITY RAPID ASSESSMENT LEADERSHIP AND GOVERNANCE Assessment Questions Yes No Partial 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 (MoH)? 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 memorandum of understanding (MOU) between the MoH and the key climate change-related ministries / departments (for example, Environment, Meteorological Services, Agriculture, and Water)? 1.7: Are decision-makers (both within the 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 adaptation reach key stakeholders across sectors? 1.9: Is climate change included in health plans at subnational levels? HEALTH WORKFORCE Assessment Questions Yes No Partial N/A 2.1: Are there dedicated full-time staff devoted to climate change and health? 2.2: Is the number of healthcare workers above 4.5 per 1,000? 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 programs focused on climate change and health within the MoH? 2.6: Have the MoH staff received training on climate change and health over the last two years? 2.7: Does the health workforce have the technical capacity to interpret and utilize climate change information (for example, scenarios, projections, and forecasts) to inform planning / decision-making? 2.8: Is climate change and health included in the educational curriculum (for example, schools of public health, medicine, nursing)? 2.9: Are there context- or country-specific climate change and health training / educational materials available for the health workforce? Annexes | 63 HEALTH INFORMATION AND DISEASE SURVEILLANCE SYSTEM Assessment Questions Yes No Partial N/A 3.1: Has the country completed a climate change and health vulnerability and adaptation or risk assessment? 3.2. Do surveillance systems exist for climate-sensitive diseases (for example, heat- related illnesses, VBDs, and WBDs)? 3.3: Does the country have a centralized monitoring system for climate-related diseases? 3.4: Do health surveillance systems integrate meteorological and / or environmen- tal information? 3.5: Are there efforts from the MoH to utilize national climate / meteorological information? 3.6: Does the country have a climate-informed EWS for any health risks? 3.7: Are there EWS in place for climate change-related extreme events / hazards? (for example, flooding, droughts, and storms)? 3.8: Does the MoH coordinate with disaster / hazard-focused EWS? ESSENTIAL MEDICAL PRODUCTS, TECHNOLOGIES, AND INFRASTRUCTURE Assessment Questions Yes No Partial 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 (for example, 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 (for example, tree planting and cooling designs)? 4.8: Are there efforts to incorporate long-term planning (for example, 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 (for example, stockpile of medical / emergency supplies)? 64 | Climate and Health Vulnerability Assessment: Nepal HEALTH SERVICE DELIVERY Assessment Questions Yes No Partial N/A 5.1: Has the country enacted legislation mandating universal healthcare coverage? 5.2: Are there climate change-specific health programs underway in the country? 5.3 Does health service delivery have contingency measures for extreme weather events (e.g., floods, storms, and heatwaves)? 5.4: Does current public health planning consider climate change information (for example, scenarios, projections, and 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 healthcare 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 Assessment Questions Yes No Partial N/A 6.1: Is the MoH 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’s 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. HEALTH ADAPTATION RECOMMENDATIONS/MENU OF OPTIONS Food security and Vector-borne Water-related Heat-Related Morbidity Air quality Mental health and nutrition diseases diseases and Mortality well-being Component 1: Incorporate climate Develop plans for vector Develop an independent Develop and implement Develop an operational Advocate for and Leadership and change risks into food control, depending on government agency to national heat health framework for climate promote mental health Governance security and nutrition agroecological zones, oversee water quality policy and city-level change programs that in- as a key component strategic plans, including particularly malaria that surveillance, monitoring, plans. tegrates climate change in MoHP’s strategic sustainable agriculture affects most of the pop- and enforcement of impacts on air quality planning that also efforts. ulation. water quality policies and and health. accounts for climate-re- laws. lated mental health risks. Strengthen coordination Formulate a national mechanisms among Enhance the climate and air quality Establish a coordina- MoHP, MoFE, coordination and policy / law that inte- tion mechanism that engagement between grates health issues. integrates religious and and international stake- rural water boards and local leaders, and the holders. national offices. Ayurveda approach, which is aimed at 66 | Climate and Health Vulnerability Assessment: Nepal Promote community- reducing the stigma based water around mental health. management and governance approaches. Component 2: Incorporate educational Implement training at Promote routine training Conduct heat- health Map gaps and create Promote and create in- Health materials on climate subnational levels to of and refresher oppor- training for health training opportunities in centives to increase the workforce change impacts on food