NOTE NOTE 55 The Africa Climate Resilience Investment Facility (AFRI-RES) Learning Note The Africa Climate Resilience Investment Facility (AFRI-RES) Learning Note Building Climate Resilient and Environmentally Sustainable Health Systems in Africa A summary of findings and recommendations from Climate and Health Vulnerability Assessments (CHVAs) funded by AFRI-RES across four countries 1. Why is climate change important for health and health systems? While electricity is required for almost all modern economic activity, in Sub-Saharan Africa access to power is limited: over 640 million are not connected to power supplies (African Development Bank 2019). Continuation of a business as usual pace, alongside population increase, Climate change is recognized as the single biggest health threat facing of the 21st centuryi with countries in the Africa region highly exposed and vulnerable due to limited adaptive capacitiesii. While these countries are highly exposed and vulnerable, they are among the lowest contributors to greenhouse gas emissions (GHGs) presenting a clear equity issue. Changes in temperature and precipitation, as well as extreme weather events, impact health through both directly and indirectly pathways. These can exacerbate existing health burdens as well as create new health risks. For example, exposure to extreme temperatures can lead directly to adverse cardiovascular and respiratory The Africa Climate Resilience developers in integrating climate funds from AFRI-RES. It draws Investment Facility (AFRI-RES) is a resilience in project planning and from application of the Resilience partnership between the Africa Union, design, thereby attracting funding Booster Tool to specific projects, African Development Bank, the United from both development and climate as relevant, Compendium Volume Nations Economic Commission for finance sources.​ on Climate Resilient Investment in Africa (UNECA), and the World Bank Sub-Saharan Africa (World Bank Group, established with support This note summarizes lessons and (2023) and Guidance, Standards, from the Nordic Development Fund practices deployed in embedding and Good Practice Notes developed (NDF). The partnership seeks to assist climate resilience into the design under the program. governments, planners, and private of projects that received catalytic Building Climate Resilient and Environmentally Sustainable Health Systems in Africa 1 NOTE The Africa Climate Resilience Investment Facility (AFRI-RES) Learning Note 5 health outcomesiii, communicable disease vectors as Increasing water-borne disease burdens due to well as water-borne diseases may increase due to changes in temperature and precipitation. Lack of changing temperatures and precipitation regimes, access to WASH services leads to increased risk of conversely lack of precipitation coupled with changing diarrheal diseases such as cholera which are then temperature put pressure on agricultural production further compounded by temperature and precipitation impacting food systems with important indirect effect changes. In Ethiopia, around 70 million people are on nutrition and human healthiv. already at-risk of cholerax, whilst in Sierra Leone, only 2 percent of the population have access to Droughts are common, and it is projected that readily available safe waterxi. It is anticipated that precipitation changes across Africa will increase the climate change will have a significant impact across frequency and intensity of droughts. In Malawi where the African region with an additional 48,000 deaths the agricultural sector is primarily rainfed and most among children under the age of 15 due to diarrheal of the population are smallholder farmers, drought diseases by 2030xii. These figures highlight the is projected to increase food security and nutrition potential grave consequences of climate change on risksv. In Ethiopia around 90 percent of the total child health in the coming decades. agricultural output comes from smallholder farmsvi. In Sierra Leone, nearly 5 million people are without Extreme weather events as well as sea-level rise adequate access to food, climate-related changes can impact human health and livelihoods, as well in crop yield could exacerbate an already precarious as critical infrastructure. Coastal communities situation, placing more people at-risk of malnutrition along the coastline of Tanzania, including Zanzibar, and nutrient deficienciesvii. are facing a significant threat from rising sea levels. The projected sea-level rises, ranging from 16 to 42 Extreme temperatures, already a challenge in the centimeters, along with expected increases in storm region, are expected to become more frequent surges of nearly 2 meters by 2050xiii, are likely to result and severe due to climate change, increasing risks in substantial damage to land and infrastructure. It is for Non-Communicable Diseases (NCDs) such as estimated that the annual cost of this damage could cardiovascular and respiratory disease. Between reach approximately USD 200 million by 2050xiv. This 2000 and 2019 heat was responsible for over 18,000 highlights the urgent need for measures to mitigate deaths across the African Regionviii, accounting for the impacts of sea-level rise and protect these roughly 4 percent of the total excess deaths during vulnerable coastal areas. In Malawi floods are already that period. In Ethiopia the regions of