Climate and Health Vulnerability Assessment CLIMATE AND HEALTH VUL- NERABILITY ASSESSMENT: MALAWI MALAWI © 2023 International Bank for Reconstruction and Development/The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory, or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. 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MALAWI Climate and Health Vulnerability Assessment CLIMATE INVESTMENT FUNDS CONTENTS ACKNOWLEDGMENTS................................................................................................................. vii LIST OF ABBREVIATIONS........................................................................................................... viii EXECUTIVE SUMMARY...................................................................................................................1 INTRODUCTION.............................................................................................................................. 5 Country Context.....................................................................................................................................................5 Aims of this assessment and conceptual framework .................................................................................... 7 CLIMATOLOGY................................................................................................................................. 9 Malawi’s Geography .............................................................................................................................................9 Observed and Projected Climatology ............................................................................................................ 10 Temperature ........................................................................................................................................................... 10 Precipitation ............................................................................................................................................................ 12 Climate-related Hazards..................................................................................................................................... 13 Floods........................................................................................................................................................................ 13 Drought..................................................................................................................................................................... 14 Cyclones................................................................................................................................................................... 15 Landslides................................................................................................................................................................ 15 CLIMATE-RELATED HEALTH RISKS............................................................................................ 19 Nutrition risks ...................................................................................................................................................... 20 Vector-borne disease risks................................................................................................................................ 21 Malaria...................................................................................................................................................................... 22 Water-borne disease risks................................................................................................................................. 24 Heat-related morbidity and mortality risks.................................................................................................... 25 Air quality related health risks.......................................................................................................................... 26 Direct injuries and mortality ............................................................................................................................. 27 Mental health and well-being risks.................................................................................................................. 28 ADAPTIVE CAPACITY OF THE HEALTH SYSTEM......................................................................31 Health System Overview.................................................................................................................................... 31 Leadership and governance ............................................................................................................................ 32 Health Financing..................................................................................................................................................37 Health workforce................................................................................................................................................. 39 Health Information Systems.............................................................................................................................. 42 Essential Medical Products and Technologies ............................................................................................ 43 Health Service Delivery .................................................................................................................................... 43 iv | Climate and Health Vulnerability Assessment: Malawi RECOMMENDATIONS TO ENHANCE HEALTH SYSTEM RESILIENCE TO CLIMATE CHANGE......................................................................................................................................... 47 Component 1. Leadership and Governance...................................................................................................47 Component 2. Health Workforce..................................................................................................................... 48 Component 4. Integrate risk monitoring and early warning...................................................................... 49 Component 7. Management of the environmental determinants of health............................................ 49 Component 10. Climate & Health Financing.................................................................................................. 49 ANNEXES........................................................................................................................................ 51 Annex A. Methods for the estimation of mosquito suitability in Malawi, under RCP 8.5 ..................... 51 Annex B. Adaptive Capacity Rapid Assessment.......................................................................................... 57 Annex C. Categorization of recommendations ........................................................................................... 60 Annex D. Key recommendations and relevant line ministries in Malawi.................................................. 61 Annex E. Recommendations by climate-related health risk...................................................................... 62 Annex F. Projected average monthly temperature and precipitation patterns in Malawi, under SSP3-7.0.............................................................................................................................................. 66 REFERENCES.................................................................................................................................67 LIST OF TABLES Table 1. Annual number of very hot days (>35°C) and tropical nights in the 2030s and 2050s throughout Malawi, under SSP3-7.0 ........................................................................................................................ 12 Table 2. Projected average largest 5-day cumulative precipitation, under the SSP3-7.0 scenario ........ 14 Table 3. Projected percentage of suitable habitat area, by region, for the malaria vector species in Malawi, under RCP8.5, through the mid-century............................................................................................. 22 Table 4. Two-week prevalence of diarrhea in children under five years in Malawi, 2017......................... 24 Table 5. Extreme weather event related, injuries, and mortality in Malawi from 2000 to 2022............. 27 Table 6.Summary of the Climate Change Risks on Health Outcomes........................................................... 29 Table 7. Vacancy rate of eight selected essential health staff per established position for MoH and CHAM....................................................................................................................................................................... 41 Table 8. Summary of the Health System Adaptive Capacity Gaps for Malawi ............................................ 45 Table A1. Model parameterization and data sources for habitat characterization...................................... 52 Table A2. Copernicus Global Land Cover Layers: CG:S-LC100 Collection 2 Global Landcover Map Classifications for Anopheles gambiae s.s. ................................................................................................ 53 Table A3. Copernicus Global Land Cover Layers: CG:S-LC100 Collection 2 Global Landcover Map Classifications for Anopheles arabiensis .................................................................................................... 54 Table A4. Copernicus Global Land Cover Layers: CG:S-LC100 Collection 2 Global Landcover Map Classifications for An. funestus ...................................................................................................................... 55 Contents | v LIST OF FIGURES Figure 1. World Health Organization (WHO) operational framework for climate-resilient healthcare systems ....................................................................................................................................................... 6 Figure 2. Administrative boundaries of Malawi ..................................................................................................... 8 Figure 3. Elevation map of Malawi ...........................................................................................................................10 Figure 4. Projected average monthly temperature and precipitation patterns in Malawi under SSP3-7.0............................................................................................................................................................................11 Figure 5. Rainfall-triggered landslide hazard index in Malawi...........................................................................16 Figure 6. Comparison of the suitable area for the malaria vector species in Malawi under Representative Concentration Pathway (RCP) 8.5, across three epochs: 1986–2005 (historical baseline), 2020–2039, and 2040–2059...............................................................................................................23 Figure 7. WHO Health System Building Blocks....................................................................................................32 Figure 8. WHO’s Operational Framework for Building Climate-Resilient Health Systems........................48 vi | Climate and Health Vulnerability Assessment: Malawi ACKNOWLEDGMENTS The authors are thankful to the Africa Climate Resilient Investment Facility (AFRI-RES) Trust Fund and the Climate Investment Funds (CIF) for funding this work. This Climate and Health Vulnerability Assessment (CHVA) for Malawi was produced by the Health, Climate, Environment and Disasters (HCED) program in the Health, Nutrition and Population (HNP) Global Practice of the World Bank, led by Tamer Rabie. The assessment was authored by April N. Frake, Judith Namanya, Mikhael G. I. Luzardo, Stephen Dorey and Muloongo Simuzingili, with contribution sfrom Ana L. Rivera, Mackenzie Dove, Maria Gracheva, Chiho Suzuki and Loreta Rufo. The team also wishes to thank Moustafa Abdalla and Urvashi Narain for their review of this assessment. This work also benefited from the administrative support of Fatima-Ezzahra Mansouri, 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. The authors are thankful to the Africa Climate Resilient Investment Facility (AFRI-RES) Trust Fund, Climate Investment Funds (CIF) and the Climate Support Facility (CSF) for funding this work. Acknowledgments | vii LIST OF ABBREVIATIONS AAP Ambient Air Pollution AIDS Acquired Immunodeficiency Syndrome AR6 Assessment Report 6 [of the IPCC] CARD Chronic and Acute Respiratory Diseases CCKP Climate Change Knowledge Portal [World Bank] CD Communicable Disease CHAM Christian Health Association of Malawi CHVA Climate and Health Vulnerability Assessment CHW Community Health Worker CMIP Coupled Model Intercomparison Project CMIP6 Coupled Model Intercomparison Project Phase 6 COVID-19 Coronavirus disease 2019 CRU Climatic Research Unit [University of East Anglia, UK] CVD Cardiovascular Disease DALYs Disability Adjusted Life Years DFID Department for International Development DHIS District Health Information System DoCCMS Department of Climate Change and Meteorological Services DoMS Department of Meteorological Services DRM Disaster Risk Management EAD Environmental Affairs Department eHIN Electronic Health Information Network EHP Essential Health Package EHRP Emergency Human Resources Program EIAs Environmental Impact Assessments ENSO El Niño Southern Oscillation GDP Gross Domestic Product GHG Greenhouse Gas [emissions] HCCT Health and Climate Change Core Team HMIS Health Management Indicators System HIS Health Information Systems HIV Human Immunodeficiency Virus HRH Human Resources for Health HNP Health, Nutrition and Population [World Bank] HSJF Health Services Joint Fund HSSP Health Sector Strategic Planning HSS Health Systems Strengthening IDSR Integrated Disease Surveillance and Response INDC Intended Nationally Determined Contribution IPCC Intergovernmental Panel on Climate Change ITCZ Intertropical Convergence Zone LDHEA Libreville Declaration on Health and Environment in Africa LUANAR Lilongwe University of Agriculture and Natural Resources viii | Climate and Health Vulnerability Assessment: Malawi LULC land use and land cover MAGICC Model for the Assessment of Greenhouse Gas Induced Climate Change MDHS Malawi Demographic and Health Survey MGDS Malawi Growth and Development Strategy MNRCC Ministry of Natural Resources and Climate Change MoE Ministry of Education MoH Ministry of Health NAIP National Agriculture and Investment Strategy NAPA National Adaptation Program of Action NCD Noncommunicable Disease NCCIP National Climate Change Investment Plan NCCMP National Climate Change Management Policy NDA National Designated Authority NDE National Designated Entity NDC Nationally Determined Contribution NEP National Environmental Policy NGO Nongovernmental Organization NSCCC National Steering Committee on Climate Change NTDs Neglected Tropical Diseases OOP Out-of-Pocket (spending on health) PFP Private for-profit PNFP Private not-for-profit PM2.5 Fine Particulate Matter (with a diameter of less than 2.5 micrometers) RCP Representative Concentration Pathway SDG Sustainable Development Goals SOPs Standard Operating Procedures SSA Sub-Saharan Africa SSP Shared Socioeconomic Pathway TB Tuberculosis TBAs Traditional Birth Attendants THs Traditional Healers TN20 Tropical Nights > 20°C TN26 Tropical Nights > 26°C UHC Universal Health Coverage UNDP United Nations Development Programme UMCM University of Malawi College of Medicine UNFCCC United Nations Framework Convention on Climate Change USAID United States Agency for International Development VBD Vector-Borne Disease WASH Water, Sanitation, and Hygiene WBD Waterborne Disease WHO World Health Organization List of Abbreviations | ix EXECUTIVE SUMMARY Malawi faces significant climate-related challenges that directly and indirectly impact health. Coupled with human-made health stressors, climate change can ex- acerbate the existing health burdens while creating new health risks. Changes in the temperature and precipitation patterns affect the geographic range and burden of a variety of climate-sensitive health risks while impacting the functioning and capacity of Malawi’s health system. Climate change-related challenges that increase Malawi’s vulnerability to poor health outcomes include a wide range of climate hazards, such as extreme temperature and humidity conditions, potential changes to precipitation patterns, extreme precipitation events, seasonal aridity, droughts, and cyclones. The country is affected by these climate hazards due to its geographical position; a strong dependency on rainfed agriculture, which is susceptible to regular climatic shocks; ongoing population growth; chronic and widespread malnutrition; as well as the high prevalence rates of HIV/AIDS. Considering Malawi’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). The objective of this CHVA is to assist decision-makers with planning effective adaptation measures to address climate-related health risks. This is first done by capturing the characteristics of the climatology of Malawi, with a focus on the observed and future health-related climate exposures. Further, climate-related health risks are examined by considering the projected climate variability, including identifying the vulnerable populations most at risk. Finally, the adaptive capacity of the health system to manage the current and future climate-related health risks is assessed to inform a series of recommendations that are aimed at reducing climate-related health vulnera- bility in Malawi. Where available, these measures are also provided at the subnational level to assist regional health planners. The recommendations of this CHVA are primarily aimed at the health sector, as well as the related sectors with influence on climate change-related health risks, such as disaster risk management (DRM). The observed and projected climatology data, obtained from the Climate Change Knowledge Portal (CCKP) and climate hazards to inform this discussion of climate-related health risks, highlights the following: → The mean annual temperatures in Malawi have risen by 0.64°C over the past half century, occurring alongside increases in the minimum (0.60°C) and maximum (0.68°C) temperatures. The maximum temperature is highest during October and November, with people in the Southern Region experiencing the greatest risk of extreme heat. → The median average precipitation ranges from 1000 millimeters (mm) in the rainy season to 140 mm during the dry season; it has declined by 100 mm since the 1960s. The Northern Region has experienced the largest declines in annual precipitation, followed by the Southern Region. 1 → Floods are among the most significant and recurring climate-related hazards in Malawi, especially for the low-lying areas along the Lake Malawi lakeshore in the Central and Southern Regions. Extreme precipitation is projected to increase for the 2030s and 2050s, exacerbating flooding risks during the rainy season, especially in the Southern Region. → Droughts are common in Malawi, and the projected decline in precipitation will likely increase their frequency and intensity. Malawi faces significant health challenges from communicable diseases (CDs) and noncommu- nicable diseases (NCDs); climate change will worsen the severity of these health challenges. It is also important to point out that climate-related health risks are not evenly distributed within the population: some groups are at greater risk than others. This will be reflected in Malawi’s CHVA that assesses seven climate-related health risk categories: (a) nutrition risks, (b) vector-borne disease (VBD) risks, (c) waterborne disease (WBD) risks, (d) heat-related morbidity and mortality risks, (e) air quality health risks, (f) direct injuries and mortality risks, along with (g) mental health and well-being risks. Nutrition risks: In a country that primarily practices rainfed agriculture, projected warmer temperatures and water deficits, along with the increasing frequency and intensity of climate-related hazards, are very likely to aggravate food insecurity and nutritional defi- ciencies, though with significant geographical variations. Vector-borne disease (VBD) risks: Malaria is endemic in Malawi; its transmission is seasonal throughout the country, peaking during or just after the conclusion of the rainy season. The malaria transmission risk in the Southern Region will likely decline in the 2050s due to ongoing climate change, while the transmission throughout the remainder of the country is expected to remain stable. Waterborne disease (WBD) risks: The burden of WBDs throughout Malawi is significant, characterized by high rates of morbidity and mortality across the country, especially among children under five years of age. The projected increases in the intensity of precipitation in Malawi will likely increase the occurrences of floods and droughts, with implications on the frequency of WBD outbreaks. Heat-related morbidity and mortality risks: Health effects caused by heat include the direct effect of heat stress, heat rash, cramps, exhaustion, and dehydration, as well as the acute exacerbation of pre-existing conditions. Extreme heat and its impact on excess heat-related morbidity and mortality is very likely to increase under the high- and low-emis- sions scenarios in Malawi. Air quality health risks: The high levels of pollution from harmful airborne particulates have led to increased incidences of illness and deaths stemming from chronic lung diseases and acute respiratory infections among the population. 2 | Climate and Health Vulnerability Assessment: Malawi Direct injuries and mortality risks: Mortalities and direct injuries, associated with heavy rains-induced flash floods, mudslides, and landslides, are becoming a serious threat to life and human health in Malawi. The Central and Southern Regions, particularly the districts of Chikwawa, Phalombe, Nsanje, and Zombe, are more susceptible to flooding than other parts of the country. Mental health & well-being risks: Impacts of extreme weather events, such as droughts, floods and cyclones on agriculture and other sources of livelihoods affect mental health and well-being of Malawians. Rural farming communities are more vulnerable to mental health impacts triggered by climate change-related hazards due to their dependence on agriculture and the environment for sustenance.  The extent to which the health system in Malawi is prepared for the changes in hazards, exposures, and susceptibility, and its capacity for managing them will determine its resilience in the coming decades. In this CHVA, Malawi’s adaptive capacity to prevent and manage climate-related health risks is examined according to the six health system building blocks143.  → The Government of the Republic of Malawi recognizes climate change and its impacts on the country’s development. It ratified the Paris Agreement in 2015. Furthermore, the government has developed several policy frameworks that aim to reduce the country’s vulnerability to climate change-related impacts, including human health outcomes. → Malawi’s health sector is heavily donor-dependent and the government’s low public financing on health has worsened healthcare access and widened health inequality gaps. Although health has been incorporated into national policies, gaps remain at the subnational level, and there is no precise strategic planning for climate-health finance, nor are there any resource allocations for climate-related health risks and vulnerabilities. → Malawi faces numerous health workforce challenges that are likely to be exacerbated by climate change. There are significant staffing gaps in the number of skilled health workers, which is further affected by their geographical distribution throughout the country; the health workforce is relatively limited in the rural areas. Climate health impacts will likely exacerbate these inequalities. → Health information systems (HIS) are incorporated as a key pillar into the government’s Health Sector Strategic Planning II (HSSP II). The information, monitoring, and surveillance systems in Malawi are identified as an area to be strengthened. → Malawi has historically experienced regular shortages of essential medical products. Furthermore, weak quality assurance and accreditation, coupled with inadequate biosafety and biosecurity mechanisms, significantly affect the availability of laboratory and imaging services throughout the country. → Inequalities in the accessibility of healthcare persist due to poor transport and a lack of ambulances for emergencies, which will likely be exacerbated by climate hazards. The country has a weak health infrastructure that is unable to withstand climate change shocks, which will affect healthcare service delivery. Executive Summary | 3 Recommendations to reduce climate-related health risks could include the following activities:  → Enhance the coordination mechanisms for climate action and articulate climate action in subnational plans. The progress on climate change commitments and objectives in development plans should be monitored and should address the rural-urban disparities in climate-health risks. Specific strategic planning should also account for subnational differences. → Articulate climate-health actions in subnational plans. → Create and promote health workforce retention packages, including risk reduction and emergency protocols, to ensure that there are sufficient skilled health workers for the areas at the highest risk of climate-related hazards. → Scale up the formal training that was developed by Malawi’s Health and Climate Change Core Team (HCCT) on climate and health and incorporate it into the medical and paramedical as well as the refresher courses for continued learning and on-the-job training opportunities. → Strengthen communication networks between the Department of Climate Change and Meteoro- logical Services (DoCCMS) and the communities at risk of extreme weather events. → Support community-led efforts to improve sanitation practices and controls to prevent WBDs and foodborne illnesses and diseases, including the generation of educational materials and public communication. Focus should be placed in particular on rural communities and temporary disaster shelters. → Engage medical colleges and the Ministry of Education (MoE) to integrate with district-level community groups in developing and implementing health promotion programs that are focused on climate-related health risks. → Ensure that strategic purchasing is guided by detailed, subnational climate information on population needs and supported by a provider mechanism that incentivizes providers. 