dengue prevention and tunities for the health workers. air pollution and related mental health of workers, security and nutrition into control, as well as the workforce, including health outcomes. along with avenues of- health worker training. knowledge on climate CHWs, on the diagnosis Ensure occupational heat training, including those change-related factors. and treatment of WBDs. exposures are managed. Provide health workers related to climate change with health- specific risks. awareness and education materials on Develop mental health the risks of indoor and services that are aimed outdoor air pollution. at providing services to healthcare workers. Develop mental health courses that are focused on emergency psy- chological services for healthcare workers who are deployed in response to extreme weather events. Food security and Vector-borne Water-related Heat-Related Morbidity Air quality Mental health and nutrition diseases diseases and Mortality well-being Component 3: Conduct a vulnerability Conduct district- and Enhance and promote Conduct assessments Assess indoor and Develop baseline data Vulnerability, assessment of the impact community- level assess- routine vulnerability as- of high-risk groups at outdoor air pollution on mental health related capacity, and of climate change on ments to better under- sessment and adaptation the local level, including levels and health impacts to climate change, and adaptation nutrition. stand local risks related planning. informal settlements and in both urban and rural improve the surveil- assessment to VBDs and the capacity remote communities, and areas. lance of mental health Assess the nutrition to manage outbreaks. incorporate economic outcomes. benefits of climate- smart analyses. agricultural interventions. Assess the capacity of community- centered Assess the capacities resilience building and of the health system to targeted vulnerable respond to acute food populations. insecurity and emergen- cy-related nutritional risks. Component 4: Develop and include Build from the HIS to Integrate climate change Strengthen heat wave Develop air quality moni- Develop monitoring and Integrated risk long-term strategies for incorporate climate-in- projections with WBD alert systems for urban toring systems and public surveillance systems that monitoring and nutrition interventions formed seasonal and surveillance to strength- and rural populations. health risk communica- account for climate-relat- early warning into the famine early agroecological outlooks. en WBD outbreak tions campaigns. ed mental health risks, warning system (FEWS). predictions. and well-being-related indicators that impact mental health (for example, livelihoods and stressful events). Component 5: Analyze the long-term Conduct climate change Enhance scientific Conduct Studies to Invest in more research Include climate-relat- Health and effects of climate change modeling studies to research to support a further explore the on air pollution-related ed mental health risks climate research on food systems, nutri- estimate risk projections better understanding of impacts of extreme health effects and further into the MoH research tional outcomes, and the for dengue and other cli- climate change variability heat on health systems, the understanding of the agenda and promote economy. mate-sensitive diseases and health impacts, and including urban heat linkage between climate partnerships with to inform adaptation guide climate change ad- island mapping. change and air quality. national universities and decisions. aptation communication. research institutions to better understand the impact of climate change on mental health. Annexes | 67 Food security and Vector-borne Water-related Heat-Related Morbidity Air quality Mental health and nutrition diseases diseases and Mortality well-being Component 6: Improve drainage Improve laboratory Improve WASH facilities Enable space cooling Invest in the use Explore technologies that Climate-resilient systems in crop fields at capabilities for testing (including appropriate in healthcare facilities of sustainable and could imporve access to and sustainable risk of floods. and the diagnosis of waste disposal systems) to prevent overheating renewable energy mental health services technologies endemic as well as both in healthcare and protect information sources, such as the (for example, and Explore smart-agriculture novel and reemerging facilities and in the technology and use of solar power, in telemedicine). infrastructure and crop diversification diseases. communities, and ensure equipment. healthcare facilities. practices. that these facilities are Develop a list of essential climate resilient. Put in place energy medicines needed for efficient or passive VBD outbreaks. measures of cooling to reduce energy costs. Adopt irrigation systems that account for increased exposure to 68 | Climate and Health Vulnerability Assessment: Nepal VBDs, such as alternate wet-dry or system of rice intensification (SRI). Component 7: Conduct communi- ty-led Conduct community Strengthen the Engage in Occu- pational Enhance routine indoor Engage in urban Management of efforts to map food awareness campaigns to environmen- tal public health management. and outdoor air pollution planning to address environmental insecurity and inform increase the awareness health program and exposure assessments. climate change impacts determinants of interventions to improve on the climate sensitivity