C limate CLIMATE and AND Health HEALTH V A VULNERABILITY ASSESSMENT: ulnerability PAKISTAN ssessment PAKISTAN CLIMATE INVESTMENT FUNDS © 2024 International Bank for Reconstruction and Development/The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work and does not assume responsibility for any errors, omissions, or discrepancies in the information, or liability with respect to the use of or failure to use the information, methods, processes, or conclusions set forth. 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PAKISTAN Climate and Health Vulnerability Assessment CLIMATE INVESTMENT FUNDS CONTENTS ACKNOWLEDGMENTS...............................................................................................................VII LIST OF ABBREVIATIONS.........................................................................................................VIII EXECUTIVE SUMMARY.................................................................................................................1 INTRODUCTION............................................................................................................................ 7 1.1 Country context...............................................................................................................................................7 1.2 Aim of the assessment and the conceptual framework........................................................................ 8 CLIMATOLOGY.............................................................................................................................. 11 2.1 Observed and projected climate change................................................................................................ 12 2.2 Climate-related hazards.............................................................................................................................15 2.2.1 Extreme Heat...............................................................................................................................................15 2.2.2 Floods...........................................................................................................................................................16 2.2.3 Landslides...................................................................................................................................................16 2.2.4 Droughts......................................................................................................................................................18 2.3 Key Messages..............................................................................................................................................19 CLIMATE-RELATED HEALTH RISKS...........................................................................................21 3.1 Heat-related risks........................................................................................................................................22 3.2 Vector-borne disease (VBD) risks.................................................................................................................................................... 23 3.2.1 Dengue ........................................................................................................................................................24 3.2.2 Malaria ........................................................................................................................................................25 3.3 Waterborne disease risks.........................................................................................................................26 3.4 Nutrition risks..............................................................................................................................................28 ADAPTIVE CAPACITY OF PAKISTAN’S HEALTH SYSTEM.....................................................33 4.1 Health system overview............................................................................................................................. 33 4.2 Leadership and governance.................................................................................................................... 34 4.3 Health workforce ....................................................................................................................................... 37 4.4 Health information and disease surveillance systems....................................................................... 38 4.5 Essential medical products and technologies .................................................................................... 39 4.6 Service delivery ......................................................................................................................................... 39 4.7 Financing .....................................................................................................................................................40 iv | Climate and Health Vulnerability Assessment: Pakistan RECOMMENDATIONS TO ENHANCE HEALTH SYSTEM RESILIENCE TO CLIMATE CHANGE......................................................................................................................45 REFERENCES ..............................................................................................................................48 ANNEX..........................................................................................................................................53 Annex I. Assumptions on the course of future global climate change.................................................. 53 Annex II. Net change in future monthly precipitation across Pakistan ................................................. 54 Annex III. Methods for the estimation of mosquito suitability, under RCP 8.5, in Pakistan .............. 55 Annex IV. Key climate change and health-related policies in Pakistan.................................................56 Annex V. Adaptive capacity and climate change-related health risks gap analysis........................... 57 Annex VI. Key Recommendations and Relevant Line Ministries in Pakistan ...................................................................................................................................................59 Annex VII. Examples of “no regrets” recommendations for climate change and health in Pakistan .......................................................................................................................................................60 Annex VIII. Menu of health adaptation options by climate-related health risk....................................66 FIGURES Figure 1. WHO’s operational framework for building climate-resilient health systems comprising 10 components and their connections to the building blocks of health systems .........................................9 Figure 2. Projected average daily maximum temperature across the provinces of Pakistan in the 2050s...............................................................................................................................................................................13 Figure 3. Monthly changes (that is, anomalies) in average precipitation in the 2050s under SSP3-7.0 among the regions of Pakistan................................................................................................................13 Figure 4. Stages of the food system driving healthy and sustainable diets ............................................... 