1. 4 | Climate and Health Vulnerability Assessment: Malawi SECTION I. INTRODUCTION COUNTRY CONTEXT 1. Malawi faces significant climate-related challenges that will directly influence its population health outcomes. Coupled with human-induced health stressors, climate change exacerbates existing health burdens while creating new health risks. Specifically, the changes in temperature and precipitation patterns will affect the geographic range and burden of a variety of climate-sensitive health risks, while impacting the functioning and capacity of Malawi’s health system. Climate change-related challenges increasing Malawi’s vulnerability to poor health outcomes include a wide range of climate hazards that affect the country due to its geography (for example, floods, droughts, and cyclones); a strong dependency on rainfed agriculture, which is susceptible to regular climatic shocks; ongoing population growth; chronic and widespread malnutrition; as well as the high prevalence rates of the human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome (AIDS). Compounding these challenges, climate also exerts impacts on health and economic inequalities, which are not uniformly distributed due to demographic, socioeconomic, geographical, and environmental factors, thereby significantly influencing the distribution of population health risks. 2. Malawi is among the poorest countries in 3. Poverty, which is widespread in Malawi, is the world, despite the appreciable efforts characterized by significant distributional in making reforms for sustaining economic inequalities. The population living in poverty growth. By 2021, its gross domestic product was 50.8 percent during 2019/2020, with 56.6 (GDP) had risen to USD12.6 billion, compared percent residing in rural areas, compared with USD1.7 billion in 2001.1 Malawi’s GDP per with 19.2 percent residing in urban areas. capita had also risen steadily from USD 116.6 Subnationally, the Central Region reported the in 1994 to USD 584.4 in 2019.2 However, the highest poverty rate at 55.8 percent, followed coronavirus disease 2019 (COVID-19) pandemic, by the Southern Region at 51 percent and the along with the government’s expansionary Northern Region at 32.9 percent. Between policies, contributed to the widening of the 2010 and 2019, the number of poor Malawians fiscal deficit by 7.1 percent of the country’s increased from 50.6% (7.4 millions) to 50.7% GDP in FY2021.3 (9.4 millions) respectively.4 Although income 5 inequality, as measured by the Gini index, Blantyre, Mzuzu, and Zomba. Urban population has decreased slightly from 45.5 in 2010 growth is projected to increase by 214,000 to 38.5 in 2018, it still represents a severe per annum between 2020 and 2025.9 inequality gap.5 5. Malawi is committed to meeting the climate 4. Malawi has an estimated population of 19.1 challenge through both adaptation and million (2020) that is expected to double by mitigation measures. Malawi ratified the Paris 2050.6 The population is disproportionately Agreement in 2015, which aims to limit the young: approximately 15 percent is under 5 global mean temperature increase to well years old and around 42 percent is under the below 2°C, compared to pre-industrial levels. age of 15. Only 1 percent of the population It has developed several policy frameworks is over 65.7 In 2018, the Northern Region that aim to reduce the country’s vulnerability had the smallest population (2.3 million), to climate change-related impacts on various while the Central (7.5 million) and Southern areas, including human health outcomes. Regions (7.8 million) had similar population Section IV of this assessment highlights the sizes.8 Eighty-four percent of the population of key steps adopted by the government of Malawi lives in rural areas, while the remainder Malawi to meet its climate aspirations. primarily resides in four urban cities: Lilongwe, FIGURE 1. World Health Organization (WHO) operational framework for climate-resilient healthcare 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 ss Clim cin bil & Governance Health se ity, an Workforce Financing Preparedness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential C li o r m e h Re ima & I n f a lt s Medical ma d C l a lt h se te Products & h He ra m Pro te a rc He Technologies - g Ma nt na ili e Env ge m ent o Res le f C li m a t e ir o n in a b D et m ental & S u st a gies ri m e o lo of H n ts Techn t ur e e a lt h a s tr u c & Infr Source: World Health Organization, 2015, Operational Framework for Building Climate Resilient Health Systems. 6 | Climate and Health Vulnerability Assessment: Malawi AIMS OF THIS ASSESSMENT AND 8. The World Health Organization’s (WHO) operational framework for building climate-re- CONCEPTUAL FRAMEWORK silient health systems10 is adopted to analyze 6. The objective of this Climate and Health the adaptive capacity to adequately deal Vulnerability Assessment (CHVA) is to support with the current and future identified risks. decision-makers with planning effective Following this framework (Figure 1), the adaptive adaptation measures to address climate- capacity section of this CHVA structures the related health risks. Where available, these assessment of adaptive capacity around the six measures are provided at the subnational health systems strengthening (HSS) building level to assist regional health planners. The blocks for considering the gaps now and into recommendations of this CHVA are primarily the future. The CHVA then considers the 10 aimed at Malawi’s Ministry of Health (MoH), but components of health system climate resilience also include other related sectors that exert an to guide its recommendations. impact on climate-related health risks, such as disaster risk management (DRM), agriculture, 9. This CHVA follows a stepwise linear approach. and natural resources and climate change. The first step describes the characteristics of the climatology in Malawi, highlighting the 7. Adaptation priorities need to be accompanied observed and future climate exposures that are by fundamental and urgent action to mitigate relevant to health. The second step examines climate change. It is important to stress how climate-related health risks. The final step complex the climate challenge is and how assesses the adaptive capacity of the health hard it is to predict exactly how severe the system, identifying gaps in the management climate exposures facing populations will of current and future climate-related health become. There are many factors that could risks. Together, these steps inform a series of slightly slow or significantly speed up rates of recommendations for reducing climate-re- change, including positive feedback effects lated health vulnerability in Malawi. This and cascading climatological tipping points CHVA is based on a review of the published that are the most worrisome. For this reason, literature and reports, national statistics, and though not the focus of this assessment, consultations with key stakeholders including mitigating existing greenhouse gas emissions MoH, the Ministry of Natural Resources and (GHGs), as well as developing and imple- Climate Change (MNRCC), the Department of menting measures to protect human health Climate Change and Meteorological Services (DoCCMS), and the Public Health Institute from the changing climate, is of paramount of Malawi. importance. Introduction | 7 10. This CHVA incorporates subnational consid- erations for health-related climate action. Malawi is divided into three areas — the Southern, Northern, and Central Regions (Figure 2) — and further subdivided into 28 districts. FIGURE 2. Administrative boundaries of Malawi Source: World Bank Cartography Unit 8 | Climate and Health Vulnerability Assessment: Malawi SECTION II. CLIMATOLOGY 11. This section describes the observed climatic changes and projected trends in Malawi, highlighting the priority climate-related hazards in relation to human health risks. Climate information is taken from the World Bank Group’s Climate Change Knowledge Portal (CCKP), where historical, observed data is derived from the Climatic Research Unit, University of East Anglia (CRU). Climate data used in the World Bank Group’s CCKP is derived from the Coupled Model Intercomparison Project, Phase 6 (CMIP6). The CMIP efforts are overseen by the World Climate Research Program: it supports the coordination of the production of global and regional climate model compilations that advance the scientific understanding of the multiscale dynamic interactions between the natural and social systems affecting climate. CMIP6 is the source of the foundational data used to present the global climate change projections set out in the Sixth Assessment Report (AR6) of the Intergovernmental Panel on Climate Change (IPCC). CMIP6 relies on the Shared Socioeconomic Pathways (SSPs), which represent the possible societal development and the policy scenarios for meeting the designated radiative forcing (watt per square meter [W/m2]) by the end of the century. Scenarios are used to represent the climate response to different plausible future societal development storylines and the associated contrasting emission pathways in order to outline how future emissions and land use changes translate into responses in the climate system. MALAWI’S GEOGRAPHY abundant surface water resources throughout the country. Topography is highly variable in 12. Malawi is a landlocked country located Malawi due to the north-south orientation of in southern Africa: it borders Tanzania to the Great Rift Valley that spans the country. the north, Mozambique to the east and The elevation ranges from less than 200 feet south, and Zambia to the west (Figure 3).11 (ft) to approximately 10,000 ft at the peak of Malawi’s eastern land border is predomi- Mount Mulanje in the southeast. Malawi has nantly with Lake Malawi, the third-largest of four main landscape features: the highlands, the African Great Lakes; the lake, together isolated mountains, the Great Rift Valley, and with the country’s six major rivers, provides the central plateaus.12 9 FIGURE 3. Elevation map of Malawi Source: Natural Earth and Aster GDEM Version 3 OBSERVED AND TEMPERATURE PROJECTED CLIMATOLOGY 14. The mean annual temperatures in Malawi 13. Malawi’s tropical climate is strongly influenced have risen by 0.64°C over the past half by the seasonal migration and intensity of century, occurring alongside increases the Intertropical Convergence Zone (ITCZ) in the minimum (0.60°C) and maximum and the El Niño Southern Oscillation (ENSO). (0.68°C) temperatures. Warming is biased There are two main seasons: a cool, dry season toward the dry season (May–October), with from May to October and a hot, wet season added marked increases in the mean monthly from November to April. Temperature varies temperatures in November (0.85°C) and latitudinally: the mean annual temperatures are December (0.73°C) since 1960. Subnational highest in the Southern Region and lowest in monthly mean temperatures are fairly uniform, the Northern Region. National and local-scale ranging from 17.3°C in the Northern Region to precipitation patterns vary according to 26.6°C in the Southern Region. The maximum elevation. Mountainous areas receive around temperatures are highest during October and 1,600 mm of rainfall per annum, while lowland November — the transition months from the areas experience approximately 600 mm. end of the dry season to the beginning of the 10 | Climate and Health Vulnerability Assessment: Malawi rainy season (November–April) — and range the number of very hot days by 14 (1, 29) and 31 from approximately 30°C to 32°C. (11, 47) days in the 2030s and 2050s, respec- tively (Table 1). 15. Extreme heat exposure will become more common through the mid-century, with Notably, daytime temperature increases will people in the Southern Region at the greatest be coupled with high nighttime tempera- risk. The mean monthly median temperature tures (that is, tropical nights). A tropical night anomaly is projected to increase from 0.4 is characterized by nighttime temperatures to 0.9°C, with a possible anomaly range of that are not low enough to allow the human -1°C to +2.4°C across Malawi, in the 2030s; body to adequately cool down after experi- the projected increase during the 2050s is encing high daytime temperatures. Herein, two from 1.38°C to 1.54°C, with a possible anomaly temperature thresholds are used to charac- range of -0.5°C to +3.8°C (Figure 4). terize tropical nights: T-min > 20°C (TN20) and T-min > 26°C (TN26). By the 2030s, the annual People in the Southern Region will be the most number of TN20 is expected to experience vulnerable to extreme heat conditions. Already, a median increase of 16 percent, with a 33 the Southern Region experiences more than percent increase during the 2050s (Table 1). double the median number of very hot days The Southern Region will be particularly (T-max > 35°C) (N=42 [30, 55]), compared to the vulnerable to high nighttime temperatures by Central (N=20 [11, 33]) and Northern (N=6 [1, 18]) the mid-century. By the 2050s, the region is Regions, mostly occurring from September to projected to experience 200 days (181, 215) at November each year. Projected temperature TN20 annually, 15 of which will have tempera- increases for the Southern Region will increase tures at or above 26°C. FIGURE 4. Projected average monthly temperature and precipitation patterns in Malawi under SSP3-7.0 350 mm 30 ˚C 300 mm 28 ˚C 250 mm 26 ˚C 200 mm 24 ˚C 150 mm 22 ˚C 100 mm 50 mm 20 ˚C 0 mm 18 ˚C Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Historical Reference Period 1995-2014 2020-2039 2040-2059 Historical Reference Period 1995-2014 2020-2039 2040-2059 Source: World Bank Climate Change Knowledge Portal. This figure presents the median values of the multi-model ensemble range; for a full presentation of projected monthly precipitation and temperature projections please see Annex E. Climatology | 11 TABLE 1. Annual number of very hot days (>35°C) and tropical nights in the 2030s and 2050s throughout Malawi, under SSP3-7.0 HIS. REF. PERIOD 2030S 2050S NO. DAYS NO. DAYS NO. DAYS Very Hot Days (>35°C) Central 20 (11, 33) 30 (21, 43) 43 (30, 58) Northern 6 (1, 18) 15 (6, 24) 24 (15, 41) Southern 42 (29, 55) 57 (44, 71) 73 (53, 90) Tropical Nights (>20°C) Central 54 (37, 99) 78 (57, 122) 110 (75, 157) Northern 13 (4, 31) 28 (13, 59) 51 (28, 105) Southern 150 (131, 167) 174 (156, 191) 200 (181, 215) Tropical Nights (>26°C) Central <1 (<1, 1) 1 (<1, 2) 2 (.5, 5) Northern 0 (0, 0) 0 (0, 0) 0 (0, <1) Southern 3 (0.5, 8.5) 7 (2, 15) 15 (4, 27) Note: This table presents the median (50th percentile) with the 10th and the 90th percentiles of the range of the multimodel ensemble in brackets. Source: World Bank Climate Change Knowledge Portal PRECIPITATION which is reflective of the natural climate 16. The average annual rainfall in Malawi variability. It is important to note that the has declined by nearly 100 mm since the occurrences of extreme rainfall events are 1960s, most notably during the dry season likely to increase (see the Floods section (May–October). Across the country, the below). The median values for average annual average precipitation during the rainy season precipitation at the national scale are projected (November–April) is nearly 1,000 mm, while to decline by nearly 40 mm (905 mm, 1,758 the rainfall during the dry season is barely over mm) during the 2030s. These projections do 140 mm. The Northern Region has experienced though reflect high uncertainty in precipitation the largest declines in the annual precipita- projections for the region. The largest deficits tion, followed by the Southern Region. There are expected to occur in the Southern Region has been considerable interannual climatic during the rainy season. By the 2050s, the variations across the country, which has average annual deficit for Malawi could be led to occurrences of extreme weather and approximately 33 mm (893 mm, 1,742 mm), with related events (see the following section on the Southern Region projected to experience climate-related hazards). an even larger deficit than the 2030 period. By the mid-century, Malawi’s dry season is 17. The total precipitation in Malawi is projected expected to experience a reduction in rainfall, to decline through the mid-century compared which would have important implications for with the historical reference, despite a slight agricultural production and food security. increase between the 2030s and the 2050s, 12 | Climate and Health Vulnerability Assessment: Malawi CLIMATE-RELATED HAZARDS districts: there were an estimated 1.1 million people affected, 230,000 people displaced, 18. Malawi is vulnerable to several climate- and 106 deaths, along with damages and related hazards, many of which have already losses totaling USD335 million.16 increased in frequency and intensity. The most pressing climate-related hazards are 20. Extreme precipitation is projected to increase floods, droughts, cyclones, and landslides. for the 2030s and 2050s, exacerbating The overall impacts of such events in Malawi flooding risks during the rainy season, cannot merely be attributable to changing envi- especially in the Southern Region. Projected ronmental conditions, including changes to the figures for the five-day cumulative rainfall climatology described in the previous section; show an average increase of 7.01 mm (-70 mm, rather, they are compounded by anthropo- 149 mm) in the 2030s and 15.78 mm (-58 mm, genic causes, including rapid deforestation, 172 mm) in the 2050s, respectively. These urbanization, and inadequate housing. increases will be the most profound during the rainy season (November–April), with the highest overall increases expected to occur FLOODS in the Southern Region. Heavy cumulative 19. Floods are among the most significant and rainfall is associated with a higher likelihood of recurring climate-related hazards in Malawi, runoff entering river channels and subsequent especially for the low-lying areas along the flooding, as soil reaches saturation. Intense Lake Malawi lakeshore in the Central and single-day events of heavy rainfall can have Southern Regions. Vulnerability to floods is the same effect, but within a shorter period of associated with the El Niño and the La Niña time, and may result in flash flooding events. phenomena, the seasonal rainfall patterns, the variability of water levels in Malawi’s three Nationally, there will be an increase for both major lakes (Malawi, Chilwa, and Chiuta), and the 2030s and 2050s in the largest 1-day the cyclonic activity in the region.13 The greatest precipitation events (+6.57 mm [-28mm, flood potential occurs in the rainy season 51mm] and +10.86 [-24mm, 65mm] respec- between November and April, peaking in tively), with the largest increases expected December and January; approximately 100,000 in February. The Southern Region is likely to people are exposed to flooding each year.14 experience the largest increases during the From 1991 to 2020, extreme precipitation 2030s (+10.7mm annually), with the average resulted in 37 flood events, leaving 935 dead largest 1-day rainfall totals ranging from 35 and affecting 3,501,645 people.15 In 2015, the mm to 114 mm during the rainy season. By the country experienced the most devastating 2050s, despite the projected increases for floods on record. Flooding occurred in 15 the Central Region being greater than those The overall impacts of the most pressing climate-related hazards in Malawi are compounded by anthropogenic causes, including rapid deforestation, urbanization, and inadequate housing. Climatology | 13 predicted for the Southern Region (+15.9 mm DROUGHT versus +7.6 mm), the Southern Region will still 21. Droughts are common in Malawi, affecting be at the greatest risk of flooding associated approximately 1.5 million people each year with intense 1-day rainfall events, especially on average.18 Over the last four decades, the from January to March. Overall, rainfall will frequency, intensity, and geographical area increase during the rainy season, based on affected by droughts have increased across the assumption that the wet / dry seasons stay the country.19 The most substantial droughts the same. However, the days with consecutive in recent years occurred during 2015 / 2016 rainfall will remain the same for the 2030s and in response to strong El Niño conditions. the 2050s, based on the assumption that the Erratic rains and prolonged dry spells led wet / dry seasons remain the same (Table 2). to severe crop failures in the Southern and The models estimate that floods may cause Central Regions, resulting in 6.5 million people an average GDP loss of almost 1 percent every requiring food aid20 and depressed macro- year.17 economic growth. The Southern and Central TABLE 2. Projected average largest 5-day cumulative precipitation, under the SSP3-7.0 scenario 2030S 2050S ANNUAL WET DRY ANNUAL WET DRY TOTAL SEASON SEASON TOTAL SEASON SEASON (NOV–APR) (MAY–OCT) (NOV–APR) (MAY–OCT) Avg 5-day Central 189.00 137.72 31.03 209.27 157.02 29.75 cumulative (130, 344) (87.22, (87.2, 236) (144, 353) (93.5, (8.5, 43) (mm) 236.4) 256.7) Southern 251.48 169.01 37.07 239.56 177.94 35.40 (121, 402) (83.5, 270) (83.5, 270) (130, 437) (92.6, 285) (11.2, 51) Northern 163.25 135.64 29.82 173.94 138.72 28.83 (125, 291) (86.25, (86.2, 204) (124, 295) (87.3, (7.8, 40) 204) 212.8) Avg 1-day Central 77.88 56.97 13.38 84.99 46.82 12.88 (mm) (48, 134) (33, 94) (4.4, 20) (52, 153) (33.4, 100) (4.3, 20) Southern 105.37 66.21 16.68 102.30 70.39 16.15 (48, 165) (32, 108) (7, 25) (52, 173) (34.7, 114) (6, 30) Northern 64.59 50.79 12.41 69.54 53.31 12.05 (42, 106) (30, 82) (4, 19) (45, 122) (31, 85) (4, 20) Consecutive Central 103.21 16.6 1.5 103.25 16.44 1.5 wet days (77, 152) (10.7, 23) (0.6, 4) (74, 155) (10.2, 23.3) (0.5, 3.7) (days) Southern 90.53 13.6 2.4 91.66 13.4 2.3 (60, 152) (7.8, 22) (0.9, 5) (55, 154) (7.6, 22) (0.9, 5) Northern 115.17 18.7 1.3 115.71 17.9 1.2 (80, 169) (11.5, 25) (0.4, 5) (72, 172) (10.5, 25) (0.4, 4.4) Source: World Bank Climate Change Knowledge Portal 14 | Climate and Health Vulnerability Assessment: Malawi Regions, especially the Balaka, Chikwawa, 300,000 homes, the displacement of approxi- and Nsanje districts, have historically been mately 87,000 people, and 60 deaths.26 Heavy the most vulnerable to meteorological and rainfall, approximately 255 mm within a 24-hour hydrological drought conditions, with the period, resulted in flooding in 15 out of 18 of Southern Region at the highest overall risk.21 Malawi’s districts.27 Cyclone Ana (2022) is estimated to have affected nearly 1 million 22. The projected declines in precipitation are people, displaced over 220,000, injured 206, very likely to increase the frequency and and killed 46. Waterborne diseases (WBDs), intensity of drought events. By the 2050s, particularly diarrheal diseases, in the disaster rainfall during the dry season is projected to camps constructed to house displaced and become scarce enough that the projected affected persons are a common concern in number of consecutive dry days during the aftermath of cyclonic events.28 Moreover, August–October will nearly equal the number cyclones can have devastating cross-sectoral of days in each month. Further, the number of impacts across sectors that include energy, consecutive dry days in November in all regions transport, healthcare service delivery, and is projected to be around 18 days. As maize is food security.29 Malawi’s Southern Region is commonly planted in November throughout the most vulnerable area to cyclones and it Malawi, the late onset or the lack of rain as is where 75 percent of the country’s hydro- early as November may continue to impact electric power stations are located.30 food security and nutrition outcomes, in the absence of drought-tolerant maize varieties and conservation agricultural practices. LANDSLIDES 24. The most vulnerable areas of Malawi to landslide risks are located in the country’s CYCLONES highlands, mountains, and the isolated 23. Although cyclonic events have histori- mastiffs of the Southern Region (Figure 5). cally been infrequent in Malawi, they have Landslides often result from a combination become more common over the last decade, of factors, most of which are not directly characterized by greater intensity and influenced by weather or climate (for example, associated destruction. Since 2012, Malawi terrain, tectonic activity, soil type, and land has experienced more cyclonic events than cover), except for intense or prolonged from 1946–2008 combined.22,23,24 According rainfall. Rainfall can trigger landslide events to the Assessment Report 6 of the Intergov- by saturating slope’s soils, therefore leading ernmental Panel on Climate Change (IPCC to slope instability and subsequent landslides. AR6 2021), it is likely that the proportion of The conditions that produce landslide events major cyclones will increase, coupled with an can take hours or, in some cases, days to increased severity of these events in Malawi.25 develop.31 The most devastating landslides Since 2019 alone, four cyclonic events have in recent years include the 1991 Phalombe occurred — two of which have been among landslide, the 1997 Banga landslide, and the the most devastating the country has ever 2019 landslide event in the Rumphi district. experienced. Cyclone Idai (2019) affected an estimated one million people in Malawi’s 25. Projected increases in the intensity of Southern Region, resulting in the destruction of rainfall events through the mid-century will Climatology | 15 exacerbate landslide risks across Malawi, totals, is very likely to aggravate and intensify especially in the Southern Region. In the slope failures in highland areas. The models Southern Region, the projected median suggest that, on average, 10 fatalities will be average largest 1-day precipitation in January associated with landslide events annually, and February will be approximately 75 mm along with structural damages amounting to in the 2030s and 80 mm in the 2050s. This USD150,000 on average. By 2050, the number amount of precipitation over such a short of persons affected by landslide events could time, coupled with normal rainy season rainfall increase from one to 300.32 FIGURE 5. Rainfall-triggered landslide hazard index in Malawi Source: Natural Earth, ASTER GDEM Version 3, and GFDRR 2020. 