Afar, Somali, having a heavy impact particularly during the rainy and Gambela are expected to encounter a rise in the season period between November and April affecting frequency of hot days (max temperature exceeding approximately 100,000 each year. 35°C) and tropical nights (nocturnal temperature remaining above 20°C))ix. Building Climate Resilient and Environmentally Sustainable Health Systems in Africa 2 NOTE The Africa Climate Resilience Investment Facility (AFRI-RES) Learning Note 5 2. Climate resilience needs for the health system A critical step to build climate-resilient health systems, health service delivery, or climate and health systems is to assess the risks and vulnerabilities financing, among others. While countries across the of climate-related health effects. In order to do this Africa region are each making efforts to guide their Afri-Res funded the World Bank’s Health Nutrition and climate responses through National Adaptation Plans Populations Global Practice to conduct four Climate in many cases Ministries of Health lack specific plans and Health Vulnerability Assessments (CHVAs) across and budgets for climate and health focused activities. the Africa region. These country level assessments The CHVA approach uses a systems lens to consider were carried out in Ethiopia, Malawi, Sierra Leone, adaptive capacity across the six-health system building and Tanzania to identify the exposure of populations blocks. Namely, Leadership and Governance, Health to climate hazards, identify risks to human health, Workforce, Health information and disease surveillance, assess existing capacity and gaps in the health Essential medical products and technologies, Health system to prepare and respond to these risks and service delivery and, Health Financing. provide recommendations for decision-makers tasked with planning effective responses. Leadership and Governance are fundamental to well-functioning health systems able to response to Building climate-resilient health systems requires a climate shocks. In Sierra Leone prioritization of systematic approach to multi-stakeholder engagement climate change, along with health risks and adaptation and effective coordination. This is necessary to options, in national policies and plans lacks specific implement interventions and policies that would detail and has limited multisectoral engagement strengthen key areas such as health information particularly at subnational levels. In Malawi recommendations have been made through the CHVA to enhance coordination mechanisms for climate Figure 1: Operational Framework for Building action and to including in sub-national plans and to Climate-Resilient Health Systems monitor and address rural-urban disparities in climate- health risks. Health sector workforces face imbalances which often put the most climate vulnerable groups at increased risk. In Sierra Leone this imbalance in numbers, skill mix, and geographical deployment includes large urban-rural disparities. There is an absence of a systematic approach for capacity development of the health workforce to manage current and future health risks imposed by the climate crisis, including the development and integration of training materials. In Malawi, facing similar challenges, the CHVA recommended the strengthening of health workforce retention packages including risk reduction and emergency protocols to ensure there are sufficient skilled health workers in areas at highest risk of climate-related hazards and to scale up formal training developed by Malawi’s Health and Climate Building Climate Resilient and Environmentally Sustainable Health Systems in Africa 3 NOTE The Africa Climate Resilience Investment Facility (AFRI-RES) Learning Note 5 Change Core team as part of medical and paramedical To strengthen capacities for essential medical and on-the-job training. The CHVA in Ethiopia also products and technologies there is a need to work recommended the development of climate-related with building codes, improve at operation and educational and training materials and training to maintenance of facilities and adopt sustainable support the workforce to understand the health procurement approaches. In Ethiopia the CHVA impacts of climate change. recommended the development of climate informed national level building codes and use of permits for all Integrated health information systems and healthcare facilities, including retrofitting, refurbishing, diseases surveillance are critical for strategic and maintaining existing health infrastructure. These planning and decision-making. While countries would incorporate climate risk projections, influencing such as Malawi produce their own climate and the location of new facilities, operation and meteorological data, this service is not well integrated maintenance approaches, energy, and water supply into the Ministry of Health activities such as for the sources – with a focus on low-carbon renewable energy, surveillance of climate-sensitive diseases or in a and sanitation services. Health sector dependence on modality that triggers preparedness mechanisms for efficient and resilient transportation networks able floods during the rainy season. In Sierra-Leone there is to ensure access to facilities during extreme weather a lack of Early Warning Systems to reduce exposure to events was also a key vulnerability highlighted. In extreme temperatures. A