29 Figure 5. WHO’s health system building blocks .................................................................................................34 Figure 6. WHO’s operational framework for building climate-resilient health systems............................ 45 Contents | v TABLES Table 1. Annual number and percentage increase of very hot days (>35°C), extremely hot days (>40°C), and tropical nights in the 2030s and 2050s, under SSP3-7.0, throughout the regions of Pakistan............................................................................................................................................................................ 17 Table 2. Projected extreme precipitation anomalies for Pakistan for the 2020–2039 and 2040–2059 periods, under SSP3-7.0, from the 1995–2014 reference period ............................................18 Table 3. Landslide events from 1991 to 2020 .......................................................................................................18 Table 4. Area of suitable dengue vector species habitat, by province, in Pakistan (percentage) ..........25 Table 5. Area of suitable malaria vector species habitat, by province, in Pakistan (percentage) .........26 Table 6. Two-week prevalence of diarrhea in children under 5 years in Pakistan, 2018 ......................... 27 Table 7. Summary of climate change-related health risks..................................................................................31 Table 8. Summary of the adaptive capacity gaps of the health system for Pakistan as they relate to climate change......................................................................................................................................................... 43 Table A1. Data sources and thresholds for vector species’ thermal tolerance and habitat characteristics...............................................................................................................................................................55 vi | Climate and Health Vulnerability Assessment: Pakistan ACKNOWLEDGMENTS The authors are thankful to the Climate Investment Funds (CIF) and the Climate Support Facility (CSF) for funding this work. This Climate and Health Vulnerability Assessment (CHVA) for Pakistan was produced by the Health- Climate, Environment and Disasters (HCED) program in the Health, Nutrition and Population (HNP) GlobalPractice of the World Bank, which is led by Tamer Rabie. The assessment is authored by April N. Frake, Tamer Rabie, Stephen Dorey, and Christopher Boyer, with guidance from Sari Kovats, along with contributions from MacKenzie Dove, Ali Saeed Mirza, Sana Ikram Sharif, Brad Peter, Ana Lucrecia Rivera-Rivera, Muloongo Simuzingili, and Mikhael Iglesias. The team also wishes to thank Maria Gracheva for her review of this assessment. The authors sincerely appreciate the valuable contributions provided by Judith Namanya and Loreta Rufo. This work benefited from the administrative support of Fatima-Ezzahra Mansouri and Julie Luvisa Bazolana, the editorial work of Kah Ying Choo, and the production of Sarah Jene Hollis. The authors are also highly grateful to the HNP management for their strong support of the HCED program and this product and would like to extend their thanks to Juan Pablo Uribe and Monique Vledder. Acknowledgments | vii LIST OF ABBREVIATIONS DEFINITION API Annual Parasite Incidence AR6 Assessment Report 6 [of the IPCC] CCC Climate Change Council CCKP Climate Change Knowledge Portal [of World Bank] CD Communicable Disease CHVA Climate and Health Vulnerability Assessment CHEVT Climate and Health Economic Valuation Tool CMIP5 Coupled Model Intercomparison Project Phase 5 COVID-19 Coronavirus Disease 2019 CPEC China-Pakistan Economic Corridor CRU Climatic Research Unit [University of East Anglia, UK] DEWS Disease Early Warning System DHIS District Health Information System DRM Disaster Risk Management EWS Early Warning Systems FEWS Famine Early Warning System GCM General Circulation Model GDP Gross Domestic Product GHG Greenhouse Gas [emissions] GHS Global Health Security GLC Global Landslide Catalogue GLOF Glacial Lake Outburst Flood GoP Government of Pakistan HEAT Heat Emergency Awareness and Treatment HiAP Health in All Policies HIS Health Information Systems HRH Human Resources for Health HSS Health System Strengthening IHR International Health Regulations ILO International Labour Organization IMR Infant Mortality Rate INDC Intended Nationally Determined Contributions IPCC Intergovernmental Panel on Climate Change JE Japanese Encephalitis JEE Joint External Evaluations (for IHR) LHW Lady Health Workers viii | Climate and Health Vulnerability Assessment: Pakistan DEFINITION MMR Maternal Mortality Ratio MoNHSRC Ministry of National Health Services and Regulations and Coordination MECS Modern Energy Cooking Solutions NASA The National Aeronautics and Space Administration NCCP National Climate Change Policy (of Pakistan) NCD Noncommunicable Disease(s) NDC Nationally Determined Contributions NDMP National Disaster Management Plan NOAA National Oceanic and Atmospheric Administration OOP Out-of-Pocket (spending on health) PHC Primary Health Care PM2.5 Fine Particulate Matter PPP Purchasing Power Parity PPPA Public Private Partnership Authority RCP Representative Concentration Pathway SLR Sea-Level Rise SOPs Standard Operating Procedures SPEI Standardized Precipitation Evapotranspiration Index ToT Training-of-Trainers UHC Universal Health Coverage UNFCCC United Nations Framework Convention on Climate Change VBD Vector-Borne Disease WASH Water Sanitation and Hygiene WBD Waterborne Disease WHO World Health Organization List of Abbreviations | ix EXECUTIVE SUMMARY INTRODUCTION Pakistan is one of the most vulnerable countries in the world to climate change. Extensive geographical diversity and exposure to a wide range of climate-related hazards, a strong dependency on agriculture and water resources, high rates of mul- tidimensional poverty, as well as a sizable and expanding population, independently and collectively contribute to climate change-related vulnerabilities across the country. Climate change can have profound effects on health outcomes in Pakistan — either by exacerbating the country’s existing health burdens or by creating new health risks. AIMS OF THE CLIMATE AND HEALTH VULNERABILITY ASSESSMENT (CHVA) The objective of this Climate and Health Vulnerability Assessment (CHVA) is to assist decision-makers in Pakistan with planning effective adaptation measures to mitigate climate-related health risks. To do so, the characteristics of the climatology of Pakistan are first described, with a