16 | Climate and Health Vulnerability Assessment: Malawi KEY MESSAGES → The mean annual temperatures have risen by 0.64°C over the past half century in Malawi, occurring alongside increases in the minimum (0.60°C) and maximum (0.68°C) temperatures. Extreme heat exposure is projected become more frequent through the mid-century, with the Southern Region at greatest risk. → The average annual rainfall in Malawi has declined by nearly 100 mm since the 1960s, most notably during the dry season, and is expected to continue to decline compared with historic levels through the mid-century. → Extreme precipitation is projected to increase for the 2030s and 2050s, thus exacerbating flooding risks during the rainy season, especially in the Southern Region. → Projected declines in precipitation are very likely to increase the frequency and intensity of drought events. → Although cyclones have been historically infrequent, they have become more recurrent in the last decade. Projections estimate that cyclones will become more severe under the climate change high-emissions scenarios. → The escalating intensity of rainfall events, predicted through the mid-century, are expected to exacerbate landslide risks across Malawi, especially in the Southern Region, this would triple the affected population by 2050. Climatology | 17 SECTION III. CLIMATE-RELATED HEALTH RISKS 26. Malawi faces a multitude of health challenges from communicable diseases (CDs) and non-communicable diseases (NCDs), which will likely be exacerbat- ed by climate change. In 2019, life expectancy in the country was 65.62 years, giving it a ranking of 17th out of 49 countries within the Sub-Saharan Africa (SSA) region.33 CDs represent the largest share of the overall burden of disease: six of the leading 10 causes of premature mortality are attributable to CDs, along with maternal, neonatal, or nutritional diseases,34 many of which are climate-sensitive (for example, diarrheal disease, malaria, tuberculosis, and lower respiratory infection). AIDS and neonatal disorders have been the two leading causes of death since 2009. Malawi’s HIV prevalence among adults is one of the highest in SSA,35 and climate change is already threatening the progress made in the fight against HIV by undermining food security, doubling the burden of infectious diseases, causing human migration, limiting access to HIV treatment, and eroding the public health infrastructure.36 27. The risks to health outcomes from the 28. Malawi’s CHVA assesses seven climate-re- climate are not evenly distributed within the lated health risk categories. They include population: some groups are at greater risk (a) risks to nutrition, (b) vector-borne disease than others. The factors that affect a popula- (VBD) risks, (c) WBD risks, (d) heat-related risks, tion’s vulnerability to climate are often similar (e) air quality health risks, (f) mental health to those that affect health more broadly.37 and well-being challenges, along with (g) the Therefore, climate may further exacerbate direct injuries and mortalities related to natural health inequalities, especially among certain hazard events. Each category is assessed, in vulnerable population groups, including terms of current and future risks, with consid- the poor, rural populations, those living in erations for both national and subnational informal urban settlements, women and peculiarities, where possible. It is important young children, the elderly, those living with to note that these risk categories represent pre-existing conditions and disabilities, and only the most pressing health risks to the displaced populations. Therefore, investments population in Malawi. Other climate-related in adaptation and mitigation measures must health risks have not been included in this carefully consider groups who would directly assessment, and they may include, but are benefit from or may be disadvantaged by not limited to, direct injuries and mortalities adopted measures. associated with natural hazard events. 19 NUTRITION RISKS Further, 41 percent of the children in the under-five age category are stunted (have 29. Weather and climate are the foundational a low height for their age)43 and 0.6 percent drivers of healthy and sustainable diets. The experience wasting.44 Stunting has histori- mechanisms by which climate change affects cally been the most prevalent in the Central nutrition via the food system are profound; they Region, while the average household caloric exert acute and chronic effects on agricultural intake shortfalls have occurred most often in production, storage, processing, distribution, the Southern Region.45 The consequences and consumption. Nutritionally secure and of malnutrition, especially in children, are stable diets not only depend on agricultural far-reaching, with profound implications production but also the complex interactions on human and physical capital, which can of demand, economics, legislation, conflict, constrain a county’s overall economic growth food waste, nutrient losses, food safety, and development. It is estimated that Malawi’s and access.38 Climate variability is already high levels of stunting and malnutrition have contributing to increases in global hunger led to an annual estimated loss of USD597 and malnutrition. While a comprehensive million, due to the lowered labor productivity analysis of climate change’s impact on the and the high costs of healthcare.46 food system is beyond the scope of this assessment, this CHVA examines climate 31. The quantity, both in terms of food availability and nutrition linkages through a food security and calories consumed, and the quality of lens in Malawi, as it relates to the weather food products play a considerable role in and climate impacts on agricultural produc- the nutrition outcomes. Additional drivers of tivity. Agricultural productivity, which is a key malnutrition include poor feeding practices determinant of food availability, is affected and infectious diseases, such as diarrhea.47 by weather and climate in a multitude of Dietary diversity in Malawi is low, with diets ways, from short-term shocks (for example, heavily dominated by maize to the point that natural disasters) to longer-term changes in food security in Malawi is often equated with agroecological conditions that can drastically sufficient access to maize.48 reduce yields or redefine the spatio-temporal patterns of crop suitability. Smallholder farming is the backbone of Malawi’s economy: 94 percent of the rural 30. Food insecurity and malnutrition are population and 38 percent of the urban chronic, and they are worsening challenges population are engaged in agriculture.49 throughout Malawi, with profound impacts Nearly all farmers (95 percent) are subsistence on human capital, economic growth, and farmers: essentially, they are farming to meet development. In 2019, an estimated 81 percent their households’ food requirements and / of the population (15.2 million) lived with or sell at local or regional markets. Maize is moderate to severe food insecurity39 and cultivated by approximately 97 percent of 17.3 percent of the population (3.2 million) farmers throughout the country. was undernourished.40 Women and children are especially vulnerable to malnutrition in 32. Food security and poor nutrition outcomes Malawi: approximately 31 percent of women in Malawi are compounded by shifting of reproductive age are anemic,41 as are 55 climate baselines and shocks, including percent of children under the age of five.42 climate-related hazards. The Southern Region, 20 | Climate and Health Vulnerability Assessment: Malawi responsible for approximately one-third of measures under consideration throughout the maize production, is highly vulnerable to Africa, including Malawi. floods that annually cause approximately 12 percent of maize production losses. Likewise, Projections of maize yields in Malawi show droughts are responsible for approximately 4.6 important geographic variations. Maize yields percent of maize production losses each year. are expected to increase across the highlands and, to a lesser degree, the western plateau: Nutrition surveying, conducted from November the warming temperatures at these elevations to December 2020 in Malawi’s flood- and provide comparatively more optimal conditions drought-prone areas, showed that the for growing. Conversely, yields are expected prevalence of global acute malnutrition to decline in the Southern Region due to even and the proportion of underweight children higher temperatures leading to more rapid in the Shire Valley in the Southern Region phenology, higher evapotranspiration, and was higher than elsewhere in the country and added water stress.53 While food security and was increasing.50 Perhaps the most profound nutrition in Malawi is not entirely dependent example of the direct climate impacts on food on maize, it does represent 60 percent of the security in Malawi was the 2015/2016 drought caloric intake for the majority of the population. in the Southern and Central Regions and the Therefore, production shortfalls are very likely subsequent flooding in the Northern region: to aggravate food insecurity, especially at the they resulted in an overall maize production household level in the Southern Region where decline of 42 percent compared with the temperatures continue to increase, along with 2013/2014 season31 and left nearly 40 prolonged dry spells and recurrent flooding. percent of the population in need of food assistance.51 VECTOR-BORNE DISEASE RISKS 33. Projected warmer temperatures and water deficits, along with the increasing frequency 34. Weather and climate are the foundational and intensity of climate-related hazards, are drivers of spatio-temporal vector-borne very likely to aggravate food insecurity and disease (VBD) distribution and transmission nutritional deficiencies, with significant dynamics. Climate variability causes vector geographical variations. The agricultural and host ranges to expand or contract, sector is overwhelmingly dependent on thereby shifting disease distribution and rainfed agriculture for crop production: only 5 seasonality, and / or facilitating the emergence percent of farmers use irrigation throughout or re-emergence of VBDs. Investigating species the country; this thus makes the sector highly distribution and the seasonality of vectors susceptible to climate change.29 Maize is invaluable for understanding plausible yields are highly sensitive to water deficits VBD distributions and planning efficient, and temperatures over 35°C,52 erratic rainfall spatially targeted methods of control. This and changing temperatures therefore risk assessment focuses on malaria — the most significantly reduced maize production. In important VBD in Malawi. Though there are response to this, irrigation, fertilizers applied to other VBDs (for example, schistosomiasis, support crops, and the adoption of drought-re- dengue, and chikungunya) present in Malawi, sistant maize varieties are common adaptation there is limited information and surveillance.54 Climate-Related Health Risks | 21 Spatial models were constructed to conclusion of the rainy season. The primary demonstrate the plausible spatial distributions mosquito vectors responsible for transmis- of the vectors of malaria to assess the risk sion are Anopheles funestus, Anopheles propensity of these diseases. The results of arabiensis, and Anopheles gambiae s.s.:57 these analyses should be taken as a conser- they are widely considered to be among the vative estimation of the areas of Malawi that most efficient of all the malaria vector species provide suitable conditions for vector breeding at transmitting malaria. and the suitable conditions for vector breeding where humans are present (that is, populated 36. The malaria transmission risk in the Southern areas). For further information on the modeling Region is expected to decline in the 2050s methodology and the inputs, see Annex C.   due to ongoing climate change, while the transmission throughout the remainder of the country is expected to remain stable. MALARIA The suitability for malaria vectors through 35. Despite a long history of prevention and the mid-century is projected to largely control efforts in Malawi, malaria remains remain unchanged throughout the country, endemic, constituting the leading cause of as projected temperature increases will not morbidity and mortality in children under exceed the thermal tolerance of malaria vector five. In 2020, there were an estimated 4.3 species. Only in the Southern Region during million cases and 7,100 deaths; Plasmodium the 2050s, near Nsanje, will temperature falciparum is the most common form of increases likely limit the Anopheline vector infection.55 Data from the 2017 Malaria Indicator survival (Figure 6). The projected decline Survey show that 24.3 percent of children aged in the suitable area is estimated to reduce six to 59 months tested positive for malaria the vulnerable population by approximately via microscopy, ranging from 11.2 percent in 300,000 people (Table 3). the Northern Region to approximately 26.0 percent in the Central and Southern Regions.56 37. The geography of the malaria risk in Malawi Malaria transmission is seasonal throughout through the mid-century is expected to be the country, peaking during or just after the affected by the human modification of the TABLE 3. Projected percentage of suitable habitat area, by region, for the malaria vector species in Malawi, under RCP8.5, through the mid-century PERCENT AREA POPULATED, SUITABLE OVERALL SUITABILITY VULNERABLE POPULATION Historic & 2050s Historic & 2050s Historic & 2050s 2030s 2030s 2030s Central 72.71 72.71 99.86 99.86 7,432,016 7,432,016 Northern 62.60 62.60 99.14 99.14 2,309,787 2,309,787 Southern 55.35 97.45 52.68 92.89 7,486,733 7,181,201 TOTAL 17,228,536 16,923,004 Sources: Temperature (NASA, NEX-GDDP) Land Cover (Copernicus Global Land Service, Proba-V-C3), Water Resources (European Commission’s Joint Research Centre, GSW1_0), Flow Accumulatio n(World Wide Fund for Nature, HydroSHEDS), Population (European Commission’s Joint Research Centre, GHSL/P2016/POP_GPW_GLOBE_V 22 | Climate and Health Vulnerability Assessment: Malawi FIGURE 6. Comparison of the suitable area for the malaria vector species in Malawi under Representative Concentration Pathway (RCP) 8.5, across three epochs: 1986–2005 (historical baseline), 2020–2039, and 2040–2059 Sources: Temperature (NASA, NEX-GDDP) Land Cover (Copernicus Global Land Service, Proba-V-C3), Water Resources (European Commission’s Joint Research Centre, GSW1_0), Flow Accumulatio n(World Wide Fund for Nature, HydroSHEDS), Population (European Commission’s Joint Research Centre, GHSL/P2016/POP_GPW_GLOBE_V Note: The analysis was conducted prior to the CMIP6 release. landscape for irrigated agriculture; the frameworks to promote the expansion of adoption of malaria prevention, treatment, irrigated agriculture throughout the country and control strategies; and ongoing climate (for example, the Green Belt Initiative, the changes. As this analysis has shown, the National Irrigation Policy, and the National temperature and precipitation changes in Agriculture and Investment Strategy [NAIP]). Malawi through the mid-century will likely not While irrigated agriculture can increase substantially impact the geography of vector crop production, the agrarian transforma- breeding throughout the country. However, tion of the landscape for irrigation is also what cannot be accurately projected are the associated with several water-related diseases human-induced changes to land use and land including malaria, thereby exacerbating the cover (LULC), which can have profound impli- malaria risk. Recent findings from the Bwanje cations on the distribution of malaria vector Valley Irrigation Scheme in central Malawi species. For example, in response to food demonstrate that proximity of human dwellings insecurity concerns, including those associated to irrigated agriculture significantly influences with climate variability and changes’ impact malaria risk. Individuals whose households on agricultural production, the government of were located within three kilometers of the Malawi has adopted several national policy irrigation scheme had a significantly higher Climate-Related Health Risks | 23 prevalence of malaria infection than those The prevalence of WBDs in Malawi is primarily residing further away.58 As Malawi expands its attributable to the poor water quality stemming irrigated agriculture throughout the country in from water contamination, coupled with the response to food security concerns (including lack of access to an improved drinking water those driven by the climate impact on agricul- source and poor sanitation, each of which may tural production), its vulnerability to malaria be affected by weather and climate change. infection is very likely to change in distribution, Findings from the Malawi Demographic and thus placing communities closer to irrigated Health Survey (2015–2016 MDHS) show schemes at greater risk than others. that within the two weeks before the survey, 22 percent of children under the age of five had diarrhea, with those aged six to 11 WATER-BORNE DISEASE RISKS months comprising 41 percent of the cases.61 Prevalence rates were highest in the Central 38. The burden of waterborne diseases (WBDs) Region (24 percent) and lowest in the Northern throughout Malawi is significant, with high Region (17.8 percent) (Table 4). rates of morbidity and mortality across the country, especially among children under 39. Climate change can impact water quality five years of age. Approximately 50 percent and associated WBDs through several of all illnesses are attributable to WBDs, pathways, including temperature increases, especially diarrheal illnesses including cholera. flood events, and drought conditions. Rising Diarrhea alone accounts for an estimated temperatures can facilitate the proliferation 8,000 deaths per year, with the highest burden of waterborne bacteria and algal toxins, while among children under five years old.59 In 2017, flood waters can be contaminated with human diarrhea accounted for 7 percent of under-five and animal waste, as well as agricultural and mortality.60 other pollutants. Further, flies and other pests TABLE 4. Two-week prevalence of diarrhea in children under five years in Malawi, 2017 PERCENTAGE WITH DIARRHEA Region Central 24.0 Northern 17.8 Southern 20.4 Source of Drinking Water Improved 21.3 Unimproved 21.0 Type of Toilet Facility Improved 19.9 Shared 24.3 Unimproved Sanitation 21.9 Source: Demographic Health Surveys in Malawi, 2017. 24 | Climate and Health Vulnerability Assessment: Malawi proliferate in flood waters, risking food contam- outbreaks. The predicted increase in flash ination. Bacterial pathogens attach to leafy floods may overwhelm the country’s sanitation crops, such as lettuce, under both flooding sewer and drainage systems, resulting and drought conditions.62 Just as significantly, in contaminated drinking water sources, droughts affect not only water quality but may especially in the urban areas of Lilongwe, also exacerbate WBD risks through limiting Blantyre, Zomba, and Mzuzu. An increase water quantity. A limited water supply can force in WBDs will overwhelm the already fragile populations to use contaminated water for health system.67 Further increases in tempera- drinking, bathing, and agricultural irrigation. tures are also likely to compromise drinking water quality through reduced water levels and Flooding and drought events, which are increase in water temperatures leading to high common in Malawi, are often associated with nutrient concentrations. Droughts will likely WBD outbreaks, especially in the lowlands of be more frequent, thus causing water scarcity the Southern Region and, to a lesser extent, in and forcing communities in drought- prone the Central Region. For example, flash floods, areas, especially Nsanje, Chikwawa, Zomba, following the heavy rains from December Salima, and Karonga,68 to resort to unsafe, 2008 through April 2009, triggered a cholera contaminated water sources for drinking outbreak in southeastern Malawi. During this water, such as watering holes and ponds. period, Malawi’s MoH reported a total of 5,198 As Malawi works to eliminate poverty, climate cholera cases and 113 deaths throughout the shocks and natural disasters will continue to country, especially in the southern fishing frustrate these efforts by exacerbating social districts of Machinga, Phalombe, and Zomba and economic inequalities, increasing the on the shores of Lake Chilwa and the central WBD burden among the poor, and limiting district of Lilongwe.63 Additionally, in March the adaptive capacity of this vulnerable group. 2022, a cholera outbreak was declared in the southern districts of Machinga and Nsanje in the aftermath of Tropical Cyclone Gombe.64 HEAT-RELATED MORBIDITY AND Furthermore, poor rural households, especially MORTALITY RISKS those located in the lowlands of the lower Shire 41. The health risks of heat are wide-ranging, Valley, are more likely to be displaced by floods including effects on mortality, heat-related caused by erratic rains, which increase their injuries, mental health, and well-being. The vulnerability to WBDs due to the limited access health effects caused by heat include the to safe drinking water and proper sanitation; direct effect of heat stress, as well as heat there is also the increased incidence of WBDs rash, cramps, exhaustion, dehydration, and the in displacement camps.65,66 Despite the strong acute exacerbation of pre-existing conditions association between climate and WBDs, the including respiratory diseases and cardio- exact attribution of Malawi’s burden of WBDs vascular diseases (CVDs). to climate change is unknown. Longer-term mental health risks are also an 40. The projected increases in the intensity of important effect to consider. In addition to the precipitation in Malawi will likely increase impacts on individuals, the whole-of-popula- the occurrences of floods and droughts, tion exposure that occurs with an extreme with implications on the frequency of WBD heat event can lead to significant increases Climate-Related Health Risks | 25 in hospitalizations, thus imposing strains on the AIR QUALITY RELATED HEALTH RISKS country’s health system.69 Further, increased 43. The high levels of pollution from harmful heat stress has reduced labor productivity in airborne particulates have led to an increased Malawi: in 1995, the working hours lost from incidence of illness and deaths stemming from heat stress, estimated at an equivalent of chronic lung diseases and acute respiratory 8,000 full-time jobs at that time, is projected infections among the population. Chronic and to increase to 47,000 by 2030.70 acute respiratory diseases (CARD), including 42. Extreme heat and its impact on excess pneumonia, tuberculosis (TB), asthma, cystic heat-related morbidity and mortality are fibrosis, and chronic obstructive pulmonary very likely to increase under the high- and disease, continue to be a major health issue in low-emissions scenarios in Malawi. Histor- Malawi. Acute respiratory infections (especially ically, “very hot days” (≥35oC) have mostly pneumonia) are one of the most common affected the Southern Region for approximately causes of morbidity and mortality among 40 days per year, which occur predominantly children under five, causing over 70 percent in October and November. As the climate of hospital visits and 6–40 percent of deaths.73 section of this report described, however, projected increases in temperatures and the The major cause of CARD in Malawi is number of very hot days will become more exposure to indoor and ambient air pollution common throughout the country through (AAP). In their study on air pollution in rural the mid-century. This trend will place the Malawi, Saleh et al. (2021) reported a high populations of the Southern Region at particular concentration of fine particulate matter with risk for excess heat-related morbidity and a diameter of less than 2.5 micrometers mortality, with a disproportionate burden on (PM2.5) at 35.2 micrograms per cubic meter the elderly, children, and those with chronic (µg/m3) (24-hour mean); this figure is higher illness. than the World Health Organization’s (WHO) recommended 24-hour mean of 15 µg/m3.74 Routine statistics of annual heat-related The main sources of air pollution in Malawi are morbidity and mortality in Malawi are not biomass, charcoal burning, vehicle emissions, available. However, the modeled annual waste incineration, tobacco processing, and heat-related deaths in SSA for 2000–2019, industrial emissions. An estimated 95 percent estimated at 2 per 100,000 (95 percent of people use biomass (firewood and charcoal) CI:1–3),71 could be extrapolated to the Malawi as the main source of household energy, context to show that there could be nearly 400 especially for cooking and heating, making heat-related deaths annually. By 2080, under household air pollution the leading cause a high-emissions scenario, this number would of respiratory illnesses and diseases in the increase to 73 per 100,000 and 16 deaths per country. Women and children, especially girls, 100,000 under a low-emissions scenario.72 experience higher exposure to air pollution With the increased prevalence of NCDs, the from biomass due to their customary role in risk of rising temperatures is currently and will cooking. Young children are equally exposed continue to be compounded by poor housing, to indoor air pollution because of their regular urban and rural poverty, water insecurity, and proximity to their mothers during cooking. an aging population. 