key limitation is in acquiring Sierra Leone the CHVA revealed healthcare facilities monitoring equipment and up to date technology, which were under-resourced and hard to reach in rural as well as technical capacities to train healthcare areas, and especially likely to be vulnerable during personnel. Integrating climate data into surveillance extreme weather events. Laboratory capacities and systems can reduce risks by helping the health system other health technologies needed further assessment to prepare for climate-sensitive diseases, such as to ascertain their ability to support management Malaria, Dengue and Cholera. Tanzania has integrated of public health threats from current and projected disease surveillance and response (IDSR) systems that climate-sensitive diseases. are monitoring 34 priority diseases and conditions. In addition to this the Tanzania Urban Resilience Successful health service delivery in a changing Program (TURP) collects data on vulnerable and at- climate necessitates a coordinated approach from risk households, identifies their coping strategies and the national level through to local community also integrates weather and climate information to led approaches. In Sierra Leone there is a need for improve responses to climate-related emergencies in joined up climate-resilient healthcare facility and urban areas. health infrastructure assessments to incorporate Building Climate Resilient and Environmentally Sustainable Health Systems in Africa 4 NOTE The Africa Climate Resilience Investment Facility (AFRI-RES) Learning Note 5 climate risks into infrastructure planning and Health Financing in general needs to take account improve coordination across sectors. Climate-disaster of current and projected climate-related demands contingency plans are also needed for the health sector and can be categorized around the three health and where feasible at the community level. In Malawi financing functions: revenue raising, risk pooling and the CHVA recommended supporting community led strategic purchasing. This novel through simple ‘Green efforts - including educational materials and public Health Financing’ (GHF) approach was unsurprisingly communication – to improve sanitation practices and not seen in any of the countries assessed. In Ethiopia controls to prevent water and foodborne illnesses and this approach has been incorporated into the draft diseases focused on rural communities and temporary Health-National Adaptation Plan (further elaborated disaster shelters. The engagement of medical colleges, in the next section). This includes revenue raising the Ministry of Education (MoE) and district-level plans to adopt the use of green bonds to fund health community groups would support and integrated sector projects with environmental benefits, such approach to delivery of these climate-related health as renewable energy projects or sustainable and promotion programs. In Ethiopia strengthened resilient agriculture initiatives. By issuing green bonds regulations are suggested to support sustainable specifically for climate related health projects, the healthcare waste management and policies on climate government hopes to raise funds for initiatives that related-environmental health services. This could reduce climate-related health-risks, such as improving be supported with the development of a climate access to clean water or developing early warning and environmental health database to facilitate systems for extreme weather events. From a strategic multisectoral engagement and inform disease control purchasing perspective, a green purchasing is planned and prevention programs ahead of forecast extreme to leverage the buying of products and services with weather events. reduced climate impact considering the impact of a product or service throughout its entire life cycle, from production to disposal. This green purchasing approach aims to reduce waste, conserve national resources, and minimize pollution. Overall, a GHF approach is expected to help ensure that health care services are sustainable and resilient in the face of climate change while also addressing the needs of vulnerable populations affected by its impacts. Building Climate Resilient and Environmentally Sustainable Health Systems in Africa 5 NOTE The Africa Climate Resilience Investment Facility (AFRI-RES) Learning Note 5 3. How could these concepts be applied? Several World Bank projects in Africa have incorporated levels. Existing sentinel sites mainly work on priority adaptation and resilience in their preparation, design, communicable diseases such as Malaria, Yellow fever, and operations. Supported directly by the CHVA Dengue Fever, Meningitis and Cholera. This work aims conducted in Ethiopia is the development of the Health to integrate disease surveillance with forecasting of – National Adaptation Plan (H-NAP). This plan is meteorological data to better predict and mount more expected to include 10 action areas1 notably including effective responses to climate-related health risks. This a review of the implementation of the Ethiopia Public work will be further strengthened with links across Health Institute (EPHI) climate sensitive disease the Africa East Region through inclusion in the Health surveillance and early warning system with the aim Emergency Preparedness, Response and Resilience of supporting the scale-up of sentinel sites at regional (HEPRR) Multi-Programmatic Approach (MPA). 