focus on the observed and projected climate exposures that are relevant to health, as well as key climate-related hazards. Then climate-related health risks, namely heat-related risks, vector-borne disease (VBD) risks, waterborne disease (WBDs) risks, and risks to nutrition are examined in light of projected climate variability and change, including identifying vulnerable populations most at risk, where possible. The final step assesses the adaptive capacity of the health system in Pakistan to manage current and future climate-related health risks. This assessment is used to inform a series of recommendations that are aimed at reducing climate-related health vulnerability and building climate resilience in Pakistan’s health sector. OBSERVED AND PROJECTED CLIMATE CHANGE Over the last half century, there has been remarkable evidence of climate change in Pakistan. Warming is accelerating, having over a half degree Celsius over the past century, and is strongly skewed toward the winter and post-monsoon months, most notably affecting Sindh, Punjab, and Balochistan. Average annual rainfall in Pakistan has increased over the last half century, albeit with important subregional variations. Pakistan’s precipitation regime is highly complex, due to the significant influence of El Niño cycles and strong variations in interannual and interseasonal rainfall. For example, provinces such as Balochistan and Sindh receive the least amount of average annual rainfall, when comparing with other provinces. 1 Projected temperatures in Pakistan through the mid-century will redefine the magnitudes of extreme heat exposure and occur alongside likely increases in precipitation. Average monthly temperature increases, under the SSP3-7.0 emissions scenario, will range from 0.73°C to 1.04°C in the 2030s and from 1.33°C to 1.91°C in the 2050s across Pakistan. These increases will make the populations of Punjab and Islamabad especially vulnerable. Based on the SSP3-7.0 scenario, projected daily maximum temperatures by the mid-century are especially alarming: they will range from 46.82°C to 47.7°C in Punjab and 46.44°C to 47.18°C in Islamabad. The historic summer season is projected to lengthen, compounded by rising nighttime temperatures. Furthermore, an increasing trend in precipitation will be occurring until the mid-century, though this projections are characterized by high levels of uncertainty due to available information. During the 2030s, national annual precipitation is projected to increase by 10 percent, with the largest increases taking place sub-nationally in Punjab and Sindh. By the 2050s precipitation is expected to keep increasing throughout Pakistan. Low-lying coastal areas south of Karachi toward Keti Bander and within the Indus River delta will be at the greatest risk of projected sea-level rises (SLRs). Extreme heat, flooding, landslides, and droughts can profoundly affect population health in Pakistan, many of which have already demonstrated increases in frequency and intensity. The most common climate-related hazards can be summarized as follows: • Extreme heat: Across most of Pakistan, mean temperatures are already at, or very near, recognized extreme-heat thresholds and increasing. Northern regions are projected to experience the most substantial increases in extreme heat exposure during the 2030s and 2050s. • Extreme precipitation: Increases in total and extreme precipitation, combined with a westward shift of the Asian monsoon, are leading to severe flood risks that are affecting every province in Pakistan, and this is predicted to increase through the 2030 and 2050s. • Landslides: Increases in heavy-precipitation events, combined with populations and land-use factors, may result in the increased risk of landslides causing damage to homes and infrastructure, as well as significant losses of life. • Droughts: High vulnerability to droughts is already occurring and is expected to increase, throughout the country, projected to have a 66 percent probability of severe drought by the end of the century. Extreme heat, flooding, landslides, and droughts can profoundly affect population health in Pakistan, many of which have already demonstrated increases in frequency and intensity. 2 | Climate and Health Vulnerability Assessment: Pakistan CLIMATE-RELATED HEALTH RISKS The effects of climate change on the health outcomes of the population of Pakistan are considered across four health risk categories in this assessment: heat-related risks, vector-borne disease (VBD) risks, waterborne disease (WBD) risks, and risks to nutrition. Heat-related health risks are wide-ranging, including the effects on mortality, heat-related injuries, as well as mental health and well-being. Extreme heat is currently a significant climate-related health risk in Pakistan, with most of areas experiencing a high heat index. The 2015 heatwave — one of the deadliest in recent history — provides an illustrative example of the current risk. Excessive heat-related deaths and impacts on labor productivity in Pakistan are likely to increase under the SSP3-7.0 scenario. Increases in the number of hot days (maximum temperature [Tmax] > 35°C) and tropical nights (minimum temperature [Tmin] > 20°C) will expose millions of people to dangerous temperatures, particularly in Sindh, Punjab, and Balochistan regions, as well as urban centers such as Karachi and Lahore. Vector-borne disease (VBD) risks pose a significant threat to the health of Pakistan’s people, as climate continues to change. Dengue is the fastest emerging arboviral threat in Pakistan, with more than 62 million people vulnerable to infection. Ongoing climate and infrastructural changes in Pakistan will alter the geography of dengue transmission risks, with the populations of Punjab and Islamabad at highest risk. Shifting the suitability of malaria vectors in Pakistan will marginally change the subnational geography of malaria transmission risk through 2050, under high-emissions scenarios, with the northern regions experiencing the largest gains in suitable areas for malaria mosquitoes. Waterborne diseases (WBDs) are likely to increase in response to the impact of climate changes on water quality, via temperature increases, flooding, and droughts, placing an additional 5 million people at risk. Populations residing along the Indus River system will be the most vulnerable to the flood related WBD risk. In addition, temperature increases projected for Sindh and Balochistan may lead to more frequent and / or intense drought events, with consequent increased rates of diarrheal diseases — driven by insufficient water quality and inadequate quantity available for hygiene practices. Nutrition Risks. Poor nutrition outcomes and food insecurity are likely to be substantially aggravated by climate change, particularly in Balochistan, and lower Sindh. Impacts on wheat and rice production will be especially important to future nutrition outcomes, given their importance as dietary staples throughout Pakistan. Wheat yields are projected to decline by 19 percent during the 2060s in the Punjab province where 80 percent of Pakistan’s wheat production takes place. Notably, water scarcity concerns could further limit rice production in favor of less water-intensive crops. Executive Summary | 3 ADAPTIVE CAPACITY OF PAKISTAN’S HEALTH SYSTEM The extent to which Pakistan’s health system is prepared for and has the capacity to respond to climate-related changes is a key modifier of climate-related health risks. In this assessment, Pakistan’s adaptive capacity to prevent and manage climate-related health risks is examined according to the World Health Organization’s (WHO) six health system building blocks. Gaps in the adaptive capacity of Pakistan’s health system include the following: 1. Leadership and Governance: Although Pakistan is committed to meeting the climate challenge through both adaptation and mitigation measures, there are limited coordina- tion mechanisms in place to facilitate cross-sector action on climate change and health. 