26 | Climate and Health Vulnerability Assessment: Malawi 44. The changes in the precipitation patterns of in the number of wildfires, estimated at 153 Malawi’s rainy season will indirectly influence each year.75 Prolonged droughts will likely the air quality health outcomes via exposure increase the frequency, intensity, geographic to indoor biomass air pollution. The exposure proximity, and length of the wildfire season in to biomass air pollution increases during the Malawi, thus worsening wildfire-induced air rainy season when cooking must be done pollution. Rising temperatures and atmospheric indoors in rooms with, at best, poor ventilation. carbon dioxide will likely extend the allergy Further, during the rainy season, there is season due to its impact on plant phonologies. limited access to dry wood for burning. Wet Although not well-documented in Malawi, firewood is not only harder to burn but also recent research elsewhere has shown that produces more smoke, thereby increasing poor air quality is significantly associated with air pollution. As the climate section of this the risk of autoimmune diseases,76,77 such assessment has shown, overall precipita- as connective tissue disorders, inflammatory tion is likely to decline in Malawi; however, bowel diseases, and rheumatoid arthritis. what is less certain and most important in this instance is the frequency and timing of rainfall events, because they relate to cooking DIRECT INJURIES AND MORTALITY times and subsequent exposures to biomass air pollution. 46. Mortalities and direct injuries in Malawi are often associated with heavy rains-induced 45. The predicted temperature increases by flash floods, mudslides, and landslides. 2050, coupled with high wind speeds and Globally, floods are one of the leading causes of prolonged droughts, are likely to increase natural disaster-related injuries and mortalities; the frequency of wildfires and the associated they were responsible for over 6,000 deaths in deterioration of air quality in Malawi. Malawi, 2020 alone. In Malawi, Tropical Storm Ana led especially in the dry months of August through to 33 deaths, displaced over 100,000 people, November, is already experiencing an increase and affected over 200,000 households.78 The TABLE 5. Extreme weather event related, injuries, and mortality in Malawi from 2000 to 2022 EXTREME EVENTS SUBTYPE EVENTS COUNT TOTAL DEATHS TOTAL AFFECTED Flood Flash flood 5 21 192,246 Riverine flood 15 297 1,052,301 Coastal flood 2 67 518,500 Other 9 73 1,334,070 Drought Drought 5 500 17,049,435 Landslide Landslide 1 8 109 Storm Convective storm 2 18 55,901 Tropical cyclone 3 60 116,958 Other 1 11 19 Source: The International Disasters Database (2022). https://public.emdat.be/data. Climate-Related Health Risks | 27 Central and Southern Regions, especially the 49. People in Malawi face a double mental districts of Chikwawa, Phalombe, Nsanje, and health burden from the consequences of Zombe, are particularly susceptible to flooding. climate-related events, coupled with the lack of access to mental health services. Mental health and overall well-being are affected by MENTAL HEALTH AND contextual and societal factors that do not necessarily cause mental disorders, though WELL-BEING RISKS they can affect overall mental well-being by 47. Severe weather related to climate change curtailing the cognitive energy needed to impacts the livelihoods and the well-being develop the coping mechanisms to deal with of individuals and communities. Notably, the the increasing intensity of extreme weather impact of climate change-related events on events. Chronic exposure to food insecurity mental health can be direct or indirect, and has also been shown to decrease overall short-term or long-term. Acute events (for mental energy, as well as affecting individual example, floods and cyclones) can precipitate and collective resilience. Exposure to extreme psychopathological experiences of traumatic weather events, such as floods and storms stress, depression, anxiety, loss, and grief, that end up affecting livelihoods, can abruptly which can even lead to suicide. In the case of impact mental health, leading to symptoms exposure to extreme or prolonged weather-re- that are similar to those of the post-traumatic lated impacts, it may result in delayed mental stress disorder.82 impacts, such as the symptoms of post-trau- matic stress in the future or the psychological 50. Rural farming communities are more impacts on younger generations.79 vulnerable to the mental health consequences of events related to climate change. The 48. Mental health in Malawi has been an ongoing impacts of climate change hazards, such as challenge for public health: 20–28.8 percent floods, storms / winds, and droughts, threaten of primary care patients are diagnosed with the limited sources of livelihood — mainly the common mental disorders.80 Overall, mental crop yields available for local communities, disorders constitute a burden of disease of thereby causing stress, distress, and mental 1,348.07 per 100,000 disability adjusted life disorders including anxiety and depression, years (DALYS) in the country, with depressive as well as unhealthy coping behaviors like disorders (including anxiety) specifically gender-based violence, alcoholism, and constituting 497.58 per 100,000 DALYS.81 substance abuse.83 The impacts of climate Despite the high prevalence of common change on mental health and well-being can be mental disorders, mental health services in worsened by poverty, food insecurity, and the the country are scarce. Addressing mental sudden loss of property, along with personal health is also exacerbated by stigma, cultural or family diseases and illness, among others.84 beliefs, and a lack of scientific knowledge After experiencing these cumulative shocks, on the impact of climate change on mental these households would be even less able health. The precise impacts of climate and to develop effective coping mechanisms that climate-related events on mental health are built upon structural and social support,85 outcomes in Malawi are unknown. therefore, worsening their well-being and prospects of improving their livelihoods. 28 | Climate and Health Vulnerability Assessment: Malawi TABLE 6. Summary of the Climate Change Risks on Health Outcomes CURRENT RISK PROJECTED RISK Food Security • Food security and malnutrition are chronic • Projected warmer temperatures and and Nutrition and worsening problems in Malawi. water deficits, along with the increasing • Food security and poor nutrition frequency and intensity of climate-related outcomes are being compounded by hazards, will aggravate food insecurity shifting climate baselines and shocks, and nutritional deficiencies, by causing including climate-related hazards. production shortfalls of maize. • While maize yields are projected to increase across the country’s highlands and the western plateau, they will likely decline in the Southern Region. Vector-borne • Malaria is the leading cause of morbidity • Malaria transmission risk in the Southern Diseases and mortality in children under five. Region will decline in the 2050s due to • The prevalence in 2017, according to ongoing climate change, thus reducing microscopy, was 24.3 percent among the vulnerable population by around children aged 6–59 months at the 300,000 in the region. The transmission national level. for the remainder of the country is likely to remain stable. • The prevalence of malaria is highest in the Central and Southern Regions (ap- • The geography of malaria risk in Malawi proximately 26 percent) compared with through the mid-century will likely be the Northern Region (11.2 percent). attributable to the human modification of the landscape for irrigated agriculture and the adoption of malaria prevention, treatment, and control strategies, as well as ongoing climate changes. Waterborne • Water-borne diseases (WBDs) are among • Projected increases in extreme rainfall and Water- the leading causes of illnesses and child and related floods will increase drinking related mortality in Malawi. water contamination and WBD outbreaks, Diseases • Floods are associated with diarrhea and especially in the Southern and Central cholera outbreaks in the country, due Regions of Malawi. primarily to the fecal contamination of • Drought-induced water scarcity will force water sources. more households to use unsafe drinking • High temperatures, associated with water sources, leading to an increase in droughts, affect drinking water quality due waterborne illnesses and WBDs. to eutrophication and algal growth. Heat-related • Estimating heat-related morbidity and • Extreme heat, as well as its impact Morbidity and mortality in Malawi is challenging, in the on excess heat-related morbidity and Mortality absence of routine vital health statistics mortality, will increase under high- and on heat-related illnesses. low-emissions scenarios in Malawi. • The Southern Region is at the highest risk for excess heat-related morbidity and mortality through the mid-century. Climate-Related Health Risks | 29 Air Quality and • Chronic and acute respiratory diseases, • Rising temperatures and precipitation Respiratory triggered by air pollution, are a major will likely increase the occurrences and Health health issue. spread of wildfires, thereby increasing air • The use of biomass energy for cooking pollution and the incidences of Chronic and heating is the leading cause of and Acute Respiratory Diseases. indoor air pollution in Malawi. Women and • The expected increase in air quality children from low-socioeconomic status deterioration will likely increase the households are comparatively more emergence and frequency of autoimmune vulnerable to acute and chronic respira- diseases among the population. tory diseases associated with biomass • With increased air pollution, NCDs, air pollution than their socioeconomically including strokes, chronic obstruc- advantaged counterparts. tive pulmonary diseases, asthma, and ischemic heart diseases, will likely become the leading cause of the disease burden and deaths in Malawi. Direct Injuries • Floods are responsible for most deaths • Projected increases in flooding, related to and Mortalities and injuries. increasing temperatures and precipitation, • Heavy rains-induced flash floods, will likely cause more deaths and direct mudslides, and landslides threaten lives injuries. and livelihoods in Malawi. Mental Health • More than 20 percent of primary care • Based on the projections indicating that and Well-being patients are diagnosed with common cyclones will increase in intensity and mental disorders. drought periods would be prolonged, • Extreme weather events, such as these climate trends will likely worsen cyclones, have a direct impact on mental mental health and well-being outcomes. health. They can lead to the development • The rural communities’ strong depen- of symptoms of traumatic stress, anxiety, dence on subsistence farming and the and depression after the climate shock. possible losses of livelihoods will have a • Rural farming communities have exhibited compounding effect on population mental comparatively worse mental health and health and well-being. well-being issues during floods and prolonged drought periods than urban communities. 30 | Climate and Health Vulnerability Assessment: Malawi S E C T I O N IV. ADAPTIVE CAPACITY OF THE HEALTH SYSTEM HEALTH SYSTEM OVERVIEW 51. The health services in Malawi are diverse: they include the government or the public sector, the private not-for-profit sector (PNFP), and the private for-profit sector (PFP). The public sector, which provides about 60 percent of all the health services, is organized under a four-tier referral system: community, primary, secondary, and tertiary.86 Health services are also provided by the Christian Health Associa- tion of Malawi (CHAM) — the largest nongovernmental health service provider in the private sector. Community health workers (CHWs), traditional healers (THs), herbalists, and traditional birth attendants (TBAs) also provide health services, particularly in the remote rural areas of Malawi, where there is limited access to health facilities. 52. The health sector in Malawi faces several limited its capacity to respond to the existing managerial, financing, and staffing challenges. and new healthcare needs. In 2019, the The public health sector provides services government’s expenditure on health was at no cost to the whole population under the about USD9.9 per capita per annum,89 with Essential Health Package (EHP). However, an additional USD27 from donors;90 this is informal payments, inadequate staffing, the significantly lower than WHO’s recommen- limited domestic resources available, the dation of USD86. Underfunded and poorly constant stockouts of essential medicines, the performing health systems, as with that of poor coordination between health providers, Malawi, may not have the ability needed to and the low service delivery leave most of respond swiftly to health emergencies and the poor population with no health services, new pandemics such as COVID-19, while still especially in the rural communities.87,88 struggling with epidemics such as malaria, HIV, and cholera. 53. The underfunded and struggling health system in Malawi, which has been largely 54. The extent to which the health system in donor-dependent, has further been strained Malawi is prepared for and has the capacity by the COVID-19 pandemic. The financial to manage changes in hazards, exposures, challenges of Malawi’s health system have and susceptibility will determine the country’s 31 resilience in the coming decades. In this LEADERSHIP AND GOVERNANCE assessment, Malawi’s adaptive capacity91 to 55. The government of Malawi is acutely aware prevent and manage climate-related health of the potential negative impacts of climate risks is examined according to WHO’s six change on various areas, including health; health system building blocks, as shown in therefore, it is committed to meeting the Figure 7. See also Annex B for the Adaptive Capacity Rapid Assessment and a summarized climate challenge through both adaptation Adaptive Capacity and Climate Change- and mitigation measures. Since ratifying Related Health Risks Gap Analysis. the United Nations Framework Convention on Climate Change (UNFCCC) in 1994, the It should be noted that several factors outside government of Malawi has demonstrated its the scope of the health sector can also drive political commitment and action to address reductions in adaptive capacity to manage climate change challenges through the imple- the health risks of climate change in Malawi’s mentation of several legislative frameworks institutions and people. These factors include and strategies, programs, and activities. The the country’s economic challenges, sustained formulation and enforcement of environmental rapid population growth combined with policies and legislative frameworks in Malawi, accelerated urbanization, and slowly improving including those related to climate change, social conditions. The promotion of equity, as a are the responsibility of the Environmental cross-cutting theme for enhancing the adaptive Affairs Department (EAD) in the Ministry of capacity and the resilience to the health risks Natural Resources, Energy, and Environment. of climate change, is also critical. Adaptive EAD, in collaboration with the Department of capacity is likely to be greater when access Meteorological Services (DoMS), coordinates to resources within a community, nation, or climate change issues throughout the county. the world is equitably distributed. The additional efforts to increase adaptive FIGURE 7. WHO 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 32 | Climate and Health Vulnerability Assessment: Malawi capacity and resilience include the appointment cross-sectoral policy objectives, principles, of a National Designated Entity (NDE) that and strategies include the minimization of the is responsible for the development and adverse impacts of climate change by reducing transfer of climate change technologies for air pollution and GHG. Further, the NEP works adaptation and mitigation; a focal point and to develop and administer the guidelines for a National Designated Authority (NDA) for the environmental impact assessments (EIAs) that Green Climate Fund; and the establishment consider not only biophysical impacts, but of a Health and Climate Change Core Team also address environmental impact on health (HCCCT) comprising various government outcomes, among other things. The policy sectors and partners that provide guidance expressly states that human settlements on health and climate change. should incorporate environmental concerns and includes strategies, such as the following: 56. The evolution of the climate and health • Develop sanitation master plans and policy landscape in Malawi since 1998 is provide environmentally friendly services summarized as follows: to district, town, and city assemblies; → 1998 — Malawi Vision 2020 (1998–2020). • Improve waterborne sanitation systems Malawi’s Vision 2020 formed the basis for the and solid waste disposal, using appropri- preparation of short- and medium-term national ate technology, as well as adopting the goals, policies, and strategies to improve the proper design, selection, and licensing of country’s development management through disposal sites and routes; 2020. Vision 2020 follows a multisectoral • Strengthen the health inspectorate for approach in both the public and private sectors urban and rural areas to assess the risks to address nine primary strategic challenges, and consequences of environmentally including health promotion and environmental related health problems; management. Air pollution and climate change • Promote the development, adoption, and issues, along with strategic options to address use of cost-effective technologies for these concerns, are outlined, though they are building works to prevent deforestation not explicitly linked to human health. and land degradation arising from brick making and other building activities; as → 2002 — The 1st National Communication to UNFCCC provides a review of climate- well as change related issues in Malawi. The impacts • Develop pollution control and disaster of climate change on health, while acknowl- management mechanisms to protect com- edged, were not among the key socioeconomic munities from disasters. sectors assessed as part of the vulnerability → 2006 — The Malawi Growth and Development and adaptation assessment of climate change. Strategy I (MGDS I, 2006–2011) provides → 2004 — The Revised National Environmental guidelines to the government of Malawi Policy (NEP) works to create and enable a on resource allocations and use in various policy and legal framework for cross-sector sectors to attain the Malawi Vision 2020. coordination. It is the key instrument and The MGDS includes sections on improving standard in Malawi for environment and health outcomes through social development, natural resources policies and legislation to though it is not among the four key focus guide all sectoral activities at all levels. The areas, nor is there explicit consideration for Adaptive Capacity of the Health System | 33 the impacts of climate change on human 2020. In this version, public health, sanitation, health outcomes across scales. malaria, HIV, and AIDS management, along The National Adaptation Program of Action with climate change, natural resources, and (NAPA) identifies and provides potential environmental management, are identified as adaptation options to minimize the impacts key priority areas, with subsequent strategies of climate change on various areas, including to improve overall livelihoods. However, the human health. Priority areas for urgent and strategies for improving health outcomes do not immediate adaptation include enhancing directly address the influence or the potential food and water security to improve health impact of climate change on population health. outcomes, especially among communities most → 2011 — The National Health Sector Strategic vulnerable to droughts and floods throughout Plan (2011–2016) was developed to guide the country. Project activities to improve health the implementation of interventions to outcomes in light of climate change include (a) improve the health status of the people the promotion and development of integrated of Malawi. The plan includes a section on sustainable livelihoods; (b) the improvement environmental health where the impact of of agricultural production under changing climate change on the environment is acknowl- climatic conditions to ensure food security edged as influencing health outcomes. The and improved nutrition; (c) the strengthening strategies and key interventions presented of preparedness to cope with droughts and consist of efforts to reduce morbidities and floods, through establishing flood forecasting mortalities associated with environmental and warning systems, for example; and (d) the factors (for example, foodborne diseases and enhancement of climate monitoring to bolster water- and sanitation-related diseases), as the early warning capabilities on Lake Malawi well as to strengthen responses to disasters and the lakeshore areas. and emergencies and promote sustainable The Environmental Management Act was vector-control measures. developed as a legal instrument for imple- Malawi’s 2nd National Communication to menting Malawi’s regulatory frameworks UNFCCC is well-informed and includes for the protection of the environment and sections on climate-related health issues, enforcing compliance with them. such as the increasing incidence of WBDs, VBDs, the direct and indirect health impacts → 2008 — Malawi signed the Libreville of climate-related hazards, and malnutrition. Declaration on Health and Environment in A vulnerability and adaptation assessment Africa (LDHEA). The LDHEA is a WHO-sup- ported framework that is aimed at building the was performed by using a model for the national, subregional, and regional capacities assessment of greenhouse gas-induced to prevent climate-related health problems climate change (MAGICC) to identify and through establishing health and environment develop the appropriate adaptation responses strategic alliances and promoting government to the impacts of climate change across investments that address climate-related issues multiple sectors, including health. affecting human health outcomes. → 2013 — The National Climate Change → 2009 — The MGDS II (2011–2016) is the Investment Plan (NCCIP, 2013–2018) was second medium-term development strategy developed to increase climate change formulated to meet the aspirations of Vision investments in Malawi, while simultaneously 34 | Climate and Health Vulnerability Assessment: Malawi addressing gaps identified in the 1st and development planning and implementation 2nd National Communications to UNFCCC by all stakeholders from local to national and the NAPA. Climate change management levels. It aims to (a) effectively manage the projects, related to health, include improving impacts of climate change through building health services to handle health challenges social and ecological resilience of all associated with climate change in all regions Malawians; (b) contribute towards stabilizing of Malawi and strengthening the sanitation GHGs; (c) incorporate climate change into infrastructure to handle climate change-re- planning, development, and coordination; lated pressures. The NCCIP identified that a and (d) integrate cross-cutting issues into critical challenge faced by the health sector, climate change management. However, when managing climate change, was a lack of the management of climate-related health research that established the magnitude of the outcomes is not expressly included as one relationship between climate variability and of the policy objectives of the NCCMP. disease incidence, occurrence, and severity. → 2017 — Malawi’s HSSP II (2017–2022) The NCCIP outlined that the inter-institutional includes sections on climate change-related coordination of climate change management is health issues, such as VBDs, malnutrition, and provided by the National Steering Committee sanitation; however, it lacks information on on Climate Change (NSCCC). Chaired by DoMS, the impact of climate change on health and NSCCC includes members of various stake- does not identify climate change as a current holders, including MoH. or a future threat to human health. The aim → 2015 — The Updated NAPA provides an of the HSSP II is to move toward universal overview of the linkages of climate change health coverage (UHC) that provides quality, and human health outcomes and serves equitable, and affordable care, while improving as an instrument to increase the adaptive health outcomes through the provision of a capacity of vulnerable communities to the revised EHP. This is operationalized through adverse effects of climate change. The eight strategic objectives that are similar to updated NAPA is operationalized through WHO’s six health systems building blocks six adaptation activity areas, some of which described in this assessment, along with are directly relevant to health outcomes (for socioeconomic determinants that work to example, enhancing disaster preparedness reduce environmental and social risk factors and response through improving established with direct impacts on health. early warning systems). Health is identified as a The National Health Policy was developed vulnerable sector in need of urgent adaptation, to guide stakeholders in the implementation given the impact of climate change impact of initiatives for improving the functioning on temperatures, floods, and droughts, which of Malawi’s health system. However, climate influence the distribution of malaria, diarrhea, change is not listed among the key challenges and cholera. Likewise, erratic rainfall, which to Malawi’s health system; thus, the National can lower agricultural production, results in Health Policy will not be operating in line with hunger and malnutrition. any climate-change related policies. → 2016 — The National Climate Change Malawi’s first intended nationally determined Management Policy (NCCMP) is a key contributions (INDCs) include a section on instrument for managing climate change human health as a function of climate change, in Malawi. The policy serves as a guide for including malaria, diarrhea, and malnutrition. Adaptive Capacity of the Health System | 35 Adaptation measures, related to climate-sen- Department of Disaster Management Affairs. sitive health outcomes, include the following: The policy reflects a commitment to climate-re- • Build capacity to diagnose, prevent, and silient development to reduce overall food control climate-sensitive diseases, such as insecurity and malnutrition, which also takes malaria, diarrheal diseases, and malnutrition; into consideration the impact of the ongoing • Enhance public awareness about water, climate change. sanitation, and hygiene (WASH) practices, → 2020 — The National Adaptation Plan along with health surveillance; (NAP) Framework was established to guide • Support expanded programs for preventing efforts for the development of the NAP. The and controlling climate-sensitive diseases; framework is built on the NAP Roadmap (2016) • Construct additional health centers to and the NAP Stocktaking Report (2016). The improve access to health facilities within overall aim is to reduce the country’s vulner- a walking distance of 8 km; as well as ability to climate change through building • Support the establishment of a center of its adaptive capacity and resilience, while excellence for research and disease control integrating climate change adaptation into its that targets climate-sensitive diseases. national programming. It was developed, in The Malawi National Community Health part, through consultations with 21 different Strategy (2017–2022) operates in line with institutions, including MoH. MoH participates as the HSSP II, with an emphasis on improving a member of the NAP’s core team of national health and livelihoods through community experts. Food security — as a function of health. This is operationalized through a improved community resilience, infrastruc- redefinition of community health to include ture development, and DRM — is the only a package of basic preventive, promotive, expressed climate-related health risk that is curative, rehabilitative, and surveillance health covered by updated mandates. services at the community level. Consider- → 2021 — Malawi’s updated nationally ations for climate change impacts on health determined contributions (NDCs) outline outcomes are not expressly included among the country’s climate change priorities from the six strategic objectives, but occupational 2020–2040 and provide specific strategies health promotion, including climate and health, for addressing climate change impacts on is incorporated in the list of EHP interventions. various areas, including health. Strategic → 2018 — Malawi’s National Environmental adaptation options include elaborating existing Health Policy provides a basis for envi- NAPs for the health sector and other priority ronmental health conditions in healthcare sectors. Changes in the incidences of VBDs settings across Malawi. The policy addresses and WBDs; undernutrition; and increased five themes: food safety and hygiene; health migration, as a function of extreme events, and safety; vector and disease prevention which leads to increased human suffering and control; WASH; along with emergencies, are identified as key climate-related risks in climate change, and human health. the health sector. Breaking the cycle of food insecurity in To promote public health and social protection, Malawi and poverty reduction are the adaptation actions are proposed and grouped primary aims of the National Resilience into three categories: (a) resilient health, Strategy (2018–2030), which is led by the (b) the scaling up of resilient nutrition, and 36 | Climate and Health Vulnerability Assessment: Malawi (c) social support. Examples of adaptation and climate-related health risks (for example, actions include promoting insecticide-treated floods, cyclones, and WBDs).  