4. What could policy makers do to move towards a more robust resilient health system? It is clear more that more needs to be done to direct costs for seeking additional health care and close the evidence gap on climate change and indirect economic costs due to income loss which also health in Africa. Though evidence does exist the exposes them to risks of further impoverishment. CHVAs demonstrated that there remains a paucity This calls for a health financing approach that takes of information on climate-related health risks across account of changing risk profiles resulting from Africa. These gaps need to be urgently compiled to climate. This ‘Green Health Financing’ approach will raise greater awareness of climate risks to health need to focus on the poor and on systems solutions and to provide policymakers across Africa with the such as delivering comprehensive primary health care information they need to act. Regional work being as well as hospital insurance reforms to subsidize pushed forward with the support of Afri-Res and the availability of cost-effective interventions for the World Bank is targeted at this issue. It is important most vulnerable. Any such financing approaches will that further analytical work continues to be developed need to be complimented by a menu of interventions to close this knowledge gap. aligned with best available evidence – a Best-Buys for climate and health. These could include adaptation It is imperative to focus on the effects of climate strategies such as interventions designed to reduce change for the health of vulnerable populations – risk exposure, such as cost-effective cooling solutions, on the poor, children, mothers, women, the elderly heat resistant built environments, and greening of – and to prioritize policies that can help them to public facilities. adapt to climate-related health risks. This unequal distribution of risk and impact means vulnerable Health sector responses to the climate crisis households are more adversely impacted, imposing need to not only focus on adaptation but also on 1 1. Strengthening multispectral collaboration, 2. Capacity Building, 3. Strengthening Early Warning and Surveillance System, 4. Vulnerability Assessments, 5. Knowledge generation and management, 6. Climate and Health Impact Assessments, 7. Health System Readiness and Response, 8. Pilot Climate Change and Health Adaptation Projects, 9. Strengthen risk communication and community engagement (RCCE), 10. Health financing for climate-related risks using green health financing (GHF) approach. Building Climate Resilient and Environmentally Sustainable Health Systems in Africa 6 NOTE The Africa Climate Resilience Investment Facility (AFRI-RES) Learning Note 5 mitigation. These two sides of the climate response Development partners can and should play a more need to be integrated into African health sectors to active role in supporting the climate and health build Climate-Resilient and Low Carbon, Sustainable agenda across Africa. There is already strong leadership Health Systems. Interventions can and should tackle feeding into the climate change and health agenda both adaptation and mitigation priorities. The 3C’s with many countries developing national adaptation Clinical (improving outcomes) Carbon (reducing Net plans (NAPs) it is important these go further to HG emissions), and Cost (making better use of scare include Health – National Adaptation plan (H-NAPs) as resources) is a simple framework for understanding has been seen in the example of Ethiopia and other activities as they relate to health. The rapid and large countries. This needs to be a health systems approach scale solarization of health facilities could reduce – avoiding the temptation to set up parallel systems the carbon footprint of the health sector as well as leading to further siloing of action. Health sector make health facilities more resilient to severe-extreme action taken to respond to the climate crisis must not weather event in case of grid-power interruption. The be parasitic on existing health development efforts. narrative of the health sector in Africa needs to be The link to the universal health coverage (UHC) agenda a focus on strengthening provision of comprehensive is therefore an integral part of this effort. The World primary health care – including preventive care – which Bank and Afri-Res will continue to support counties also helps reduce the health sector’s carbon footprint. across the Africa Region to foster implementation of scalable solutions in the area of climate change and health through analytics, knowledge and capacity, technical assistance, and financing. This will ensure the health sector can support the achievement of NDC, LTS and NAP targets and put people at the heart of climate investment and action. Building Climate Resilient and Environmentally Sustainable Health Systems in Africa 7 NOTE The Africa Climate Resilience Investment Facility (AFRI-RES) Learning Note 5 References i WHO Factsheet: Climate and health https://www.who. vii WFP. 2021. State of Food Security in Sierra Leone: 2020 int/news-room/fact-sheets/detail/climate-change-and- Comprehensive Food Security health#:~:text=Climate%20change%20%2D%20the%20biggest%20 health,caused%20by%20this%20unfolding%20crisis. 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