surveillance. on the environmental health the food system in a of VBDs and engage determi- nants of mental changing climate. vulnerable groups on Enhance a reliable plan health. outbreak prevention. for routine public water source cleaning and testing. Component 8: Implement interventions Incorporate climate Strengthen public Ensure heat risks Raise awareness on air Integrate mental health Climate- involving the change information awareness program are incorporated pollution and its impacts services that account for informed establishment of gardens into VBD prevention on proper hygiene and into maternal health on health in communities climate-related mental health program or food- growing and outbreak response sanitation, and climate guidance, guidance for and health risks into primary opportunities. standard operating diabetes management, and secondary health procedures (SOPs). change impacts on etc. engage communities in services. Implement community- health. air pollution awareness mediated delivery programs. of nutrition services, including screening. Food security and Vector-borne Water-related Heat-Related Morbidity Air quality Mental health and nutrition diseases diseases and Mortality well-being Component 9: Reinforce the food Factor VBD outbreaks Enhance emergency Include heat-related Integrate air quality Develop a program on an Emergency production and into DRM plans at response planning for responses into DRM emergencies into DRM emergency psychology preparedness distribution chain to national, provincial, safe and sustainable operations. plans and program. response to climate- and withstand impacts from district, and community water supply and related hazards. management extreme weather events. levels. clean sanitation in Enhance routine air and healthcare facilities and monitoring. communities. Component 10: Establish a budget Formulate proposals Prioritize Finance sustainable/cool Improve multi- Establish a budget Climate and line for the reaserch for external donors to investments in cities that adress heat sectoral coordination line allocated to the health financing and development support the improved climate-resilent WASH risks. and international improvment of mental of technologies for control of VBDs. infrastructure in collaboration health and well-being agricultural resiliency. heathcare facilities and Implement other opportunities for services, as well as displacement camps. interventions related to financing air pollution awareness and outreach. Invest in the disemination heat-health responses reaserch, equipment, of crop varieties and (for example, cool roofs). training, and prevention breeds adapted to programs. changing climatic conditions. Annexes | 69 ANNEX E. KEY RECOMMENDATIONS AND RELEVANT LINE MINISTRIES IN NEPAL WHO’S CLIMATE AND HEALTH RECOMMENDATIONS RELEVANT LINE MINISTRIES OPERATIONAL COMPONENT • Increase and strengthen MoHP; MoFE; Provincial Leadership and Governance collaboration among the Health Director- ates; Local national government, subna- Government Authorities; Key tional regions, as well as the development partners, such as communi- ties and the civil WHO, ICIMOD, UNEP, and key society. civil society organizations like • The multi-sectoral platform, LI-BIRD which already exists at the federal and provin- cial level, needs to be extended to the local level. • Harness a public private National Planning Commission; Climate and Health Financing partnership approach to make Ministry of Finance; MoHP; Pro- available further resources vincial and Local government for a climate-sensitive health authorities system. • Review the current basic health service package to ensure that it covers key cli- mate-related health risks. • Develop a capacity building MoHP; MoFE; Ministry of Health Workforce program that builds on the Federal Affairs and General National Human Resources for Administration; Ministry Health Strategy (2021– 2030), of Education Science and including the development of Technolo- gy; Nepal Medical national technical guidelines Association; NHRC; NHTC; Key for cli- mate-related health academia institutions, such risks. as Kathmandu and Tribhuvan Univer- sity; Key development partners, such as WHO, UNEP, the World Bank, and ICIMOD 70 | Climate and Health Vulnerability Assessment: Nepal WHO’S CLIMATE AND HEALTH RECOMMENDATIONS RELEVANT LINE MINISTRIES OPERATIONAL COMPONENT • Strengthen communication National Planning Commission; Integrated Risk, Monitoring & networks between DHM, MoHP; DHM; Ministry of Agri- Early Warning MoHP, and communities at risk culture and Livestock Develop- of extreme weather events. ment; MoFE; MoHA; National Disaster Risk Reduction and Management Authority; ACORAB • Integrate climate-related MoHP; MoFE; Key development health risks into existing HIS in partners, such as WHO and order to establish an integrat- NHRC ed climate-informed disease surveillance system. • Harness the linkage between National Planning Commission; Climate-Resilient & Sustainable MoHP and MoPI to ensure the MoHP; MoPI; National Disaster Technologies and Infrastructure adoption of a climate-smart Risk Reduction and Manage- / Emergency Preparedness and approach to the health care ment Authority; and MoFE Management infrastructure. • Conduct a review of climate MoHP; MoHA; Key develop- readiness in the current health ment partners such as WHO care system by adopting DRM into the health networks approach. 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