mosquito nets, encouraging dietary diversity and integrating nutrition-sensitive practices, as well as establishing a social support fund to HEALTH FINANCING cover climate shock-related events and social 59. Malawi’s budget allocation to the health protection services. sector is low, and the country faces huge financing gaps to address health needs. 57. Malawi has made substantial efforts in Health is the third priority in government further incorporating health into the country’s spending, after education and agriculture, policies and strategies to address climate constituting 9.3 percent of the total budget change. Yet despite health being identified in in 2020/2021 (which includes COVID-19 many of the climate change policies and plans spending). However, this still falls behind the included above, there are few health sector Abuja Declaration target for African states to policies where climate change is addressed as allocate 15 percent of the total budget to the a challenge or prioritized for strategic planning. health sector. By the 2017/2018 period, the Further, the engagement of MoH appears to be government’s health allocation (USD528.3 limited and the coordination mechanisms for million) fell behind by 66 percent of the supporting climate change and health actions required budget, according to the HSSP II. seem to be ineffective. Although a health-cli- Although there has been an improvement in mate core group comprising actors from MoH, the 2020/2021 period, the gap still represents among others, has been formed, strategic 48 percent of the required budget. planning remains absent, and a national climate change and health-specific strategy / action The low public funding to the health sector plan has not been developed. Furthermore, poses a significant challenge in ensuring while policy makers have demonstrated an sufficient drugs, equipment, labor, and infra- awareness of the health impacts of climate structure for adequate service provision. It change, the engagement of MoH with its is not helped by the fact that more than half climate change, disaster risk management, of the public funds are spent on personnel and agriculture counterparts has been slow.  emoluments, leading to low expenditures on drugs and medical supplies.92 Within the 58. At the subnational level, the development of context of Africa, Malawi’s public spending policies and plans to address climate-related on drugs (16 percent) is lower than the share health risks is lacking. Although MoH has spent by other African countries, with health developed district-level operational plans, facilities in the country having only 38 percent so far, climate change and health in these of the essential medicines in 2019. Finally, only subnational plans have not been well-inte- half of the required health infrastructure is grated into local-level planning initiatives. available, even though spending in this area Regions that are highly vulnerable to had increased from 5 percent in FY2014/2015 climate-related hazards, such as the Southern to 16 percent in FY2015/2016. Region, would require tailored programs and strategic planning in order to address the 60. Malawi is among the most donor-dependent compounded effect of different climate hazards countries in the world, but donor funds Adaptive Capacity of the Health System | 37 are off-budget and may not be aligned to ment’s share in 2019 was 32.59 percent, national priorities. For FY2017–2018, the while private health expenditure was 23.84 country’s health budget was USD639 million, percent. Although the government and the of which 75 percent (USD477 million) came private health expenditure have a higher share from external partners in bilateral and multilat- of the total current health expenditure, the eral contexts, nongovernmental organizations out-of-pocket (OOP) expenditure increased (NGOs), private companies, and private indi- by approximately 60 percent between 2013 viduals.93 The government contribution is and 2019. Specifically, the OOP expenditure estimated to be around 25 percent (USD163 increased from 6.71 percent as a share of million). Overall, the budget is derived from current health expenditure in 2013 to 16.86 the following financing sources: (a) the Global percent by 2019.97 Although the share of Fund (28 percent), (b) MoH (25.3 percent), the OOP expenditure is lower than the (c) the United States (US) (16.5 percent), (d) recommended WHO threshold of 20 percent, the Health Services Joint Fund (HSJF) (5.6 the increase in the OOP expenditure burden percent), (e) the United Kingdom (UK) (5.1 likely hampers the access of poor households, percent), (f) the World Bank (3.9 percent), who have low disposable income, to health and other financing sources (15.7 percent).94 services. Moreover, international financing and aid 62. There is insufficient funding to cover Malawi’s tend to be detached from a national plan, EHP that is aimed at achieving universal due to the absence of a systemic approach coverage, and risk pooling does not appear of consolidating the information on the contri- to account for climate vulnerabilities. As butions and the programs from foreign aid part of its goal toward achieving universal and NGOs. Malawi’s health financing gap is healthcare coverage,98 Malawi has in place covered by donors, who typically allocate the EHP that seeks to provide free health resources to communities through off-budget care and covers the following conditions: (a) means. Off-budget resource allocations 95 reproductive, maternal, neonatal, and children complexify health financing, as resources health; (b) vaccines for preventable diseases; are hard to track and might not be aligned (c) malaria; (d) the integrated management with national health priorities. Despite donors of childhood illnesses (such as diarrheal contributing substantial resources to cover the diseases and nutrition); (e) community health; health sector’s financing gap, there is a need (f) neglected tropical diseases (NTDs); (g) HIV / to better coordinate and align donor resources AIDS; (h) nutrition; (i) TB; ( j) NCDs (such as with MoH’s priorities to improve transparency, mental health and diabetes); and (k) oral better access, and the equitable distribution health. However, the EHP does not have of healthcare. sufficient funding to cover the care outlined in the benefits package. 61. The financial burden of health expendi- tures on households has been increasing. Furthermore, the EHP does not appear to take Malawi’s health finance system comprises climate vulnerability into consideration. The resources from the government, donors, the climate vulnerability differences of the different private sector, and households.96 In terms of population groups are not integrated with risks the current health expenditure, the govern- for diseases, such as malaria, nutrition risks, or 38 | Climate and Health Vulnerability Assessment: Malawi mental disorders; in that sense, it is not clear nutrition risks (causing the highest burden of if the EHP considers climate-related risks for disease in the country) do not have a budget these diseases.99, 100 line in the government’s budget allocation strategy. Instead, the country is dependent In general terms, illnesses and health care on donors, which tend to have their own costs are not evenly distributed, with some objectives in finance planning. Considering population groups facing higher health risks, that food insecurity and malnutrition are a which may be exacerbated by climate change. historic challenge in Malawi, it is pivotal to Climate change can intensify underlying health develop a financing strategy to improve burdens, while increasing the potential and resource allocations and pooling for nutrition size of certain catastrophic financial health management. risks, especially among the most vulnerable. Therefore, structuring spending to support 64. The health co-benefits of climate change the most vulnerable to climate change and mitigation have not been adequately hazards can improve human capital outcomes promoted as cost-effective options in the in the country. health sector. The arguments for implementing climate change mitigation policies are often 63. Although environmental health is incorpo- focused on perceived short-term financial costs. rated as a health financing priority, MoH does However, cost assessments rarely account not seem to have committed an allocation for the health co-benefits of these policies, for addressing the impacts of climate change resilience strengthening, and the outcomes on health and the health system. Although for human health, while also reducing costs there is a commitment in the NAP to climate for the health sector. Therefore, additional change for addressing climate-related health studies are needed to quantify the longer-term risks, there is no precise strategic planning for cost savings through the health co-benefits climate-health finance and resource allocations of climate change adaptation and mitigation for climate-related health risks and vulnera- policies in Malawi. bilities. Building resilient health systems for climate change requires the budget allocation to be an integrated component in the overall HEALTH WORKFORCE planning of a national health plan. 65. Despite considerable investments to improve health service delivery, there are ongoing Furthermore, while Malawi has prioritized challenges in training, recruiting, and climate change projects — mostly on resilience maintaining an adequate health workforce. in food production systems / agriculture, To address the shortages of skilled workers in water management and irrigation, and the public health sector, MoH, with the support climate information systems, these efforts of the Ministry of Finance, the Global Fund, and are being developed without incorporating the Department for International Development health outcomes into their strategic planning. (DFID), introduced the six-year Emergency Guidelines for integrating a climate-resilient Human Resources Program (EHRP)101 in 2004, approach for health care and public health which led to an increase in the number of systems are not available to ensure ratio- skilled health workers by 53 percent (8,369 in nalized resource allocations. For example, 2009 from 5,453 in 2004).102 Similar strategies Adaptive Capacity of the Health System | 39 to improve health services and systems include Furthermore, a healthcare needs assessment the Program of Work 2004–2010, the HSSP and census in the health sector is not 2011–2016, the human resources for health conducted on a routine basis, which is crucial (HRH) strategic plan,103 HSSP II 2017–2022,104 for ensuring the equal distribution of skilled and the HRH2030 program of the United health workers and identifying healthcare States Agency for International Development needs. Among the eight selected essential (USAID) and CHAM. health staff positions, just 17,298 of the 25,755 positions were filled in 2016, leaving 33 Although Malawi’s six-year EHRP achieved its percent of the positions vacant (Table 7). As the main goal of increasing the health workforce, population continues to expand, coupled with the achievements were not sustained due climate change-related healthcare challenges, to a lack of appropriate strategic planning. needs assessments are and will continue to Overall, the recruitment of healthcare workers be vital to the (re)distribution of health workers to meet service delivery demand has and will to meet healthcare needs. continue to be limited by the availability of fiscal resources available to MoH. 67. The labor conditions of health workers have curtailed the health workforce capacity. The 66. There are significant staffing gaps in the recruitment and retention of skilled health number of skilled health workers and their workers — especially in higher cadres, including geographical distribution throughout the medical and clinical officers, nursing officers, country. According to WHO’s recommended and nurse-midwives — is an ongoing challenge. Sustainable Development Goals (SDG) index This is mainly attributed to low salaries, heavy threshold of 4.45 skilled health workers workloads, poor working conditions, a lack (physicians, nurses, and midwives) per 1,000 of medical supplies / resources, and poor population, Malawi is in the critical shortage management, along with a lack of housing, zone: it has just 0.019 doctors and 0.283 nurses transport, and allowances.108 In 2000, the and midwives per 1,000 population.105 healthcare system suffered a drastic decline in the number of skilled health workers due There is an estimated shortage of at least to emigration, low pay, and poor working 7,000 CHWs, with an overall unequal distri- conditions.109 This led to an overburdened bution of skilled health workers between rural and understaffed public health system, thus and urban areas.106 According to MoH’s HRH affecting the coverage and quality of health country profile for 2008, 95 percent of the services. Furthermore, the migration of skilled specialist medical practitioners, 77 percent of health workers for better job opportunities the general medical practitioners, 79 percent within and outside the country has created of the paramedical practitioners, 71 percent of staffing gaps within Malawi’s health system the nursing professionals, 79 percent of the and created gaps in the service delivery medical imaging and therapeutic equipment to rural populations. The health impacts of operators, and 75 percent of the environmental climate change will further strain the capacity health officers practiced in urban areas.107 In of health workers, due to an increase in the the public health sector, there are gaps in the burden of disease. human resource capacity across the different essential cadres, levels, and regions. 40 | Climate and Health Vulnerability Assessment: Malawi TABLE 7. Vacancy rate of eight selected essential health staff per established position for MoH and CHAM CADRE ESTABLISHMENT FILLED VACANT % VACANT Medical Officer 398 284 114 29% Clinical Officer 3,135 1,159 1,976 63% Nursing Officer 3,275 1,098 2,177 66% Nurse Midwife Technician 8,626 3,475 5,151 60% Medical Assistant 1,506 1,199 307 20% Pharmacy Technician 1,063 218 845 79% Lab Technician 1,053 397 656 62% Health Surveillance 6,699 9,468 (2,769) -41% Assistants Total 25,755 17,298 8,457 33% Source: Government of Malawi (2017) Health Sector Strategic Plan II - 2017-2022. https://extranet.who.int/countryplanning- cycles/sites/default/files/planning_cycle_repository/malawi/health_sector_strategic_plan_ii_030417_smt_dps.pdf. 68. Malawi has limited in-country human resource Agriculture and Natural Resources (LUANAR) capacity, with few medical training institu- and the School of Public Health and Family tions and teaching hospitals. The country Medicine at the University of Malawi revealed has only one medical school — the University that overall, health workers lacked training on of Malawi College of Medicine (UMCM) — climate change and its impacts on health, as and 18 nursing training schools with a limited well as climate change and gender-based number of medical courses.110 The in-country health inequalities.112 training of the cohort of doctors in family medicine began only in 2015.111 At the current 69. The extent to which Malawi’s health workforce rate, the production of skilled health workers has adequate knowledge, technical capacity, is not adequate to meet the health needs of and resources to prevent and manage current a population that is increasing at a rate of 2.9 and future climate change-related health percent per year and projected to double by risks is largely uncertain. Healthcare profes- 2042. Further, the lack of adequate on-the-job sionals and CHWs lack adequate skills and trainings, continuous education, and career competencies to attend to patients showing up development makes the provision of health with unfamiliar climate-related health issues, care challenging. including respiratory illnesses, allergies, mental health, and diarrhea. There is a lack of evidence In a country with limited health professionals, on the knowledge and capacity of Malawi’s short refresher training courses are crucial health workforce to deal with climate health to keep the available health workers up to risks and the awareness of risks. Although date on public health needs, including those there is some level of integration of climate directly related to climate change. The results in the national health policy and planning, of a training needs assessment on climate little is known about the existence of capacity and gender by the Lilongwe University of development programs that train the health Adaptive Capacity of the Health System | 41 workforce to identify, prevent, and manage 72. Malawi has already developed a climate- climate health risks. Evidence shows that health vulnerability assessment and is aiming climate change will be a key defining factor at updating and expanding its scope. The for health systems in the 21st century; yet no assessment identified gaps in the HIS and assessment on climate change knowledge research, namely, the relationship between and the health workforce’s ability to identify VBDs and climate, the capacity of the health climate health risks has been conducted. sector to address the current and future climate, the integration of weather and climate information systems into health projects and strategic planning, along with the incorporation HEALTH INFORMATION SYSTEMS of Indigenous knowledge and practices.118 70. Health information systems (HIS) in Malawi Overall, the information, monitoring, and are incorporated as a key pillar into the HSSP surveillance systems in Malawi, which have II. MoH gathers data by following the main been identified as an area to be strengthened, guidelines: (a) the HSSP II and guidelines in are included in MoH’s HSSP II 2017–2022.119 the monitoring and evaluation section;113 (b) the Malawi Monitoring and Evaluation Task 73. The Department of Climate Change and Force Priorities 2017–2021; (c) the Malawi Meteorological Services, together with the National Health Indicators Handbook;114 (d) the United Nations Development Programme Malawi National Health Information System (UNDP), is currently working on a project Policy;115 (e) the WHO’s global reference list to scale up the use of modernized climate of 100 Core Health Indicators;116 and (f) the information for early warning systems and Health Management Indicators System (HMIS) integrating the data with food-insecure that includes the District Health Information departments and DRM and prepared- Software (DHIS 2). ness.120,121 The project is aimed at (a) providing tailored climate-based agricultural advisories 71. The Epidemiology Unit at MoH is responsible for 14 food-insecure districts; (b) scaling up for integrated disease surveillance and community-based early warning systems in communities that are vulnerable to floods, while response (IDSR): it monitors 15 diseases, strengthening the capacities for emergency including climate-related health risks such response; (c) expanding hydrometeorological as VBDs and WBDs. However, it is not clear monitoring stations in order to improve flood if climate data, including the projections of monitoring and water resource planning and temperature and precipitation patterns and management; and (d) installing 34 automatic change, are integrated into IDSR or how it weather stations to improve the coverage of is used in strategic planning. Researchers existing forecasting capabilities by providing highlighted that the current IDSR has proven information on extreme weather events. to be extensive, in terms of the data it gathers, but it faces challenges around timeliness and Although the project includes working with implementation, mostly due to the lack of food-insecure districts and flood-prone areas, capacity for case identification, as well as there is no integration with MoH in order to the compilation and submission of reports.117 integrate data from early warning systems with health outcomes, such as direct morbidity 42 | Climate and Health Vulnerability Assessment: Malawi and mortality from extreme weather events the availability of laboratory and imaging or nutritional risks. Other projects including services throughout the country signifi- the Capacity Building for Managing Climate cantly. Malawi’s National Medical Laboratory Change in Malawi programme are being policy and strategic plans were developed developed, with the support of international to support laboratory services in the public stakeholders; they are focused on enhancing healthcare system and ensure patient safety the HMIS and integrating climate information and quality diagnostics. The highlighted areas with health planning, research, and responses of support included laboratory regulation, to climate-related health risks.122,123,124 quality assurance, safety, ethics, research and development, monitoring and evaluation, laboratory premises, human resources, ESSENTIAL MEDICAL PRODUCTS financing and budgeting, medical laboratory AND TECHNOLOGIES service provision, laboratory equipment and supplies, as well as the management and 74. Malawi has historically experienced regular organization of laboratory services.127 shortages of essential medical products. In FY2015/2016, less than 25 percent of the However, gaps and challenges remain. health facilities across the country could Although there are several laboratories in maintain adequate stock to cover 23 HSSP Malawi, including more than 211 laboratories I tracer medicine and medical supplies for 1–3 owned by MoH and CHAM,128 only 10 of them months. These shortages have been attrib- have international accreditation. According to utable to weak supply chain management USAID’s assessment of Malawi’s laboratory and persistent stockouts, inadequate funding, services and supply chain, the laboratories irrational prescriptions, leakages, and regular lacked standard operating procedures (SOPs) pilferages. The management, warehousing, for some diseases, or they were not available and storage of health products constitute at all in the laboratories, nor did they have additional challenges across all levels of the SOPs for the proper disposal of expired or health system.125 unused items. The increased disease burden, due to climate hazards, is likely to overwhelm To expedite the management of medical the poorly equipped laboratories, thus causing supplies, MoH, with support from UNDP, more shortages in testing supplies. recently launched the Electronic Health Information Network (eHIN) in three districts, with the intention of expanding it to all health facilities later. eHIN utilizes mobile technology HEALTH SERVICE DELIVERY to track medicines from the Central Medical 76. Health service delivery in Malawi is Stores Trust to end-users in real time; its aim challenged by the regular stockouts of is to better deal with the expiry of medicines, essential medicines, the lack of equipment, reduce stockouts, as well as improve account- and the shortage of skilled health workers. ability and transparency.126 The reintroduction of user fees in some CHAM health facilities is also a hindrance to the 75. Weak quality assurance and accredita- access of health services for women and the tion, coupled with inadequate biosafety poor who cannot afford to pay.129 The high and biosecurity mechanisms, are affecting prevalence of informal payments in public Adaptive Capacity of the Health System | 43 health facilities further widens inequalities in 79. There is a lack of comprehensive integration health care access and violates the right of of climate change in the health sector’s poor people to obtain free health services.130 policies, strategic planning, and programming. In the Malawi HSSP I (2011–2016), climate is 77. Inequalities in the accessibility of healthcare briefly mentioned as a threat to health, but persist, due to poor transport and the lack of no action plans are outlined.Climate and ambulances for emergencies, and these are related hazards are not mentioned in the likely to be exacerbated by climate hazards. Malawi HSSP II (2017–2022).As climate is There are barriers associated with both the not included in the health sector’s planning availability and affordability of transportation and program, this means that no budget line to health facilities, especially for the rural is allocated to account for climate impacts on population. The distance is even longer health at the national level, thus undermining (median of 2.5 hours to a district hospital) for the health system’s capacity to respond to specialized health services, including access climate health risks.   