2. Health Workforce: Pakistan already faces numerous health workforce challenges that climate change is likely to exacerbate. The current health workforce varies significantly across districts, with significant urban-rural disparities across both private and government health sectors. Further, there is the lack of a systematic approach toward capacity development on climate-related health risks, with emergency preparedness and responses a key challenge for Pakistan’s health workforce. 3. Health Information and Disease Surveillance: Pakistan’s current health information system is fragmented, with insufficient vertical coverage. Further, climate and weather information is not sufficiently integrated into the District Health Information System (DHIS) and early warning systems (EWS) to inform the prevention and management of climate-sen- sitive health risks as well as the early response to them. 4. Essential Medical Products and Technologies: While Pakistan has a National Essential Medicines List with policy measures and operative guidelines in place for regulating essential medicines and laboratories, gaps exist between policy and practice. Furthermore, there has been no assessment of technologies to ensure that the health equipment is resilient to climate change. 5. Service Delivery: The devolution of federal responsibilities for health and population welfare to the provincial level has led to challenges in health service delivery. There has been no comprehensive review of current health care infrastructure in Pakistan to identify climate change-related vulnerabilities, and minimum standards for climate-sensitive healthcare have not been developed. 6. Financing: Pakistan’s historically low public financing on health has led to significant out-of-pocket (OOP) payments, thus increasing poverty, especially in light of ongoing climate-related risks. This is of particular concern when responding to large-scale disasters, such as those related to climate change. Likewise, risk pooling in Pakistan does not account for climate and health risks. Limited experience with strategic purchasing in the Pakistan health sector further precludes climate and health results from being appropriately achieved. 4 | Climate and Health Vulnerability Assessment: Pakistan RECOMMENDATIONS TO ENHANCE HEALTH SYSTEM RESILIENCE TO CLIMATE CHANGE The findings of this assessment are used to inform its recommendations to enhance the resilience of Pakistan’s health system to climate change, including health interventions and strategies for adaptation in Pakistan. Recommendations are guided by WHO’s operational framework for building climate-resilient health systems. High-level recommendations include the following: 1. Strengthen climate-health policy environment at national and subnational levels. The government of Pakistan (GoP) would be well-advised to ensure that health is featured prominently in the country’s national climate change adaptation plans and strategies. To this end, the integration of climate-related health risks into the next iteration of the Pakistan National Health Vision would be a critical step. Moreover, it is recommended that the further development of subnational adaptation plans is adapted to provide specific climate-related health actions, building from examples such as the Karachi Heat Health Action Plan. 2. Enhance coordination mechanisms for climate and health action. This involves the designation of a national climate and health focal point for liaising with stakeholders at different levels. Establishing coordination mechanisms with key actors both inside and outside the health sector — including line ministries of climate change, agriculture, planning and development, and transportation, among others — will be highly beneficial. 3. Develop health workforce capacity to manage climate and health risks. Realizing the intended objectives of the proposed capacity development actions requires two cardinal steps: (a) the intro- duction of formal pedagogical training on climate change and health as part of medical, paramedical, and nursing curricula at higher-education and vocational institutions; and (b) the development of training and awareness-raising materials tailored for health providers and community health workers on climate change and health risks and adaptation responses. A focus on the management of extreme heat exposure risks — especially in Sindh, Punjab and Balochistan— where the most substantial increases in heat exposure are projected, could be a first priority. 4. Develop an intersectoral platform to monitor climate-related health risks and support the estab- lishment of a climate-informed disease early warning and response system. Under the patronage of the Ministry of Climate Change and Environmental Coordination, it is recommended that the surveil- lance of key climate risks, as they relate to health, be conducted to inform the operationalization of the Ministry of National Health Services and Regulations and Coordination (MoNHSRC) programs. Building on prior efforts to strengthen the disease early warning system (DEWS), it is recommended to further expand the scope of such a system to incorporate climate-sensitive diseases. 5. Climate-proof health infrastructure and technologies. In light of findings stemming from these proposed assessments, the government may wish to revisit building codes to ensure that they are climate-smart and consider the likely impacts of climate-related hazards. Executive Summary | 5 6. Establish a national risk register for climate-health risks in Pakistan, with seasonal climate outlooks to inform health sector programming. The register would provide the likelihood, scale, and extent of such emergencies affecting the population to inform the government’s emergency response. In tandem, and feeding into the proposed national risk register, the government would be well-advised to develop seasonal climate outlooks. 