to surgical services.131 The limited access to healthcare is a major contributor to under-five 80. The country’s health infrastructure is weak; mortality in rural Malawi.132 In Southern and its inability to withstand climate change Central Malawi, where floods are common, the shocks thus affects healthcare service access to public health facilities is compara- delivery adversely. In the aftermath of Tropical tively more challenging due to damaged and Storm Ana, a situation analysis in the Nsanje impassable roads.133 and Chikwawa districts revealed that 19 out of the 23 health facilities were inoperable, 78. There are geographical inequalities in the due to infrastructure damage, flooding, and distribution of higher-level public health destroyed medical supplies, thereby leaving facilities between rural and urban areas. only four health facilities operational and Laboratory, surgery, and specialized services people desperate for healthcare. Furthermore, are provided at the district hospitals, which are these four facilities struggled to keep their often too far away from rural populations.134,135 medical equipment functioning due to power Private clinics offer services at a cost that is outages. In a limited-resource and climate-vul- not affordable by the majority of the poor.136 nerable country like Malawi, the lack of a Health facilities in rural areas — especially for climate-resilient and sustainable health care treating some illnesses like mental disorders, infrastructure will exacerbate geograph- and delivering services such as diagnostic ical health disparities and compromise the imaging and radiology, as well as maternity, quality of health service delivery, particu- services — are limited. This reality forces larly in the flood-prone regions of southern people to visit THs, herbalists, and TBAs, Malawi. However, in the absence of climate who are not trained to provide skilled health resiliency assessments of healthcare facilities services, which can lead to complications and health infrastructure, the magnitude of the and premature deaths.137 service delivery risk due to climate change remains uncertain. 44 | Climate and Health Vulnerability Assessment: Malawi TABLE 8. Summary of the Health System Adaptive Capacity Gaps for Malawi BUILDING BLOCK SUMMARY OF GAPS IN ADAPTIVE CAPACITY Leadership and • The prioritization of climate change, health risks, and adaptation options in the Governance national policies and plans remains varied, with less specificity from MoH on strategic planning for climate change effects on health outcomes. • The engagement of MoH is limited, with coordination mechanisms to facilitate integrated, cross-sectoral action on climate change ineffective. • There is a lack of policies and plans at the subnational level to address cli- mate-related health risks. Health Workforce • The health sector faces an imbalance in the number, skill mix, and deployment of the health workforce, including large urban-rural disparities. • The EHRP suffers from a lack of sustainable planning. • On-the-job training, continuous education, and career development plans are insufficient, and they do not account for the impact of climate-related events on health and the health system. • The overdependence on NGOs and other international stakeholders for capacity building, due to the lack of financing commitments from Malawi Ministry of Health, increases the burden of high workload, burnout and stress on health workers. Health Information and • The climate data produced by the Department of Climate Change and Meteoro- Disease Surveillance logical Services are not well-integrated into MoH’s activities. Systems • The IDSR lacks the capacities for case identification, as well as for collating and organizing reports and data. Essential Medical • The regular shortages of essential medical products are a pervasive challenge. Products and Further, the management, warehousing, and storage of available health products Technologies pose additional challenges that impede quality service delivery. • Weak quality assurance and accreditation, coupled with inadequate biosafety and biosecurity mechanisms, significantly affect the availability of laboratory and imaging services. Health Service • Inequalities in the accessibility of health care persist due to poor transport and a Delivery lack of ambulances for emergencies. • There are geographical inequalities in the distribution of higher-level public health facilities between rural and urban areas. • Climate change and associated impacts are not mainstreamed into the opera- tions of health programs at all levels. • Climate-resilient healthcare facilities and health infrastructure assessments are lacking; this makes assessing the magnitude of the climate change impact on service delivery especially challenging. Health Financing • There is no evident MoH budget allocation dedicated to addressing climate change’s impacts on health and the health system. • Risk pooling in Malawi does not account for climate vulnerability differences among the different population groups. • Guidelines for integrating the climate-resilient approach for health care and the public health systems are not available to ensure rationalized resource alloca- tions. Adaptive Capacity of the Health System | 45 SECTION V. RECOMMENDATIONS TO ENHANCE HEALTH SYSTEM RESILIENCE TO CLIMATE CHANGE 81. This section outlines a set of recommendations for enhancing Malawi’s health system resilience and adaptation to climate change, including the 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 and the existing gaps in adaptive capacity to manage and / or prevent these risks. This section is organized by using the 10 components of climate-resilient health systems (Figure 8) and drawing from con- sultations and the review of all relevant governmental policies. See Annex C for a summary of the recommendations for building a climate-resilient health system across the identified climate change-related health risks. COMPONENT 1. implementing projects and program on climate change and/or health in the country. LEADERSHIP AND GOVERNANCE → Enhance the coordination mechanisms for → Articulate climate-health actions in sub- climate action, championed by MoH and the national plans. While national plans that HCCT, to liaise with stakeholders inside and consider climate-health risks have been outside the health sector.138 It is recommended developed (see Section 4), subnational that the key areas of focus include (a) planning is far from comprehensive. It is developing further strategies that integrate recommended that MoH develop specific and build knowledge on climate-related strategic planning for climate-related health health risks into MoH’s operational planning; risks that account for subnational differences (b) monitoring progress from strategies and in climate-related exposures (see Section action plans, such as the Climate Change and 2), highlighting the resilience of healthcare Health National Strategy and Action Plan, service delivery. Further, such policies and the NDCs, and the long-term strategies; and plans should work to address climate-related (c) ensuring the alignment of development health risks specific to urban and rural areas partners and other organizations that are also within each region. 47 FIGURE 8. WHO’s Operational Framework for Building Climate-Resilient Health Systems ATE RESILIENCE CLIM hip & Heal eaders nce Workf th L verna orce Go V uln pac ation t Fin alth & A Ca pt en He ate era ity & Leadership As g da essm Clim cin bil & Governance Health s ity, an Workforce Financing Preparedness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential C li o r m e h Re ima & I n f a lt s Medical ma d C l a lt h se te Products & h He ra m Pro te a rc He Technologies - g Ma nt na Env ge m ent o R e s ili e f C li m a t e le ir o n in a b D et m ental & S u st a gies ri m e lo of H n ts Techno cture e a lt h I n f r a s tr u & Source: World Health Organization, 2015, Operational Framework for Building Climate Resilient Health Systems. COMPONENT 2. HEALTH WORKFORCE and health and incorporate it as part of the medical and paramedical curricula → Create and promote health workforce (targeted at medical professionals, including retention packages to ensure that there are nursing professionals and CHWs) at higher sufficient skilled health workers in areas at education and vocational institutions. It is the highest risk of climate-related hazards. further recommended that regular refresher The retention packages should also include courses for continued learning and on-the-job risk reduction and emergency protocols, as training opportunities be made available. well as proper housing and basic services National curriculum and refresher courses for health workers (and communities). would benefit from climate-health vulnera- → Scale up the formal pedagogical training bility assessments and the prioritization of developed by Malawi’s HCCT on climate key climate-related health risks. 48 | Climate and Health Vulnerability Assessment: Malawi COMPONENT 4. INTEGRATE RISK → Engage medical colleges and the Ministry of Education (MoE) and integrate with MONITORING AND EARLY WARNING district-level community groups to support → Strengthen communication networks dialogues, awareness, and the development between the Department of Climate Change of prospective climate and health programs, and Meteorological Services (DoCCMS) such as health promotion programs and the communities at risk for extreme focused on climate-related health risks. weather events. While DoCCMS possesses The engagement could include the use of the information necessary to provide at-risk mainstream media or community-level climate communities with advance warning of extreme and health training modules. climate events, warning messages often do not reach at-risk communities, with sufficient time for adequate preparation. Options for COMPONENT 10. CLIMATE & HEALTH strengthening communication may include FINANCING (a) push notifications (both in English and Chichewa) to mobile users in anticipation of → Ensure strategic health purchasing that meteorological events through a partnership includes considerations for climate- with Airtel; and / or (b) coordination with broad- related health risks. It is recommended that casting stations (for example, Zodiac) to relay the government moves toward a provider warning messages to listeners. payment mechanism to incentivize healthcare providers with regards to managing and treating climate sensitive diseases, partic- COMPONENT 7. MANAGEMENT OF THE ularly for the Southern Region that is most vulnerable to climate change impacts. The ENVIRONMENTAL DETERMINANTS OF mechanism should be guided by detailed, HEALTH subnational climate information on population needs related to ongoing climate exposures. → Support community-led efforts to improve sanitation practices and controls to prevent WBDs and foodborne illnesses and diseases, as well as communicate the potential climate change-related health risks. It is recommended that such efforts include educational materials and communication on the hazards of open defecation, as this issue relates to water quality and WBD risks, especially among the rural communities and for those residing in temporary disaster shelters after extreme weather events. Recommendations to Enhance Health System Resilience to Climate Change | 49 ANNEXES ANNEX A. METHODS FOR THE ESTIMATION OF MOSQUITO SUITABILITY IN MALAWI, UNDER RCP 8.5 MODEL CONSTRUCTION The spatio-temporal distributions of Anopheles (An.) gambiae s.s., An. funestus, and An. arabiensis mosquitoes were determined, using a raster-based suitability model constructed in Google Earth Engine by adapting methodology presented by Frake et al.139 This methodology uses abiotic variables specific to the thermal tolerances of vector species and biotic variables that give consideration to the species’ habitat preferences. Suitable areas are defined as patches of landscape that facilitate the development of malaria mosquitoes through the production and persistence of oviposition sites, and where temperatures do not exceed or fall below thermal tolerances. Parameter thresholds for all input variables were selected based on a literature review of An. gambiae s.s., An. funestus, and An. arabiensis habitats: temperature, land cover, precipitation, flow accumulation, and water resources (Table A1). Thresholds were then used to create binary maps for each predictor (that is, suitable [1] or unsuitable [0]) that were combined by using the Boolean logic to produce suitability maps across three epochs. They are the historical reference period (1986–2005), 2030–2049, and 2040–2059, during Malawi’s historic malaria trans- mission period of November to April.140 Population vulnerability was demonstrated by spatially overlaying suitability maps for malaria mosquitoes in Malawi with the population data from the Global Human Settlement Layers (2015) to calculate the number of people residing in suitable areas, by region. Population data were held constant in all models, in the absence of spatial population projection data. The output spatial resolution of products is 1,000 m: this analysis is performed at the landscape, not the microscale, level. Microscale variations in climatology, as well as LULC, can and do affect the species’ actual distributions. 51 TABLE A1. Model parameterization and data sources for habitat characterization INDICATOR DATA SOURCE PRODUCT SPATIAL THRESHOLD RESOLUTION Temperature The National Aero- NEX-GDDP 0.25 degrees An. gambiae s.s. nautics and Space Min: 18°C Administration Max: 34°C (NASA) An. arabiensis Min: 13°C Max: 35°C An. funestus Min: 14°C Max: 35°C Land Cover Copernicus Global Proba-V-C3 100 m See Table A2* Land Service Water Joint Research GSW1_0 30 m > 0% water occur- Resources Centre (JRC) rence Flow Accumu- World Wildlife Fund HydroSHEDS 500 m lation (WWF) Population JRC GHSL/P2016/POP_GPW_ GLOBE_V1 SUITABILITY DATA AND PARAMETERS Temperature Temperature is critical in the development and life history of mosquitoes. Temperatures that are either too low or too high can increase the mortality during the aquatic or adult stages. Bayoh and Lindsay141 demonstrated that the upper and lower thresholds for the aquatic development of An. gambiae s.s. were 18°C and 34°C, respectively. In the case of An. arabiensis and An. Funestus, the lower development thresholds have been demonstrated at 13°C and 14°C, respectively, while the upper limits are 35°C for both species.142 Data were acquired from the NASA NEX-GDDP at a 0.25-degree spatial resolution. Land Use and Land Cover (LULC) There is a significant relationship between LULC and the distribution of mosquito species, with many species demonstrating strong preferences for specific land cover types. LULC data were acquired from the Copernicus Global Land Service Proba-V-c3 product. To determine whether classes were suitable for An. gambiae s.s., An. funestus, An. arabiensis mosquitoes, class descriptions were compared to the habitat preferences of the species, according to the literature review. To account for these species preferences, Proba class values, 20, 30, 40, 50, 60, 90, 111, 112, 113, 114, 115, 116, 121, 122, 123, 124, 125, and 126 were set to “suitable” (Tables A2-A4). 52 | Climate and Health Vulnerability Assessment: Malawi TABLE A2. Copernicus Global Land Cover Layers: CG:S-LC100 Collection 2 Global Landcover Map Classifications for Anopheles gambiae s.s. CLASS CLASS DESCRIPTION SUITABLE AN. VALUE GAMBIAE S.L. LAND COVER 0 Unknown. No or not enough satellite data available. No 20 Shrubs. Woody perennial plants with persistent and woody stems, and without Yes any defined main stem being less than 5 m tall. The shrub foliage can be either evergreen or deciduous. 30 Herbaceous vegetation. Plants without persistent stems or shoots above the ground Yes and lacking a definite firm structure. Tree and shrub cover is less than 10%. 40 Cultivated and managed vegetation / agriculture. Lands covered with temporary Yes crops, followed by harvest and a bare soil period (for example, single and multiple cropping systems). Note that perennial woody crops will be classified as the appro- priate forest or shrub land cover type. 50 Urban / built-up. Land covered by buildings and other constructed structures. Yes 60 Bare / sparse vegetation. Lands with exposed soil, sand, or rocks, and vegetation Yes cover never more than 10% during any time of the year. 70 Snow and ice. Lands under snow or ice cover throughout the year. No 80 Permanent water bodies. Lakes, reservoirs, and rivers. Can be either freshwater or No saltwater bodies. 90 Herbaceous wetland. Lands with a permanent mixture of water and herbaceous / Yes woody vegetation. The vegetation can be present in salt, brackish, or fresh water. 100 Moss and lichen. No 111 Closed forest, evergreen needle leaf. Tree canopy > 70%, almost all needle leaf trees Yes remain green all year. Canopy is never without green foliage. 112 Closed forest, evergreen broadleaf. Tree canopy > 70%, almost all broadleaf trees Yes remain green year-round. Canopy is never without green foliage. 113 Closed forest, deciduous needle leaf. Tree canopy > 70%, consists of seasonal Yes needle leaf tree communities with an annual cycle of leaf-on and leaf-off periods. 114 Closed forest, deciduous broad leaf. Tree canopy > 70%, consists of seasonal Yes broadleaf tree communities with an annual cycle of leaf-on and leaf-off periods. 115 Closed forest, mixed. Yes 116 Closed forest, not matching any of the other definitions. Yes 121 Open forest, evergreen needle leaf. Top layer — trees 15–70% and second layer — Yes mixture of shrubs and grassland, almost all needle leaf trees remaining green all year. Canopy is never without green foliage. 122 Open forest, evergreen broad leaf. Top layer — trees 15–70% and second layer — Yes mixture of shrubs and grassland, almost all broadleaf trees remaining green year- round. Canopy is never without green foliage. 123 Open forest, deciduous needle leaf. Top layer — trees 15–70% and second layer — Yes mixture of shrubs and grassland, consists of seasonal needle leaf tree communities with an annual cycle of leaf-on and leaf-off periods. Annexes | 53 124 Open forest, deciduous broadleaf. Top layer — trees 15–70% and second layer — Yes mixture of shrubs and grassland, consists of seasonal broadleaf tree communities with an annual cycle of leaf-on and leaf-off periods. 125 Open forest, mixed. Yes 126 Open forest, not matching any of the other definitions. Yes 200 Oceans, seas. Can be either freshwater or saltwater bodies. No TABLE A3. Copernicus Global Land Cover Layers: CG:S-LC100 Collection 2 Global Landcover Map Classifications for Anopheles arabiensis CLASS CLASS DESCRIPTION SUITABLE AN. VALUE GAMBIAE S.L. LAND COVER 0 Unknown. No or not enough satellite data available. No 20 Shrubs. Woody perennial plants with persistent and woody stems, and without Yes any defined main stem being less than 5 m tall. The shrub foliage can be either evergreen or deciduous. 30 Herbaceous vegetation. Plants without persistent stems or shoots above the ground Yes and a lacking definite firm structure. Tree and shrub cover is less than 10%. 40 Cultivated and managed vegetation / agriculture. Lands covered with temporary Yes crops, followed by harvest and a bare soil period (for example, single and multiple cropping systems). Note that perennial woody crops will be classified as the appro- priate forest or shrub land cover type. 50 Urban / built-up. Land covered by buildings and other constructed structures. Yes 60 Bare / sparse vegetation. Lands with exposed soil, sand, or rocks, and vegetation Yes cover never more than 10% during any time of the year. 70 Snow and ice. Lands under snow or ice cover throughout the year. No 80 Permanent water bodies. Lakes, reservoirs, and rivers. Can be either freshwater or No saltwater bodies. 90 Herbaceous wetland. Lands with a permanent mixture of water and herbaceous / Yes woody vegetation. The vegetation can be present in salt, brackish, or fresh water. 100 Moss and lichen. No 111 Closed forest, evergreen needle leaf. Tree canopy > 70%, almost all needle leaf trees No remaining green all year. Canopy is never without green foliage. 112 Closed forest, evergreen broadleaf. Tree canopy > 70%, almost all broadleaf trees No remaining green year-round. Canopy is never without green foliage. 113 Closed forest, deciduous needle leaf. Tree canopy > 70%, consists of seasonal No needle leaf tree communities with an annual cycle of leaf-on and leaf-off periods. 114 Closed forest, deciduous broadleaf. Tree canopy > 70%, consists of seasonal No broadleaf tree communities with an annual cycle of leaf-on and leaf-off periods. 115 Closed forest, mixed. No 116 Closed forest, not matching any of the other definitions. No 54 | Climate and Health Vulnerability Assessment: Malawi 121 Open forest, evergreen needle leaf. Top layer — trees 15–70% and second layer — No mixed shrubs and grassland, almost all needle leaf trees remaining green all year. Canopy is never without green foliage. 122 Open forest, evergreen broad leaf. Top layer — trees 15–70% and second layer — No mixed shrubs and grassland, almost all broadleaf trees remaining green year-round. Canopy is never without green foliage. 123 Open forest, deciduous needle leaf. Top layer — trees 15–70% and second layer — No mixed shrubs and grassland, consists of seasonal needle leaf tree communities with an annual cycle of leaf-on and leaf-off periods. 124 Open forest, deciduous broadleaf. Top layer — trees 15–70% and second layer — No mixed shrubs and grassland, consists of seasonal broadleaf tree communities with an annual cycle of leaf-on and leaf-off periods. 125 Open forest, mixed. Yes 126 Open forest, not matching any of the other definitions. Yes 200 Oceans, seas. Can be either freshwater or saltwater bodies. No TABLE A4. Copernicus Global Land Cover Layers: CG:S-LC100 Collection 2 Global Landcover Map Classifications for An. funestus CLASS CLASS DESCRIPTION SUITABLE AN. VALUE GAMBIAE S.L. LAND COVER 0 Unknown. No or not enough satellite data available. No 20 Shrubs. Woody perennial plants with persistent and woody stems, and without Yes any defined main stem being less than 5 m tall. The shrub foliage can be either evergreen or deciduous. 30 Herbaceous vegetation. Plants without persistent stems or shoots above the ground Yes and lacking a definite firm structure. Tree and shrub cover is less than 10%. 40 Cultivated and managed vegetation / agriculture. Lands covered with temporary Yes crops, followed by harvest and a bare soil period (for example, single and multiple cropping systems). Note that perennial woody crops will be classified as the appro- priate forest or shrub land cover type. 50 Urban / built-up. Land covered by buildings and other constructed structures. Yes 60 Bare / sparse vegetation. Lands with exposed soil, sand, or rocks, and vegetation No cover never more than 10% during any time of the year. 70 Snow and ice. Lands under snow or ice cover throughout the year. No 80 Permanent water bodies. Lakes, reservoirs, and rivers. Can be either freshwater or No saltwater bodies. 90 Herbaceous wetland. Lands with a permanent mixture of water and herbaceous / Yes woody vegetation. The vegetation can be present in salt, brackish, or fresh water. 100 Moss and lichen. No 111 Closed forest, evergreen needle leaf. Tree canopy > 70%, almost all needle leaf trees Yes remaining green all year. Canopy is never without green foliage. 112 Closed forest, evergreen broadleaf. Tree canopy > 70%, almost all broadleaf trees Yes remaining green year-round. Canopy is never without green foliage. Annexes | 55 113 Closed forest, deciduous needle leaf. Tree canopy > 70%, consists of seasonal Yes needle leaf tree communities with an annual cycle of leaf-on and leaf-off periods. 114 Closed forest, deciduous broadleaf. Tree canopy > 70%, consists of seasonal Yes broadleaf tree communities with an annual cycle of leaf-on and leaf-off periods. 115 Closed forest, mixed. Yes 116 Closed forest, not matching any of the other definitions. Yes 121 Open forest, evergreen needle leaf. Top layer — trees 15–70% and second layer Yes — mixed shrubs and grassland, almost all needle leaf trees remain green all year. Canopy is never without green foliage. 122 Open forest, evergreen broad leaf. Top layer — trees 15–70% and second layer — Yes mixed shrubs and grassland, almost all broadleaf trees remain green year-round. Canopy is never without green foliage. 123 Open forest, deciduous needle leaf. Top layer — trees 15–70% and second layer — Yes mixed shrubs and grassland, consists of seasonal needle leaf tree communities with an annual cycle of leaf-on and leaf-off periods. 124 Open forest, deciduous broadleaf. Top layer — trees 15–70% and second layer — Yes mixed shrubs and grassland, consists of seasonal broadleaf tree communities with an annual cycle of leaf-on and leaf-off periods. 125 Open forest, mixed. Yes 126 Open forest, not matching any of the other definitions. Yes 200 Oceans, seas. Can be either freshwater or saltwater bodies. No Precipitation Water is fundamental to mosquito larvae development. To estimate the areas that are likely to become inundated, the annual average precipitation was calculated from the Climate Hazards Group InfraRed Precipitation and Station Data (CHIRPS v2.0). Likewise, the flow accumulation was derived from the HydroSHEDS Flow Accumulation product to determine the natural drainage from a given pixel to the adjacent, downslope pixel in order to determine the areas of inundation for larval oviposition sites. Finally, a water resources layer, derived from the JRC Global Surface Water Bodies Mapping Layer v1.0 product, was developed: this was done by buffering water bodies by 250 m to approximate water-rich soils that would support larval development. 56 | Climate and Health Vulnerability Assessment: Malawi ANNEX B. 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 the ministry of health (MoH)? 1.4: Is there a multisectoral technical working group / committee that is focused on climate change and health? 1.5: Does MoH actively participate in climate change coordination and / or working groups? 1.6: Is there a memorandum of understanding (MOU) between MoH and key climate change-related ministries / departments (for example, Environment, Meteorological Services, Agriculture, and Water)? 1.7: Are decision-makers (both within MoH and outside) aware of climate change and health risks, as well as potential adaptation options? 1.8: Does the relevant information related to climate change, health risks, and adaptation reach the 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 MoH? 2.6: Have the MoH staff received training on climate change and health in the last two years? 2.7: Does the health workforce have the technical capacity to interpret and utilize climate change information (for example, scenarios, projections, and forecasts) to inform planning / decision-making? 2.8: Are climate change and health included in the educational curriculum (for example, the schools of public health, medicine, and nursing)? 2.9: Are there context- or country-specific climate change and health training / educational materials for the health workforce? Annexes | 57 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 environmental information? 3.5: Are there efforts from MoH to utilize national climate / meteorological information? 3.6: Does the country have a climate-informed early warning system for any health risks? 3.7: Are there early warning systems in place for climate change-related extreme events / hazards (for example, floods, droughts, and storms)? 3.8: Does MoH coordinate with disaster- / hazard-focused early warning systems? ESSENTIAL MEDICAL PRODUCTS, TECHNOLOGIES, AND INFRASTRUCTURE Assessment Questions Yes No Partial N/A 4.1 Have the country’s healthcare facilities been assessed for climate resilience? 4.2 Are health facilities accessible to 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 the 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, a stockpile of medical / emergency supplies)? 58 | Climate and Health Vulnerability Assessment: Malawi HEALTH SERVICE DELIVERY Assessment Questions Yes No Partial N/A 5.1: Has the country enacted legislation to mandate 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 (for example, floods, storms, and heatwaves)? 5.4: Does the current public health planning consider climate change information (for example, scenarios, projections, and forecasts)? 5.5: Has MoH implemented any climate-health awareness campaigns to increase public awareness? 5.6: Is there access to safe water, sanitation, and hygiene (WASH) facilities for over 80 percent of the country? 5.7: Do over 80 percent of the healthcare facilities have access to safe WASH and healthcare waste removal / storage? 5.8: Have multihazard risk assessments been conducted in the country? 5.9: If conducted, do the multihazard risk assessments include potential health risks? FINANCING Assessment Questions Yes No Partial N/A 6.1: Is MoH currently receiving international funds to support climate change and health work? 6.2: Is there dedicated funding for climate change and health activities under MoH? 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 | 59 ANNEX C. CATEGORIZATION OF RECOMMENDATIONS Short-term — less than 2 years; Medium — 2 to 5 years; and Long-term — more than 5 years COMPONENTS SUMMARY OF RECOMMENDATIONS Leadership and Medium-term: Governance Enhance the coordination mechanisms for climate action, championed by MoH and the HCCT, to liaise with stakeholders inside and outside the health sector. Articulate climate-health actions in subnational plans. Health Workforce Short-term: Create and promote health workforce retention packages to ensure that there are sufficient skilled health workers in areas at the highest risk of climate-related hazards. Long-term: Scale up formal pedagogical training developed by Malawi’s HCCT on climate and health, by incorporating it into the medical and paramedical curricula (targeted at medical professionals, including nursing professionals and CHWs) at higher education and vocational institutions. Integrated Risk Short-term: Monitoring and Early Strengthen communication networks between DoCCMS and communities at risk Warning for extreme weather events. Management of Short-term: Environmental Support community-led efforts to improve sanitation practices and controls to Determinants of Health prevent WBDs and foodborne illnesses and diseases, as well as communicate about potential climate change-related health risks. Medium-term: Engage medical colleges and MoE and integrate with district-level community groups to support dialogues, the promotion of awareness, and the develop- ment of prospective climate and health programs, such as the health promotion programs that are focused on climate-related health risks. Climate and Health Short-term: Financing Ensure that strategic purchasing includes climate-related health risk consider- ations. 60 | Climate and Health Vulnerability Assessment: Malawi ANNEX D. KEY RECOMMENDATIONS AND RELEVANT LINE MINISTRIES IN MALAWI HIGH-LEVEL RECOMMENDATIONS RELEVANT LINE MINISTRIES WHO’S CLIMATE AND HEALTH OPERATIONAL COMPONENT • Enhance the coordination mechanisms for MoH, the Ministry of Natural Leadership and Gov- climate action, championed by MoH and the Resources and Climate Change ernance HCCT, to liaise with stakeholders inside and (MNRCC), and the Department of outside the health sector. Climate Change • Articulate climate-health actions in subnational plans. • Create and promote health workforce MoH, MoE, MNRCC Health Workforce retention packages to ensure that there are sufficient skilled health workers in areas at the highest risk of climate-related hazards. • Scale up the formal pedagogical training developed by Malawi’s HCCT on climate and health and incorporate it into the medical and paramedical curricula (targeted at medical professionals, including nursing professionals and CHWs) at higher education and vocational institutions. • Strengthen the communication networks MoH, MNRCC Integrated Risk between DoCCMS and the communities at Monitoring and Early risk for extreme weather events. Warning  • Reinforce public awareness on the health im- Ministry of Health, Ministry of Local Management of En- plications of poor sanitary and waste disposal Government, MNRCC, and MoE vironmental Determi- practices, including open defecations, amidst nants of Health  a changing climate. • Engage medical colleges and MoE and integrate with district-level community groups to support dialogues, the promotion of awareness, and the development of prospec- tive climate and health programs, such as health promotion programs that are focused on climate-related health risks. • Ensure that strategic purchasing includes cli- MoH, the Ministry of Finance, Climate and Health mate-related health risk considerations. MNRCC Financing Annexes | 61 ANNEX E. RECOMMENDATIONS BY CLIMATE-RELATED HEALTH RISK Food security and Vector-borne Waterborne Diseases Extreme Weather Heat-Related Air Quality Mental Health and Nutrition Diseases (VBDs) (WBDs) and Climate Hazard- Morbidity and Well-being Associated Mortality Mortality and Morbidity Component 1: Incorporate climate Implement the malaria Develop an indepen- Develop and Develop and Develop an opera- Promote mental Leadership change risks into food control strategic plan. dent government implement a implement a national tional framework that health and advocate and Gover- security and nutrition agency to oversee health-specific DRM heat health policy and integrates the impacts for it as a key nance strategic plans, water quality surveil- plan for integra- city-level plans. of climate change on component in MoH’s including sustainable lance, monitoring, and tion with national air quality and health strategic planning to agriculture efforts. the enforcement of policies and support in climate change also account for cli- water quality policies it with the necessary programs. mate-related mental Strengthen the coor- and laws, mandates. health risks dination mechanisms Formulate a national among MoH, MoAg, Enhance the coordi- climate and air quality Establish a coordi- and international nation between rural policy / law that inte- nation mechanism stakeholders. water boards and grates health issues. involving religious national offices. and local leaders, with the aim of Promote communi- reducing stigma ty-based water man- around mental health. 62 | Climate and Health Vulnerability Assessment: Malawi agement and gover- nance approaches. Component 2: Incorporate edu- Provide training at Promote routine Conduct simulation Conduct heat-health Map gaps and create Promote and create Health cational materials subnational levels to training and refresher exercises with health training for health training opportuni- incentives to increase workforce on climate change enhance the capacity opportunities for the workers at subna- workers. ties in air pollution the number of mental impacts on food of dengue prevention health workforce, tional levels, focusing and related health health workers and Ensure occupational security and nutrition and control, as well including CHWs, on on service delivery outcomes. the avenues of heat exposures are into health worker as the knowledge of the diagnosis and during emergencies, training, which also managed. Develop health-spe- training. climate change-relat- treatment of WBDs. including compound- take into consider- cific awareness and ed factors. ing / cascading ation climate change education materials climate-induced risks. for health workers disasters. on the risks of indoor Develop mental and outdoor air health services pollution. aimed at providing services to healthcare workers. Develop mental health courses focused on emergency psycho- logical services for healthcare workers who are going to be deployed in response to extreme weather events. Component 3: Conduct a vulnera- Conduct district- and Enhance and promote Conduct integrated Conduct the assess- Assess indoor and Develop baseline Vulnerability, bility assessment of community-level routine vulnerability multihazard vulnera- ments of high-risk outdoor air pollution data on mental health capacity, and nutrition to climate assessments to better assessments and bility and risk assess- groups at the city levels and health in relation to climate adaptation change. understand local risks adaptation planning. ments at the local / level, including impacts in both urban change and improve assessment related to VBDs and district levels. informal settlements, and rural areas. the surveillance Assess the nutrition the capacities for and incorporate of mental health benefits of cli- managing outbreaks. economic analyses. outcomes. mate-smart agricultur- al interventions. Assess the capacity of community-cen- Assess the capacities tered resilience of the health system building and targeted to respond to acute vulnerable popula- food insecurity and tions. emergency-related nutritional risks. Component 4: Develop and include Build from HIS to in- Integrate climate Strengthen HIS to in- Strengthen the Develop air quality Develop monitoring Integrated long-term strategies corporate climate-in- change projections corporate emergency heatwave alert monitoring systems and surveillance risk monitor- for nutrition interven- formed seasonal with WBD surveil- preparedness and systems for urban and and public health risk systems that account ing and early tions into the famine outlooks. lance to strengthen use technology for rural populations. communication. for climate-related warning early warning system WBD outbreak pre- the monitoring and mental health risks, (FEWS). dictions. surveillance of health and mental health conditions in emer- indicators related gencies. to well-being (for example, livelihoods and stressful events). Component 5: Analyze the long-term Conduct climate Enhance scientific Develop and include Conduct studies to Invest in more Include climate-relat- Health and effects of climate change modeling research to support a extreme weather further explore the research on air pol- ed mental health risks climate change on food studies to estimate better understanding event attribution impacts of extreme lution-related health into MoH’s research research systems, nutritional dengue risk pro- of climate change studies as evidence heat on health effects and further agenda and promote outcomes, and the jections and inform variability and health of impacts on human systems, including the understanding of partnerships with economy. adaptation decisions. impacts, and guide health. urban heat island the linkage between national universities climate change adap- mapping. climate change and and research insti- tation communication. air quality. tutions to better un- derstand the impact of climate change on mental health. Annexes | 63 Component 6: Improve drainage Improve laboratory Improve WASH facili- Revise specifications Ensure space cooling Invest in the use Explore technologies Climate- systems in crop fields capabilities for testing ties (including appro- to include climate in healthcare facilities of sustainable and that could improve resilient and at risk of floods. and diagnosing priate waste disposal risk projections in the to prevent overheat- renewable energy access to mental sustainable endemic, novel, and systems), both at siting and construc- ing and protect infor- sources, such as the health services (for Explore smart-agricul- technologies re-emerging diseases. healthcare facilities tion, functioning and mation technology (IT) use of solar power, in example, telemedi- ture and crop-diversi- and infrastruc- and in the communi- operation, energy and equipment. healthcare facilities. cine). fication practices. Develop a list of ture ties, and ensure that and water supplies, essential medicines Implement energy-ef- these facilities are and the sanitation needed for VBD ficient or passive climate resilient. services of healthcare outbreaks measures of cooling facilities. to reduce energy Adopt irrigation costs. systems that take into consideration the increased exposure to VBDs, such as alternate wet-dry irri- gation or the system of rice intensification (SRI). 64 | Climate and Health Vulnerability Assessment: Malawi Component 7: Conduct communi- Conduct community Strengthen envi- Develop and Provide occupational Enhance routine Management ty-led efforts to map awareness campaigns ronmental public implement regulations health management. indoor and outdoor of environmen- food insecurity and to increase the health programs and for disease outbreak air pollution exposure tal determi- inform interventions awareness of the surveillance. responses and other assessments. nants of health for improving the food impact of climate on climate-related health Establish a plan to system in a changing VBD outbreaks and emergencies and enhance the reliabil- climate. engage vulnerable incorporate them into ity of routine public groups in outbreak disaster management water source cleaning prevention. planning. and testing. Component 8: Implement inter- Incorporate climate Strengthen the public Integrate DRM into Ensure that heat risks Raise awareness Integrate mental Climate- ventions involving change information awareness program public health training are incorporated about air pollution health services informed the establishment into the prevention on proper hygiene and implement into maternal health and its impacts on that account for health of gardens or of VBDs and develop and sanitation, along public awareness guidance, guidance health in communities climate-related program food-growing oppor- SOPs to respond to with climate change campaigns that are for diabetes manage- and engage commu- mental health risks tunities. outbreaks. impacts on health. focused on the links ment, etc. nities in air pollution into primary and between disasters, awareness programs. secondary health Conduct a climate change, and services. community- mediated health. delivery of nutrition services, including screening. Component 9: Reinforce the food Incorporate VBD Enhance the Conduct exercises Include heat into DRM Integrate air quality Develop a program Emergency production and outbreaks into DRM emergency response / testing of disaster operations. emergencies into on the emergency preparedness distribution chain to plans at the national, planning to ensure preparedness plans DRM plans and psychology response and manage- withstand the impacts provincial, district, safe and sustainable (tabletop and re- programs. to climate-related ment of extreme weather and community water supply and al-world), along with hazards. Enhance routine air events. levels. clean sanitation at the evaluations of the quality surveillance healthcare facilities responses / uses of and monitoring. and displacement the plans in the health camps, as well as in sector. communities. Component 10: Invest in the dis- Formulate proposals Prioritize invest- Deploy resources to Finance sustainable Improve multisectoral Establish a budget Climate semination of crop to seek support from ments for building support preparedness cities / cool cities that coordination and line allocated to and health varieties and breeds external donors to climate-resilient for extreme weather address heat risks international collab- mental health within financing adapted to changing improve the control WASH infrastructures events and the and other heat-health oration opportunities MoH. climatic conditions. of VBDs in healthcare facilities response to them. interventions, such as for financing air and displacement cool roofs. pollution research, Establish a budget camps. equipment, training, line allocated and programs. to nutrition (and climate-related nutritional risks) within MoH. Annexes | 65 ANNEX F. PROJECTED AVERAGE MONTHLY TEMPERATURE AND PRECIPITATION PATTERNS IN MALAWI, UNDER SSP3-7.0 MEAN TEMPERATURE (_C) Historical Reference, 1995–2014 2020–2039 2040–2059 Jan 23.75 (22.64; 28.89) 24.3 (23.32; 25.54) 25.09 (24.08; 26.50)) Feb 23.83 (22.52; 24.82) 24.31 (23.27; 25.4) 25.07 (23.79; 26.31) Mar 23.5 (22.38; 24.39) 24.18 (23.03; 25.05) 24.84 (23.63; 25.82) Apr 22.48 (21.44; 23.31) 23.19 (22.24; 23.91) 23.89 (22.89; 24.71) May 20.68 (19.91; 21.46 21.33 (20.69; 22.03) 22.17 (21.32; 22.96) Jun 18.8 (18.13; 19.47) 19.61 (18.83; 20.21) 20.27 (19.32; 21.02) Jul 18.28 (17.41; 19.57) 19.09 (17.93; 19.91) 19.84 (18.79; 20.73) Aug 19.75 (18.68; 21.38) 20.57 (19.32; 21.87) 21.23 (20.19; 22.53) Sep 22.87 (21.21; 24.01) 23.78 (22.33; 24.49) 24.51 (23.14; 25.51) Oct 25.73 (23.96; 26.64) 26.61 (24.81; 27.39) 27.56 (25.64; 28.35) Nov 25.82 (24.95; 26.58) 26.77 (25.89; 27.9) 27.48 (26.77; 28.58) Dec 24.42 (23.14; 25.54) 25.07 (24.23; 26.49) 25.9 (25.0; 27.45) PRECIPITATION (MM) Historical Reference, 1995–2014 2020–2039 2040–2059 Jan 297.35 (211.64; 375.72) 295.1 (2176.55; 397.73) 302.64 (215.8; 389.36) Feb 263.15 (172.15; 327.8) 257.4 (182.44; 354.79) 257.79 (183.42; 338.5) Mar 199.96 (120.27’ 280.09) 204.33 (123.72; 285.38) 204.25 (134.82; 300.16) Apr 84.8 (41.41; 129.5) 90.78 (32.88; 130.03) 85.98 (36.43; 128.84) May 27.88 (10.36; 48.95) 24.38 (9.44; 53.81) 23.8 (8.41; 48.12) Jun 13.38 (4.52; 30.52) 11.34 (4.15; 33.34) 11.04 (4.34; 31.5) Jul 10.33 (3.7; 25.38) 9.6 (3.75; 23.97) 9.88 (3.79; 25.77) Aug 8.04 (2.95; 21.11) 6.02 (2.59; 22.26) 5.92 (2.02; 20.19) Sep 7.01 (2.91; 18.84) 5.06 (2.23; 15.51) 4.29 (1.88; 13.85) Oct 18.46 (8.84; 46.67) 14.76 (4.88; 36.41) 12.95 (4.99; 29.3) Nov 103.14 (56.52; 150.19) 93.73 (46.51; 141.98) 95.59 (47.14; 145.72) Dec 247.23 (156.53; 339.01) 239.05 (158.16; 329.02) 231.66 (140.55; 349.2) Note: Data presented shows the median (50th percentile) and the 10th and 90th percentiles, in brackets, of the multimodel ensemble for the designated time periods, under SSP3-7.0. Source: World Bank Climate Change Knowledge Portal 66 | Climate and Health Vulnerability Assessment: Malawi REFERENCES 1 The World Bank (2023) GDP (Current US$) — Malawi, https://data. Assessment – PDNA, https://documents1.worldbank.org/curated/ worldbank.org/country/MW en/640011479881661626/text/110423-WP-PDNAMalawispreads- FINAL-PUBLIC.txt 2 The World Bank (2023) GDP per capita (Current US$) — Malawi, https:// data.worldbank.org/country/MW 20 David D. Mkwambisi, Eleanor K. K. Jew, and Andrew J. Dougill, 2020, “Farmer Preparedness for Building Resilient Agri-Food Systems: 3 African Development Bank (2023) Malawi Economic Outlook, https:// Lessons From the 2015/2016 El Niño Drought in Malawi,” Frontiers in www.afdb.org/en/countries/southern-africa/malawi/malawi-econom- Climate 20, doi: 10.3389/fclim.2020.584245. ic-outlook 21 GFDRR, 2011, “Vulnerability, Risk Reduction, and Adaptation to Climate 4 Caruso, German Daniel; Cardona Sosa, Lina Marcela. Malawi Change: Malawi,” Climate Risk and Adaptation Country Profile, April Poverty Assessment: Poverty Persistence in Malawi - Climate 2011, https://climateknowledgeportal.worldbank.org/sites/default/ Shocks, Low Agricultural Productivity, and Slow Structural files/2018-10/wb_gfdrr_climate_change_country_profile_for_MWI.pdf. Transformation (English). Washington, D.C.: World Bank Group. http:// documents.worldbank.org/curated/en/099920006302215250/ 22 Lameck Masina (March 14, 2022) Cyclone Gombe Kills 7, Damages P174948072f3880690afb70c20973fe214d Houses and Roads in Malawi. Voice of America – VOA, https://www. voanews.com/a/cyclone-gombe-kills-7-damages-houses-and-roads-in- 5 The World Bank (2023) Gini Index — Malawi, https://data.worldbank. malawi/6484818.html org/indicator/SI.POV.GINI?locations=MW. 23 United Nations (March 6, 2022) Restoring safety and dignity to women 6 UN Department of Economic and Social Affairs, n.d., World Population in Malawi, displaced by Tropical Storm Ana. https://news.un.org/en/ Prospects 2019, Total Population by Sex (thousands) — Malawi, https:// story/2022/03/1112702. population.un.org/wpp/DataQuery/. 24 UNICEF (e.d.) Massive flooding in Mozambique, Malawi and Zimbabwe. 7 UN Department of Economic and Social Affairs, n.d., World Population https://www.unicef.org/stories/massive-flooding-malawi-mozam- Prospects 2019, Population by Age and Sex (thousands) — Malawi, bique-and-zimbabwe https://population.un.org/wpp/DataQuery/. 25 IPCC, 2021: Summary for Policymakers. In: Climate Change 2021: The 8 Government of Malawi, 2019, 2018 Malawi Population and Housing Physical Science Basis. Contribution of Working Group I to the Sixth Census: Main Report, National Statistical Office, May 2019, https:// Assessment Report of the Intergovernmental Panel on Climate Change malawi.unfpa.org/sites/default/files/resource-pdf/2018%20Malawi%20 [Masson-Delmotte, V., P. Zhai, A. Pirani, S.L. Connors, C. Péan, S. Population%20and%20Housing%20Census%20Main%20Report%20 Berger, N. Caud, Y. Chen, L. Goldfarb, M.I. Gomis, M. Huang, K. Leitzell, %281%29.pdf. E. Lonnoy, J.B.R. Matthews, T.K. Maycock, T. Waterfield, O. Yelekçi, R. 9 UN Habitat, n.d., Malawi: Overview, https://unhabitat.org/malawi#:~:- Yu, and B. Zhou (eds.)]. In Press. https://www.ipcc.ch/report/ar6/wg1/ text=Absolute%20urban%20growth%20in%20Malawi,193%2C000%20 downloads/report/IPCC_AR6_WGI_SPM_final.pdf. in%20the%20rural%20areas. 26 CONCERN Worldwide Malawi Graduation Programme (2020) The 10 WHO (World Health Organization), 2015, Operational Framework for impact of Cyclone Idai on the poorest. https://www.tcd.ie/time/assets/ Building Climate Resilient Health Systems, Geneva, Switzerland: WHO, pdf/the-impact-of-cyclone-idai.pdf. https://www.who.int/publications/i/item/9789241565073 27 The Government of Malawi (2019) Malawi 2019 Floods Post Disaster 11 GFDRR (Global Facility for Disaster Reduction and Recovery), 2011, Needs Assessment Report. https://reliefweb.int/sites/reliefweb.int/ “Vulnerability, Risk Reduction, and Adaptation to Climate Change: files/resources/Malawi%202019%20Floods%20Post%20Disaster%20 Malawi,” Climate Risk and Adaptation Country Profile, April 2011, https:// Needs%20Assessment%20Report.pdf. climateknowledgeportal.worldbank.org/sites/default/files/2018-10/ 28 Josephine Chinele (March 18, 2022) The Worst disaster in a generation: wb_gfdrr_climate_change_country_profile_for_MWI.pdf.https:// Cyclone Ana wreaks havoc on health in Malawi. https://www.gavi.org/ climateknowledgeportal.worldbank.org/sites/default/files/2018-10/ vaccineswork/worst-disaster-generation-cyclone-ana-wreaks-hav- wb_gfdrr_climate_change_country_profile_for_MWI.pdf oc-health-malawi. 