7. Pool health funds to cover climate-related health risks and include climate risk considerations in strategic purchasing. A pre-payment mechanism providing this financial protection for climate-related health impacts, through the pooling of resources, could be considered. Moreover, a bold move could be made toward instituting a provider-payment mechanism that incentivizes healthcare providers to focus on climate-related health outcomes. To this effect, a strategic purchasing mechanism that pays for climate results should be designed and implemented across the provinces of Pakistan, particularly those most vulnerable to climate-related health risks. 6 | Climate and Health Vulnerability Assessment: Pakistan SECTION 1. INTRODUCTION 1.1 COUNTRY CONTEXT Pakistan is a lower-middle-income country with an economy that has slowly been growing over the last two decades. By 2018, the country’s gross domestic product (GDP) had risen to USD314.6 billion, compared with USD82.0 billion in 2000 [1]. The coronavirus disease 2019 (COVID-19) pandemic, as well as both high fiscal and balance of payment deficits, collectively resulted in an economic downturn to USD262.6 billion by 2020 [2]. Pakistan’s GDP per capita was USD1,189 in 2020 — part of a downturn over the last two years precipitated by the pandemic; until then, its GDP per capita had been rising steadily, reaching USD1,482 in 2018 [1]. Poverty in Pakistan is widespread, with important population sizes among the regions in Pakistan: distributional inequalities. Over a third (35.7 they range from 110 million in the Punjab province percent) of the population lives below the extreme (more than half of the population) to 2 million in poverty threshold of USD3.20 per day, while a Islamabad [3]. In 2020, nearly two-thirds was little over three-quarters (76.2 percent) lives living in rural areas (62.8 percent); however, by below the USD5.50 poverty threshold [1].1 Both 2030, it is expected that this figure would drop of these measures have shown steadily improving to 59.3 percent, and by 2050, more than half trends over recent decades (68.1 percent and the population would be expected to reside in 90.8 percent, respectively). Income inequality, as urban areas (52.2 percent) [1]. measured by the Gini index for 2018, was 31.6, representing adequate equality; this figure had Pakistan is vulnerable to the health impacts of remained at this level over the past two decades [1]. climate change. Coupled with human-induced health stressors, climate change exacerbates Pakistan is the fifth-most populous country in existing health burdens and creates new health the world. In 2020, the population was just over risks. Changes in temperature and precipitation 220 million [1], representing an increase from 142 patterns affect the geographic range and burden million in 2000 and is expected to increase to 263 of a variety of climate-sensitive health risks, while million by 2030 and 338 million by 2050 [1]. Nearly simultaneously impacting the functioning and 7 percent of the population is under 5 years old capacity of health systems. Compounding these and nearly 35 percent of the population is under challenges, climate has impacts on health and the age of 15, while less than 5 percent is over economic inequalities that are not uniformly the age of 65. There are significant variations in distributed — demographic, socioeconomic, geographical, and environmental factors — which can significantly affect population health risks. 1 Poverty headcount ratio of USD3.20 and USD5.50, using the 2011 Purchasing Power Parity (PPP) formula. These vulnerabilities are a result of several factors. 7 Geographical diversity, ranging from high altitudes There are many factors that could slightly slow in the northeast to arid coastal plains in the south, or significantly speed up rates of change, including renders the population vulnerable to a wide range positive feedback effects and, most worrying of of extreme climate-related events. Pakistan is also all, cascading climatological tipping points. For a strongly agrarian country, therefore making it this reason, mitigating existing greenhouse gas sensitive to climate shocks affecting agricultural emissions (GHGs), as well as developing and productivity and food security. High population implementing measures to protect health from density and population growth projections further the changing climate, is of paramount importance. increase the likelihood of climate-sensitive disease outbreaks. Investment in adaptation strategies to proactively address the effects of climate change on health Pakistan is committed to meeting the climate outcomes is critical. This assessment is concerned challenge through both adaptation and mitigation with the climate risks to health and health systems, measures. Pakistan ratified the Paris Agreement the adaptive capacities that are in place to deal of the United Nations Framework Convention with these risks, and the recommendations for on Climate Change (UNFCCC) on November meeting identified gaps. The primary focus of this 10, 2016, which aims to limit the global mean assessment is, therefore, on climate adaptation and temperature increase to well below 2°C compared resilience measures. However, as the Assessment with pre-industrial levels. Section IV of this Report Six (AR6) of the Intergovernmental Panel assessment highlights the key steps adopted on Climate Change (IPCC) makes clear, “Global by the government of Pakistan (GoP) to meet its surface temperature will continue to increase climate aspirations. until at least the mid-century under all emissions scenarios considered” [4]. Mitigation alone is no longer a sufficient strategy, regardless of the 1.2 AIM OF THE ASSESSMENT AND pace with which governments and communities THE CONCEPTUAL FRAMEWORK around the world act. Adaptation is now as critical The objective of this Climate and Health a part of climate action as mitigation. This report Vulnerability Assessment (CHVA) is to assist deci- focuses on adaptation measures, but where sion-makers with planning effective adaptation possible, it also includes recommendations for measures to deal with climate-related health risks. reducing GHGs or facilitating the decoupling of Where available, these measures are provided emissions from progress toward human health at the subnational level to assist regional health and development goals. planners. The recommendations of this CHVA are primarily aimed at the health sector, as well as The World Health Organization’s (WHO) related sectors that affect climate-related health operational framework for building climate- risks such as disaster risk management (DRM). resilient health systems [5] is adopted to analyze Pakistan’s adaptive capacity to adequately deal Adaptation priorities need to be implemented with current and future identified risks. Based on alongside fundamental and urgent action to this framework (Figure 1), this assessment is first mitigate climate change. It is important to stress structured around the six health system strength- how complex the climate challenge is and how ening (HSS) building blocks: these six categories hard it is to predict exactly how severe climate encompass the assessment of capacities and exposures facing populations will become. gaps — now and into the future. The framework 8 | Climate and Health Vulnerability Assessment: Pakistan then moves on to consider the 10 components gaps to manage current and future climate- of health system climate resilience. related health risks. Together, these steps serve to inform a series of recommendations for reducing This assessment follows a stepwise linear climate-related health vulnerability in Pakistan. The approach. The first step characterizes the assessment is based on a review of the published climatology in Pakistan, highlighting the observed literature, national statistics, and consultations with and future climate exposures relevant to health. key counterparts in government: they include the The second step examines climate-related health Ministry of Climate Change and Environmental risks, including identifying vulnerable populations Coordination; the Ministry of National Health most at risk. The final step assesses the adaptive Services and Regulations and Coordination capacity of the Pakistan health system, identifying (MoNHSRC); and the Directorate of Malaria, Dengue, and other Vector Borne Disease Control. FIGURE 1. WHO’s operational framework for building climate-resilient health systems comprising 10 components and their con- nections to the building blocks of health systems ATE RESILIENCE CLIM hip & Heal eaders nce Workf th L verna orce Go V uln pac ation t Fin ealth & A Ca apt men H ate era ity & Leadership As g d ess Clim cin bil & Governance Health s ity, an Workforce Financing P paredness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS e Service r Delivery Essential C li o r m e h Re ima & I n f a lt s Medical ma d C l a lt h se te Products & h He ra m Pro te a rc He Technologies - g Ma nt na Env ge m ent o Re 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 s tr u & Infra Source: World Health Organization, 2015, Operational Framework for Building Climate Resilient Health Systems. Introduction | 9 This assessment has inherent limitations, due in The assessment incorporates subnational consid- part to the lack of access to specific data and/ erations for health-related climate action. For or information and availability issues, as well the purpose of this assessment, the administrative as the inability to conduct mission travel and regions of Pakistan are considered as follows: collect primary data as part of the CHVA process four provinces (Balochistan, Punjab, Khyber due to the ongoing COVID-19 pandemic at the Pakhtunkhwa and Sindh); and one federal territory time of this assessment. Hence, the ability to (Islamabad Capital Territory). This assessment uses conduct comprehensive quantitative analyses for the term, “regions,” when referring collectively specific climate-related health risks, along with to all of the above administrative “provinces” in-depth reviews of the resilience of aspects of and “territories.” the health system, was constrained. 10 | Climate and Health Vulnerability Assessment: Pakistan SECTION 2. CLIMATOLOGY This section describes observed climatic changes and projected trends, highlighting the priority climate-related hazards in relation to human health risks in Pakistan. Climate information is taken from the World Bank Group’s Climate Change Knowledge Portal (CCKP). Observed changes in mean annual, mean maximum, and mean minimum temperatures and precipitation are presented on CCKP for the period 1901–2021. Climate data in the World Bank Group’s CCKP is derived from the Coupled Model In- tercomparison Project, Phase 6 (CMIP6), the foundational data used to present global climate change projections in the Sixth Assessment Report (AR6) of the Intergovern- mental Panel on Climate Change (IPCC). CMIP6 relies on the Shared Socioeconomic Pathways (SSPs), which represent possible societal development and policy scenarios, which are used to represent the climate response to different plausible future societal development storylines and associated contrasting emission pathways to outline how future emissions and land use changes translate into responses in the climate system. This assessment explores observed climate conditions for the latest climatology, 1991- 2020, and projected climate conditions and changes under SSP3-7.02 for the near (2030s; 2020-2039) and medium term (2050s; 2040-2059). Pakistan’s topography is characterized by high-al- of the most heavily glaciated countries outside titude mountain ranges, significant arid and the polar regions. Several major desert areas desert areas, as well as major rivers flowing to exist across Pakistan, each surrounded by arid its coastline along the Arabian Sea. The country regions at various altitudes. borders India to the east, Iran and Afghanistan to the west, and China to the north. The high-al- Pakistan’s Indus River is the one of the largest titude regions, encompassing the Himalayas and rivers in the world: it is fed by a combination of Karakorum mountains in the northeast, with several glacial meltwater and seasonal precipitation from peaks over 8,000 meters (m), collectively cover the Asian monsoon flowing through the plains approximately 11 million hectares (ha) (approxi- of Punjab and Sindh. Due to the country’s highly mately 14 percent of the total landmass) [6]. These connected hydrological regime, surplus water in mountains include almost 15,000 square kilometers the north — due to heavy rainfall, snow, and / or (km2) of nearly 7,000 glaciers, making Pakistan one glacier melting — will flow rapidly down to the 2 Note: SSP3-7.0 represents a higher emissions scenario and is considered a more realistic worst-case scenario in which warming reaches ~3.5-4 deg C by 2100. When considering ‘risk’ it is most prudent to use higher scenarios in order to not dangerously under-estimate potential changes and risk conditions. 11 low elevation plains of Sindh and Punjab, thus to February, most notably affecting the regions flooding cultivated lands, which can potentially of Punjab, Sindh, and Balochistan [7]. destroy crops and infrastructure. Conversely, when the monsoon fails, leading to lower rainfall in the Average annual rainfall in Pakistan has increased northern regions, the agricultural plains in the south over the last half century, albeit with important will suffer. This situation is further compounded subregional variations. Besides the northern by intense heat, increased evapotranspiration regions where monsoon rains are often around 200 conditions, and higher water demand. millimeters (mm) a month from July to September, the remainder of the country receives little precipi- Finally, Pakistan has a long southern coastline tation throughout the year [7]. Overall, Balochistan region along the Arabian Sea stretching just and Sindh receive the least amount of average under 1,000 km. In the east, this coastline is annual rainfall. Successive patterns of flood and shallower, leading to increasing coastal flood risks. drought events are common in Pakistan: they result from a high degree of interseasonal and interannual variability in rainfall and El Niño cycles 2.1 OBSERVED AND PROJECTED [7]. Glacier volumes in the central Karakoram CLIMATE CHANGE have been stable or increasing over the past The diversity of Pakistan’s topography results two decades due to the rise in the summer and in substantial climatic differences across the winter precipitation levels. country. Along the coast and the lowland plains of the Indus, it is predominately hot and dry, becoming Projected temperature increases in Pakistan progressively cooler moving northeast toward will redefine the magnitudes of extreme-heat the mountains. There have historically been four exposure. Average monthly temperature increases distinct seasons: (a) the dry, cool winter from across Pakistan, under the SSP3-7.0 emissions December to February; (b) the dry, hot spring scenarios, will range from 0.73°C to 1.04°C in the from March to May; (c) the southwest monsoon 2030s and from 1.33°C to 1.91°C in the 2050s. period or the summer rainy season from June These increases are similar for both average to September; and (d) the retreating monsoons minimum and maximum daily temperatures. from October to November [7]. These increases will make the populations of Average annual temperatures across Pakistan Punjab and Sindh especially vulnerable. From have risen by over half a degree Celsius over the past century. Subnational average annual May to August, average temperatures will range temperature spiked as high as 27.75°C in the Sindh from 34.19°C to 36.28°C in Punjab and 32.88°C to province, demonstrating profound temperature- 36.3°C in Sindh during the 2050s. Daily maximum related exposures across the country. The northern temperatures during the same time period are provinces — such as Khyber Pakhtunkhwa — are especially alarming, ranging from 46.82°C to vulnerable to lower temperatures, while Punjab, 47.7°C in Punjab and 46.44°C to 47.18°C in Sindh Sindh, and Balochistan are vulnerable to higher (Figure 2). temperatures throughout the year. Much of the observed warming has been skewed toward the winter and the post-monsoon months of November 12 | Climate and Health Vulnerability Assessment: Pakistan The diversity of Pakistan’s topography results in substantial climatic differences across the country. FIGURE 2. Projected average daily maximum temperature across the provinces of Pakistan in the 2050s 50˚C 40˚C 30˚C 20˚C 10˚C 0˚C Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Balochistan Federal Capital Territory Khyber Pakhtunkhwa Punjab Sindh Source: World Bank Climate Change Knowledge Portal FIGURE 3. Monthly changes (that is, anomalies) in average precipitation in the 2050s under SSP3-7.0 among the regions of Pakistan 35 30 25 20 15 10 5 0 -5 -10 Balochistan Federal Capital Khyber Pakhtunkhwa Punjab Sindh Territory Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Source: World Bank Climate Change Knowledge Portal Climatology | 13 Sea-level rises (SLR) pose significant threats to Pakistan’s physical coastlines and coastal ecosystems. The largest increases in average monthly By the 2050s, precipitation is expected to keep temperatures are projected to occur during the increasing throughout Pakistan. The projected spring season (March–May) and in September, national rate of increase is 10.30 percent, observing signaling a lengthening of the “summer,” that is, most of this trend in Sindh and Punjab (13.23 and warmer temperatures that will be compounded 19.05 respectively). by escalating nighttime temperatures. By the 2050s, the annual number of tropical nights — Sea-level rises (SLR) pose significant threats characterized by nighttime temperatures that do to Pakistan’s physical coastlines and coastal not fall below 20°C — will reach a maximum of ecosystems. Without adaptation, studies suggest 241.28 days in the province of Sindh (Table 1). The that over 1 million people may face coastal result of this is that nighttime temperatures in Sindh flooding annually by the end of the century under will not fall below 20°C from April to October. This a high-emissions scenario [48]. Over the past is a concern because the human body needs to century, the mean sea level has risen by 1.1 mm/ have the opportunity to cool down adequately year on average for Pakistan, and between 1989 after experiencing high daytime temperatures. and 2018, the Sindh coastline had seen a mean erosion rate of 15–20 m/year4 in the Indus Delta A more thorough discussion of the implications [8]. It is anticipated that global mean SLR will be of these temperature changes and extreme heat 0.2–0.6 m by the end of this century, whereas in general is provided in the following section. for South Asia (including Pakistan), the figure is projected to be slightly higher at 0.7 m (0.42 – Pakistan has a relatively high degree of 1.12 m in range) [9]. interannual and interdecadal variability in its precipitation regime. Projections indicate an In terms of regions, Sindh is particularly increasing trend in precipitation for Pakistan vulnerable to increases in coastal flood risks, toward the mid-century, with significant subnational due to its coastal topography, in combination differences in projected rainfall.3 During the 2030s, with higher storm surges caused by SLR and Pakistan’s annual precipitation is projected to predicted changes in storm frequency and increase by 10 percent at the country scale. The severity. Future SLR risks are expected to be largest increases are likely to occur in Punjab the highest in the more eastern low-lying coastal and Sindh (+12.11 and 11.66 percent each). areas south of Karachi toward Keti Bander and within the Indus River delta [10]. Balochistan, though a coastal province, is less vulnerable to the impacts of these events due to its higher coastal topography. Tropical cyclones do make landfalls on Pakistan’s coastline, though these 3 Information presented in this assessment reflects current scientific understanding and modeling capabilities. There are high levels of uncertainty for future precipitation rates in Pakistan, due to the model’s weak performance in simulating future changes in the South Asian 4 Erosion rates of -14.17 +/- 0.55 m/year and -19.96 +/- 0.65 m/year on the monsoon and the dynamics of the El Niño Southern Oscillation. western and eastern sides of the Indus Delta Region, respectively. 