12 Country reports (2023) Malawi geography, maps, climate, environment 29 Sandra Frobe-Kaltenbach and Bob Baulch (March 28, 2019) Cyclone and terrain, https://www.countryreports.org/country/Malawi/geography. Idai, flooding, and food security in Malawi. https://www.ifpri.org/blog/ htm cyclone-idai-flooding-and-food-security-malawi 13 International Federation of Red Cross and Red Crescent Societies (20 30 Electricity Generation Company (Malawi) Limited. https://www.egenco. December 2020) Malawi: Floods Final Report - Emergency Appeal: n° mw/ MDRMW014, https://reliefweb.int/report/malawi/malawi-floods-final-re- port-emergency-appeal-n-mdrmw014-20-december-2020 31 Laura Naranjo (Feb 13, 2007) Connecting Rainfall and Landslides. https://earthdata.nasa.gov/learn/sensing-our-planet/connect- 14 The World Bank, GFDRR (2019) Disaster Risk Profile – Malawi, https:// ing-rainfall-and-landslides#:~:text=While%20rainfall%2Dinduced%20 www.gfdrr.org/sites/default/files/publication/malawi_low.pdf. landslides%20can,to%20successfully%20observe%20these%20 15 EM-DAT PUBLIC (accessed December 15, 2021), https://public.emdat. conditions. be/ 32 The World Bank, GFDRR (2019) Disaster Risk Profile – Malawi. https:// 16 The Government of Malawi (2015) Malawi 2015 Floods Post Disaster www.gfdrr.org/sites/default/files/publication/malawi_low.pdf. Needs Assessment Report, https://reliefweb.int/sites/reliefweb.int/files/ 33 USAID. International Data & Economic Analysis. https://idea.usaid.gov/ resources/Malawi-2015-Floods-Post-Disaster-Needs-Assessment-Re- cd/malawi/health. port.pdf 34 Institue for Health Metrics and Evaluation – IHME (2023) Malawi. 17 World Bank, GFDRR (April 2011) Climate Risk and Adaptation Country https://www.healthdata.org/malawi. Profile – Malawi, https://climateknowledgeportal.worldbank.org/sites/ default/files/2018-10/wb_gfdrr_climate_change_country_profile_for_ 35 Jerry John Nutor, Henry Ofori Duah, Pascal Agbadi, Precious Adade MWI.pdf. Duodu, and Kaboni Whitney Gondwe, 2020, “Spatial Analysis of Factors Associated with HIV Infection in Malawi: Indicators for Effective 18 The World Bank, GFDRR (2019) Disaster Risk Profile – Malawi, https:// Prevention,” BMC Public Health 20 (1): 1–14, doi: 10.1186/s12889-020- www.gfdrr.org/sites/default/files/publication/malawi_low.pdf. 09278-0. 19 World Bank (e.d.) Malawi Drought 2015-2016 Post-Disaster Needs References | 67 36 Mark Lieber, Peter Chin-Hong, Henry J. Whittle, Robert Hogg, and State University, East Lansing, Michigan, USA. Sheri D. Weiser, 2021, “The Synergistic Relationship Between Climate 53 Jennifer Olson, Gopal Alagarswamy, Jenni Gronseth, and Nathan Change and the HIV/AIDS Epidemic: A Conceptual Framework. AIDS Moore. (2017) Impacts of Climate Change on Rice and Maize, and and Behavior 25 (7): 2266–77, doi: 10.1007/s10461-020-03155-y. Opportunities to Increase Productivity and Resilience in Malawi. Malawi 37 Michael Marmot, 2011, Fair Society, Healthy Lives: The Marmot Review Report No. 9. Global Center for Food Systems Innovation, Michigan — Strategic Review of Health Inequalities in England Post-2010, Febuary State University, East Lansing, Michigan, USA 2011, https://www.instituteofhealthequity.org/resources-reports/fair- 54 Red Cross Red Cresent, IFRC (2021) Climate Change Impacts on society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full- Health: Malawi Assessment. https://www.climatecentre.org/wp-content/ report-pdf.pdf uploads/RCRC_IFRC-Country-assessments-Malawi_Final3.pdf. 38 FAO (Food and Agriculture Organization of the United Nations), IFAD 55 World malaria report 2021. Geneva: World Health Organization; 2021. (International Fund for Agricultural Development), UNICEF (United Licence: CC BY-NC-SA 3.0 IGO. Nations Children’s Fund), WFP (World Food Programme), and WHO (World Health Organization), The State of Food Security and Nutrition https://www.who.int/teams/global-malaria-programme/reports/world-malar- in the World: Transforming Food Systems for Food Security, Improved ia-report-2021. Nutrition and Affordable Healthy Diets for All, Rome, Italy: FAO, doi: 10.4060/cb4474en. 56 National Malaria Control Programme (NMCP) and ICF. 2018. Malawi Malaria Indicator Survey 2017. Lilongwe, Malawi, and Rockville, 39 World Bank (2022) Prevalence of moderate or severe food insecurity Maryland, USA: NMCP and ICF. in the population (%) – Malawi. https://data.worldbank.org/indicator/ SN.ITK.MSFI.ZS?locations=MW https://dhsprogram.com/pubs/pdf/MIS28/MIS28.pdf. 40 World Bank (2022) Prevalence of undernourishment (% of population) – 57 Don P. Mathanga, Edward D. Walker, Mark L. Wilson, Doreen Ali, Terrie Malawi. https://data.worldbank.org/indicator/SN.ITK.DEFC.ZS?loca- E. Taylor, and Miriam K. Laufer, 2012, “Malaria Control in Malawi: Current tions=MW Status and Directions for the Future,” Acta Tropica 121 (3): 212–7, doi: 10.1016/j.actatropica.2011.06.017. 41 World Bank (2022) Prevalence of anemia among women of reproductive age (% of women ages 15-49) – Malawi. https://data. 58 Charles Mangani, April N. Frake, Grivin Chipula, Wezi Mkwaila, Tasokwa worldbank.org/indicator/SH.ANM.ALLW.ZS?locations=MW Kakota, Isaac Mambo, Jerome Chim’gonda, et al., 2022, “Proximity of Residence to Irrigation Determines Malaria Risk and Anopheles 42 World Bank (2022) Prevalence of anemia among children (% of children Abundance at an Irrigated Agroecosystem in Malawi,” American ages 6-59 months) – Malawi. https://data.worldbank.org/indicator/ Journal of Tropical Medicine and Hygiene 106 (1): 283–92, doi: 10.4269/ SH.ANM.CHLD.ZS?locations=MW ajtmh.21-0390. 43 World Bank (2022) Prevalence of stunting, height of age (% of children 59  https://www.wsp.org/sites/wsp/files/publications/WSP-ESI-Malawi.pdf.  under 5) – Malawi. https://data.worldbank.org/indicator/SH.STA.STNT. ZS?locations=MW 60 Juyoung Moon, Jae Wook Choi, Jiyoung Oh, and KyungHee Kim, 2019, “Risk Factors of Diarrhea of Children under Five in Malawi: Based on 44 World Bank (2022) Prevalence of wasting, weight for height (% of Malawi Demographic and Health Survey 2015–2016,” Journal of Global children under 5) – Malawi. https://data.worldbank.org/indicator/ Health Science 1 (2): e45, doi: 10.35500/jghs.2019.1.e45. SH.STA.WAST.ZS?locations=MW 61 https://dhsprogram.com/pubs/pdf/FR319/FR319.pdf. 45 Aberman, N. L., Meerman, J., & Benson, T. (Eds.). (2018). Agriculture, food security, and nutrition in Malawi: leveraging the links. Intl Food 62 Changtao Ge, Cheonghoon Lee, and Jiyoung Lee, 2012, “The Impact Policy Res Inst. of Extreme Weather Events on Salmonella Internalization in Lettuce and Green Onion,” Food Research International 45 (2): 1118–22, doi: 10.1016/j. 46 World Bank (December 12, 2019) New Economic Analysis for Malawi foodres.2011.06.054. Urges More Investments in Nutrition for Stronger Human Capital. https://www.worldbank.org/en/news/press-release/2019/12/12/ 63 Amin Khonje, Carol Ann Metcalf, Emma Diggle, Dudley Mlozowa, new-economic-analysis-for-malawi-urges-more-investments-in-nu- Chandiwira Jere, Ann Akesson, Tom Corbet, and Zachariah Chimanga, trition-for-stronger-human-capital#:~:text=LILONGWE%2C%20 2012, “Cholera Outbreak in Districts Around Lake Chilwa, Malawi: December%2012%2C%202019%20%2D,edition%20of%20the%20 Lessons Learned,” Malawi Medical Journal 24 (2): 29–33, World%20Bank. 64 UNICEF (March 24, 2022) UNICEF Malawi Floods, Polio, Cholera 47 UNICEF (2018) The Nutrition Programme in Malawi. https://www.unicef. Humanitarian Situation Report. https://reliefweb.int/report/malawi/ org/malawi/media/596/file/Nutrition%20Narrative%20Factsheet%20 unicef-malawi-floods-polio-cholera-humanitarian-situation-re- 2018.pdf. port-17-march-2022 48 Aberman, N. L., Meerman, J., & Benson, T. (Eds.). (2018). Agriculture, 65 World Bank, GFDRR (2011) Vulnerability, Risk Redcution, and Adaptation food security, and nutrition in Malawi: leveraging the links. Intl Food to Climate Change – Malawi.https://climateknowledgeportal.worldbank. Policy Res Inst. org/sites/default/files/2018-10/wb_gfdrr_climate_change_country_ profile_for_MWI.pdf. 49 Andrew D. Jones, Aditya Shrinivas, and Rachel Bezner-Kerr, 2014, “Farm Production Diversity is Associated with Greater Household 66 Doctors Without Borders (February 18, 2022) After flooding, displaced Dietary Diversity in Malawi: Findings from Nationally Representative Malawians are living in dire conditions. https://www.doctorswithoutbor- Data,” Food Policy 46 (C): 1–12, doi: 10.1016/j.foodpol.2014.02.001. ders.ca/article/after-flooding-displaced-malawians-are-living-dire-con- ditions. 67 Red Cross Red Cresent, IFRC (2021) Climate Change Impacts on 50 Alexander, K., Zione, K., Gertrude, M., Innocent, P., George, B, & Health: Malawi Assessment. https://www.climatecentre.org/wp-content/ Cacious, P. (2021) Report of Round 7 Nutrition Smart Surveys Conducted uploads/RCRC_IFRC-Country-assessments-MALAWI-3.pdf. in Flood-and Drought-Prone Livelihood Zones of Malawi. https:// reliefweb.int/sites/reliefweb.int/files/resources/smart_round_7_final_ 68 Chabvungma, S.D., Mawenda, J., & Kambauwa. G. (2014) Drought report_march_2021_1.pdf conditions and management strategies in Malawi. https://www.drought- management.info/literature/UNW-DPC_NDMP_Country_Report_ 51 United Nations (July 20, 2016) UN agency starts food aid to 6.5 million Malawi_2014.pdf. people affected by severe drought in Malawi. https://news.un.org/en/ story/2016/07/534912-un-agency-starts-food-aid-65-million-people- 69 R. Sari Kovats, and Shakoor Hajat, 2008, “Heat Stress and Public affected-severe-drought-malawi Health: A Critical Review,” Annual Review of Public Health 29: 41–55, doi: 10.1146/annurev.publhealth.29.020907.090843. 52 Jennifer Olson, Gopal Alagarswamy, Jenni Gronseth, and Nathan Moore. (2017) Impacts of Climate Change on Rice and Maize, and 70 International Labour Organization (2019) Working on a warmer planet: Opportunities to Increase Productivity and Resilience in Malawi. Malawi The impact of heat stress on labour productivity and decent work Report No. 9. Global Center for Food Systems Innovation, Michigan International Labour Office – Geneva, ILO, 2019 68 | Climate and Health Vulnerability Assessment: Malawi https://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/---publ/ 89 World Bank (2022) Domestic general government health expenditure documents/publication/wcms_711919.pdf. per capita (current US$) – Malawi. https://data.worldbank.org/indicator/ SH.XPD.GHED.PC.CD?locations=MW 71 Zhao, Q., Guo, Y., Ye, T., Gasparrini, A., Tong, S., Overcenco, A., ... & Li, S. (2021). Global, regional, and national burden of mortality 90 Ian Yoon, Pakwanja Twea, Stephanie Heung, Sakshi Mohan, Nikhil associated with non-optimal ambient temperatures from 2000 to Mandalia, Saadiya Razzaq, Leslie Berman, Eoghan Brady, Andrews 2019: a three-stage modelling study. The Lancet Planetary Health, 5(7), Gunda, and Gerald Manthalu, 2021, “Health Sector Resource Mapping e415-e425. in Malawi: Sharing the Collection and Use of Budget Data for Evidence-Based Decision Making,” Global Health: Science and Practice 72 WHO and UNFCCC (United Nations Framework Convention on Climate 9 (4): 793–803, doi: 10.9745/GHSP-D-21-00232. Change), 2015, “Climate and Health Country Profile Malawi,” https:// climhealthafrica.org/wp-content/uploads/2017/06/Malawi-WHO-UNFC- 91 Adaptive capacity is defined by IPCC as “the ability of a system to CC-Country-Profile.pdf. adjust to climate change, moderate potential damages, take advantage of opportunities, and cope with the consequences” (IPCC AR5). The 73 Miriam Cox, Louis Rose, Khumbo Kalua, Gilles de Wildt, Robin Bailey, related term, “resilience,” is the ability to prepare and plan for, absorb, and John Hart, 2017, “The Prevalence and Risk Factors for Acute recover from, and more successfully adapt to adverse events. People Respiratory Infections in Children Aged 0–59 Months in Rural Malawi: A and communities with strong adaptive capacity have greater resilience. Cross‐Sectional Study,” Influenza and Other Respiratory Viruses 11 (6): [[This assessment makes use of the terms — “adaptation” and “adaptive 489–96, doi: 10.1111/irv.12481. capacity” — to refer to both terms. – please check copy edit]] 74 Sepeedeh Saleh, Henry Sambakunsi, Kevin Mortimer, Ben Morton, 92 World Bank (2021) Spending for Health in Malawi: Current Trends and Moses Kumwenda, Jamie Rylance, and Martha Chinouya, 2021, Strategies to Improve Efficiency and Equity in Health Financing. https:// “Exploring Smoke: An Ethnographic Study of Air Pollution in Rural openknowledge.worldbank.org/bitstream/handle/10986/35864/ Malawi,” BMJ Global Health 6: e004970, doi: 10.1136/ bmjgh-2021- Spending-for-Health-in-Malawi-Current-Trends-and-Strategies-to-Im- 004970. prove-Efficiency-and-Equity-in-Health-Financing.pdf?sequence=1&isAl- 75 Willem A. Nieman, Brian W. van Wilgen, and Alison J. Leslie, 2021, “A lowed=y. Reconstruction of the Recent Fire Regimes of Majete Wildlife Reserve, 93 UNICEF (2021) Improving Public Investments in the Health Sector in Malawi, Using Remote Sensing,” Fire Ecology 17 (1): 1–13. the context of COVID-19. https://www.unicef.org/esa/media/8991/file/ 76 Chan-Na Zhao, Zhiwei Xu, Guo-Cui Wu, Yan-Mei Mao, Li-Na Liu, UNICEF-Malawi-2020-2021-Health-Budget-Brief.pdf Qian-Wu, Yi-Lin Dan, et al., 2019, “Emerging Role of Air Pollution in 94 Government of Malawi (2021) Health Sector Resource Mapping. FY Autoimmune Diseases,” Autoimmunity Reviews 18 (6): 607–14, doi: 2017/18 – FY 2019/20 10.1016/j.autrev.2018.12.010. (https://indexmedicus.afro.who.int/iah/fulltext/Health_sector_resources_ 77 Adami, G., Pontalti, M., Cattani, G., Rossini, M., Viapiana, O., Orsolini, G., mapping.pdf. ... & Fassio, A. (2022). Association between long-term exposure to air pollution and immune-mediated diseases: a population-based cohort 95 For the purpose of this assessment. “off-budget resource allocation” study. RMD open, 8(1), e002055. is defined as funding from donors or NGOs that is directly disbursed to healthcare providers to support health projects, rather than going 78 Voice of America (January 25, 2022) UN Kicks Off Relief Assistance to through the government. Malawi Flood Victims. https://www.voanews.com/a/un-kicks-off-relief- assistance-to-malawi-flood-victims/6423409.html. 96 Mchenga, M., Chirwa, G. C., & Chiwaula, L. S. (2017). Impoverishing effects of catastrophic health expenditures in Malawi. International 79 Red Cross Red Cresent, IFRC Psychosocial Centre (July 1, 2019). journal for equity in health, 16(1), 1-8. Climate Change and Mental Health. https://pscentre.org/climate- change-and-mental-health/. 97 World Bank (2022) Out-of-pocket expenditure (% of current health expenditure) – Malawi. https://data.worldbank.org/indicator/SH.XPD. 80 Udedi, M. (2016). Improving access to mental health services in OOPC.CH.ZS?locations=MW. Malawi. Ministry of health policy brief, 26, 505-18. 98 Gheorghe, A., Straehler-Pohl, K., Nkhoma, D., Mughandira, W., Garand, 81 IHME (Institute for Health Metrics and Evaluation), 2019. D., Malema, D., ... & Lievens, T. (2019). Assessing the feasibility and 82 Red Cross Red Cresent, IFRC Psychosocial Centre (July 1, 2019). appropriateness of introducing a national health insurance scheme in Climate Change and Mental Health. https://pscentre.org/climate- Malawi. Global health research and policy, 4(1), 1-11. change-and-mental-health/. 99 Government of Malawi (2017) Health Sector Strategic Plan II 2017-2022. 83 American Psychiatric Association (March 2017) Climate Change and https://www.healthdatacollaborative.org/fileadmin/uploads/hdc/ Mental Health Connections. https://psychiatry.org/patients-families/ Documents/Country_documents/HSSP_II_Final_HQ_complete_file. climate-change-and-mental-health-connections. pdf.pdf. 84 Hanna-Andrea Rother, R. Anna Hayward, Jerome A. Paulson, Ruth A. 100 UNICEF (2021) Improving Public Investments in the Health Sector in Etzel, Mary Shelton, and Linda C. Theron, 2022, “Impact of Extreme the context of COVID-19. https://www.unicef.org/esa/media/8991/file/ Weather Events on Sub-Saharan African Child and Adolescent Mental UNICEF-Malawi-2020-2021-Health-Budget-Brief.pdf. Health: The Implications of a Systematic Review of Sparse Research 101  Global Health Workforce Alliance, WHO (2014) Malawi’s Emergency Findings,” The Journal of Climate Change and Health 5: 100087, doi: Human Resources Programme. https://ghcorps.org/wp-content/ 10.1016/j.joclim.2021.100087. uploads//2014/10/Malawis-Emergency-Human-Resources-Programme. 85 Red Cross Red Cresent, IFRC (2021) Climate Change Impacts on pdf.  Health: Malawi Assessment. https://www.climatecentre.org/wp-content/ 102 O’Neil, M., Jarrah, Z., Nkosi, L., Collins, D., Perry, C., Jackson, J., ... uploads/RCRC_IFRC-Country-assessments-MALAWI-3.pdf. & Mlambala, A. (2010). Evaluation of Malawi’s emergency human 86 Malawi Ministry of Health (2017) Malawi National Community resources programme. Health Strategy 2017 – 2022. https://www.healthynewbornnetwork. 103 Elizabeth Mziray, Marelize Gorgens, and Pamela McCauley, 2017, org/hnn-content/uploads/National_Community_Health_Strate- Analysis of Human Resources for Health in Malawi: Implementation of gy_2017-2022-FINAL.pdf WISN Study in Seventy-Five Facilities, Washington, DC: World Bank, 87 Annette Mphande-Namangale and Isabel Kazanga-Chiumia, 2021, https://elibrary.worldbank.org/doi/epdf/10.1596/33307. “Informal Payments in Public Hospitals in Malawi: The Case of Kamuzu 104 Government of Malawi (2017) Health Sector Strategic Plan II - Central Hospital,” Global Health Research and Policy 6: 1-11, doi: 10.1186/ 2017-2022. https://extranet.who.int/countryplanningcycles/sites/ s41256-021-00225-z. default/files/planning_cycle_repository/malawi/health_sector_ 88 Malawi National Planning Commission (2020) Human Resource strategic_plan_ii_030417_smt_dps.pdf. Development and Management. http://www.sdnp.org.mw/malawi/ 105 The Global Fund (2016) Global Fund Grants to the Republic of Malawi. vision-2020/chapter-7.htm https://www.theglobalfund.org/media/2665/oig_gf-oig-16-024_report_ References | 69 en.pdf. management information system in Malawi: Issues and innovations. In Proceedings of the RHINO Workshop (pp. 14-16). 106 Ministry of Health (2017) National Community Health Strategy – 2017-2022. https://www.healthynewbornnetwork.org/hnn-content/ 124 WHO (December 5, 2017) The Global Framework for Climate Servies uploads/National_Community_Health_Strategy_2017-2022-FINAL.pdf. (GFCS) Adaptation Programme in Arica. https://www.who.int/news/ item/05-12-2017-the-global-framework-for-climate-services-(gfcs)-adap- 107 Kamuzu University of Health Sciences (e.d.) Human Resources for tation-programme-in-africa. Health Country Profile - Malawi.http://nkhokwe.kuhes.ac.mw/bitstream/ handle/20.500.12845/193/HRH%20Malawi%20Country%20Profile_ 125 Governmnet of Malawi (2017) Health Sector Strategic Plan II Approved%20MOH.pdf?sequence=1&isAllowed=y. (2017-2022). https://extranet.who.int/countryplanningcycles/sites/ default/files/planning_cycle_repository/malawi/health_sector_ 108 Wanangwa Chimwaza, Effie Chipeta, Andrew Ngwira, Francis strategic_plan_ii_030417_smt_dps.pdf. Kamwendo, Frank Taulo, Susan Bradley, and Eilish McAuliffe, 2014, “What Makes Staff Consider Leaving the Health Service in Malawi?” 126 UNDP (2021) Better Health : Embracing Technology in Medicine Supply Human Resources for Health 12: 1-9, doi: 10.1186/1478-4491-12-17. Chain Managment.https://www.mw.undp.org/content/malawi/en/ home/presscenter/articles/2021/better-health--embracing-technolo- 109 Vidal. P. (October 21, 2015) The Emigration of Health-Care Workers: gy-in-medicine-supply-chain-man.html. Malawi’s Recurring Challenges. https://www.migrationpolicy.org/article/ emigration-health-care-workers-malawi%E2%80%99s-recurring-chal- 127 Butao, Doris, Barbara Felling, and Patrick Msipa. (2009) Malawi: lenges. Laboratory Services and Supply Chain Assessment. Arlington, Va.: USAID | DELIVER PROJECT, Task Order 1. 110 Takeda (n.d.) Spotlight Malawi: Many Paths Towards Universal Health Coverage and a Strong Health Workforce. https://www.takeda.com/ 128 Butao, Doris, Barbara Felling, and Patrick Msipa. (2009) Malawi: newsroom/featured-topics/spotlight-malawi-many-paths-towards-uni- Laboratory Services and Supply Chain Assessment. Arlington, Va.: versal-health-coverage-and-a-strong-health-workforce/ USAID | DELIVER PROJECT, Task Order 1. 111 University of Washington (2017) Family Medicine developments at the 129 OXFAM (n.d.) A Dangerous Divide. The State of Inequality in Malawi. Malawi College of Medicine. https://familymedicine.uw.edu/blog/fami- https://www-cdn.oxfam.org/s3fs-public/file_attachments/rr-inequali- ly-medicine-developments-at-the-malawi-college-of-medicine/. ty-in-malawi-261115-en.pdf. 112 Adamson Muula, 2016, “Training Needs Assessment in Climate 130 Annette Mphande-Namangale and Isabel Kazanga-Chiumia, 2021, Change, Gender and Health for Health Workers in Malawi,” in Training “Informal Payments in Public Hospitals in Malawi: The Case of Kamuzu Needs Assessment in Climate Change, Gender and Health, edited Central Hospital,” Global Health Research and Policy 6: 1–11, doi: 10.1186/ by Adamson S. Muula, Rumbidzai Mlewah, and Clara Sambani, 1–28. s41256-021-00225-z. Blantyre, Malawi: School of Public Health, University of Malawi-College 131 Carlos Varela, Sven Young, Nyengo Mkandawire, Reinou S. Groen, of Medicine, https://www.researchgate.net/publication/308418563_ Leonard Banza, and Asgaut Viste, 2019, “Transportation Barriers Training_Needs_Assessment_in_Climate_Change_Gender_and_ to Access Health Care for Surgical Conditions in Malawi: A Cross Health_For_Health_workers_in_Malawi. Sectional Nationwide Household Survey,” BMC Public Health 19 (1): 264, 113 Government of Malawi (2017) Health Sector Strategic Plan II - doi: 10.1186/s12889-019-6577-8. 2017-2022. https://www.healthdatacollaborative.org/fileadmin/uploads/ 132 Marte Ustrup, Bagrey Ngwira, Lauren J. Stockman, Michael Deming, hdc/Documents/Country_documents/HSSP_II_Final_HQ_complete_ Peter Nyasulu, Cameron Bowie, Kelias Msyamboza, et al., 2014, file.pdf.pdf. “Potential Barriers to Healthcare in Malawi for Under-Five Children with 114 Malawi M&E task force priorities (April 21, 2016) https://www.health- Cough and Fever: A National Household Survey,” Journal of Health, datacollaborative.org/fileadmin/uploads/hdc/Documents/Country_ Population, and Nutrition 32 (1), 68–78, https://www.ncbi.nlm.nih.gov/ documents/Malawi_ME_task_force_priorities_21apr2016_2_.pdf. pmc/articles/PMC4089074/. 115 Ministry of Health (2015) Malawi National Health Information System 133 UNICEF (2022) Malawi Floods – Humanitarian Situation report. https:// Policy. https://www.healthdatacollaborative.org/fileadmin/uploads/hdc/ www.unicef.org/media/118006/file/Malawi-Floods-Humanitarian-Si- Documents/Country_documents/September_2015_Malawi_National_ tRep-17-March-2022.pdf. Health_Information_System_Policy.pdf. 134 Ripple Africa (2022) Healthcare in Malawi, Africa. https://rippleafrica. 116 WHO (2018) Global Reference List of 100 Core Health Indicators org/project/healthcare-in-malawi-africa/ (plus health-related SDGs). Geneva: World Health Organization; 2018. 135 Makwero, M. T. (2018). Delivery of primary health care in Malawi. African Licence: CC BY-NC-SA 3.0 IGO.https://score.tools.who.int/fileadmin/ Journal of Primary Health Care and Family Medicine, 10(1), 1-3. uploads/score/Documents/Enable_data_use_for_policy_and_ action/100_Core_Health_Indicators_2018.pdf. 136 OXFAM (n.d.) A Dangerous Divide. The State of Inequality in Malawi. https://www-cdn.oxfam.org/s3fs-public/file_attachments/rr-inequali- 117 Joseph Wu, T. S., Kagoli, M., Kaasbøll, J. J., & Bjune, G. A. (2018). ty-in-malawi-261115-en.pdf. Integrated Disease Surveillance and Response (IDSR) in Malawi: Implementation gaps and challenges for timely alert. PLoS One, 13(11), 137 Alister Munthali, Stine H. Braathen, Lisbet Grut, Yusman Kamaleri, and e0200858. Benedicte Ingstad, 2013, “Seeking Care for Epilepsy and Its Impacts on Households in a Rural District in Southern Malawi,” African Journal of 118 Malawi Ministry of Health (2015) Vulnerability and Adaptation Disability 2: 54, doi: 10.4102/ajod.v2i1.54. Assessment of the Health Sector in Malawi to Impacts of Climate Change. https://health.bmz.de/wp-content/uploads/page/06-12-2015_ Health_Sector_December_Final_.pdf. 138 Relevant stakeholders would include the Ministry of Agriculture (MoAg), 119 Government of Malawi (2017) Health Sector Strategic Plan II - the Department of Climate Change and Meteorological Services, the 2017-2022. https://www.healthdatacollaborative.org/fileadmin/uploads/ Department of Disaster Management and Preparedness, Water, etc. hdc/Documents/Country_documents/HSSP_II_Final_HQ_complete_ file.pdf.pdf. 139 April N. Frake, Brad G. Peter, Edward D. Walker, and Joseph P. Messina, 2020, “Leveraging Big Data for Public Health: Mapping Malaria Vector 120 UNDP, n.d., Saving Lives, Protecting Agriculture Based Livelihoods in Suitability in Malawi with Google Earth Engine,” PLoS One 15 (8): Malawi (M-Climes), https://www.adaptation-undp.org/projects/gcf-sav- e0235697, doi: 10.1371/journal.pone.0235697. ing-lives-protecting-agriculture-based-livelihoods-malawi-m-climes. 140 Adam Bennett, Lawrence Kazembe, Don P. Mathanga, Damaris Kinyoki, 121 https://www.dodma.gov.mw/index.php/projects/m-climes-project. Doreen Ali, Robert W. Snow, and Abdisalan M. Noor, 2013, “Mapping Malaria Transmission Intensity in Malawi, 2000–2010,”  American 122 Boddens-Hosang, J. (2018) Capacity Building for Managing Climate Journal of Tropical Medicine and Hygiene 89 (5): 840–9, doi: 10.4269/ Change in Malawi (CABMACC) programme. https://www.nmbu.no/en/ ajtmh.13-0028. faculty/landsam/department/noragric/institutional_coop/cabmacc 141 M. Nable Bayoh and Steve W. Lindsay, 2003, “Effect of Temperature on 123 Chaulagai, C. N., Moyo, C., & Pendame, R. (2001, March). Health 70 | Climate and Health Vulnerability Assessment: Malawi the Development of the Aquatic Stages of Anopheles Gambiae Sensu Stricto (Diptera: Culicidae),” Bulletin of Entomological Research 93 (5): 375–81, doi:10.1079/BER2003259. 142 Candice L. Lyons, Maureen Coetzee, and Steven L. Chown, 2013, “Stable and Fluctuating Temperature Effects on the Development Rate and Survival of Two Malaria Vectors, Anopheles Arabiensis and Anopheles Funestus,” Parasites & Vectors 6: 1–9, doi: 10.1186/1756- 3305-6-104. 143 Leadership and governance, Health workforce, Health information systems, Medical products, Vaccines and technologies, Service delivery, and Health system financing, References | 71 SEPTEMBER 2023 72 | Climate and Health Vulnerability Assessment: Malawi