14 | Climate and Health Vulnerability Assessment: Pakistan have historically been uncommon, as windstorms to August. In addition to the already high daily typically lose much of their intensity before maximum temperatures, heatwave events6 reaching Pakistan [11]. However, it is important commonly affect both these regions, further to point out that the amplitude of surge events, exacerbating the situation. The 2015 heatwave associated with these types of storms, can be event was especially deadly, the health outcomes several meters high and the continued rise of of which are discussed in the next section. global mean sea levels is likely to exacerbate storm-surge effects [10]. Water, used for drinking, bathing, and cooling, is an important adaptation resource during periods of intense heat. With Pakistan expected 2.2 CLIMATE-RELATED HAZARDS to experience changing precipitation patterns, characterized by increased periods of aridity that There are several climate-related hazards are predicted to overlap with the hot seasons, affecting population health in Pakistan, many particularly as this gets longer due to climate of which have already demonstrated increases change, water resources will be limited, and water in frequency and intensity. Pakistan is among availability constrained. This will, therefore, have the most disaster-prone countries in the world: an impact on adaptive capacity, which can be it is ranked eighth among the 10 most affected expected to increase vulnerability, especially for countries globally, according to the Climate the populations of the Sindh and Punjab regions. Vulnerability Index of 2019 [12]. The most common climate-related hazards are extreme heat, floods, Sub nationally, Punjab and Sindh, are projected landslides, mudslides, and droughts — each of to experience the most extreme heat exposure which can profoundly affect population health. during the 2030s and 2050s. The largest percentage increases in the number of days above 35°C and 40°C will occur in the Federal Capital 2.2.1 EXTREME HEAT Territory— a 22 percent increase in the number In some regions of Pakistan, mean tempera- of very hot days and a 64 percent increase in the tures are already at, or very near, recognized number of extremely hot days by 2050 (Table extreme heat thresholds and are increasing.5 1). Though Sindh, Punjab and Balochistan has Whereas the previous discussion covers overall historically experienced extreme temperatures, historic and projected temperature changes, the population in this region and other regions this section focuses on temperature extremes, may lack the capacity and the experience to using two recognized classification thresholds: (i) adequately deal with such extreme, sustained very hot days: ≥35°C and (ii) extremely hot days: temperatures. Across Pakistan, the increase in the ≥40°C. Notably, there are overlaps between these number of very hot and extremely hot days will discussions, given how high temperatures across mean that for regions such as Punjab and Sindh, Pakistan are occurring now and into the future. only rarely will there be days where temperatures are below 35°C from May to September. Observed temperatures from 1995 to 2014 show that Sindh and Punjab are the most vulnerable Populations in the major urban areas of these to temperatures ≥35oC. Mean monthly tempera- regions are especially at risk since tempera- tures in these regions exceed 35°C from May 6 In this instance, a heatwave is defined as five or more consecutive days during which the daily maximum temperature surpasses the average 5 As defined by temperatures ≥35°C. maximum temperature by 5°C (9°F) or more. Climatology | 15 tures in cities will exceed those of surrounding in the 2030s and by 3.49 mm (to 31.65 mm) on rural areas. Urban areas become “heat islands” average by the 2050s. During the 2030s, these of higher temperatures than outlying areas, due to increases will be the most profound in February the relative lack of greenery, coupled with the high through April and in September (+5.23mm), partic- concentration of infrastructural development that ularly in the Sindh province (Table 2). During the re-emits heat more than natural landscapes [13]. 2050s, Sindh will experience the greatest increase Therefore, heatwave events in urban regions will (+9.32mm), but the Federal Capital Territory will be more severe than surrounding areas. Extreme be experiencing greater average 1-day precipi- daytime temperatures will be compounded by a tation with 71.36mm. simultaneous rise in the projected number of tropical nights (Table 1), providing inadequate nocturnal A second measure to consider is projections for recovery from daytime extremes, particularly due five-day cumulative rainfalls; these represent to the absence of artificial cooling measures. a different flood risk where areas can become saturated over a number of days. In this sense, Pakistan will experience an increase of 14.28mm 2.2.2 FLOODS and 22.05mm in the 2030s and 2050s respec- Climate-related increases in total and extreme tively. Sindh will experience the greatest increase precipitation, combined with the westward shift (+9.32mm), but the Federal Capital Territory will of the Asian monsoon, are leading to severe be experiencing greater average 1-day precipi- flood risks affecting every province in Pakistan. tation with 71.36mm. The 2010 monsoon was particularly significant, leading to some of Pakistan’s most severe floods. 2.2.3 LANDSLIDES This event inundated one-fifth of the country — affecting 20 million people and claiming over Landslides can cause damage to homes and 2,000 lives [14]. Since 1991, over 84 severe flood infrastructure, as well as significant losses of life events have occurred, affecting over 65 million in Pakistan. The relationship between landslides people [15]. In addition to riverine floods from and climate change is complex. While changes extreme precipitation, the high-altitude regions of in rainfall and temperature may lead to more Pakistan are also vulnerable to glacial lake outburst landslides, increasing droughts and vegetation floods (GLOFs): they are triggered by melting can decrease the likelihood of these events ice, which can release large volumes of water, [16]. Table 3 shows reported landslide events in often down heavily populated mountain valleys. Pakistan from 1991 to 2020, including the total Significant uncertainty exists around predicting number affected and mortalities associated GLOFs, since these events are dependent on with each event. It should be noted that these the future extent of glaciers in the mountainous statistics differ considerably from the National areas affecting Pakistan. This in turn is heavily Aeronautics and Space Administration’s (NASA) dependent on temperature rises and changes Global Landslide Catalog (GLC), since they only in local precipitation levels. report the 85 landslides and the mudslides that have taken place since 2007 [17]. Centralized Extreme precipitation magnitudes are projected reporting from the Ministry of Climate Change and to increase over the 2030s and 2050s. Projected Environmental Coordination on landslide events, figures for the largest 1-day precipitation will along with associated morbidity and mortality increase by 2.6 mm (to 30.84 mm) on average rates in Pakistan, is not available. 16 | Climate and Health Vulnerability Assessment: Pakistan TABLE 1. Annual number and percentage increase of very hot days (>35°C), extremely hot days (>40°C), and tropical nights in the 2030s and 2050s, under SSP3-7.0, throughout the regions of Pakistan COLUMN 1 REF. PERIOD 2030s 2050s COLUMN ONE # Days # Days % Increase # Days % Increase VERY HOT DAYS (>35°C) Pakistan 114.09 123.56 8.30% 135.08 9.32% Balochistan 112.22 124.81 11.22% 138.51 10.98% Federal Capital Territory 39.2 45.29 15.54% 55.66 22.90% Khyber Pakhtunkhwa 33.75 39.1 15.85% 45.62 16.68% Punjab 146.24 154.13 5.40% 166.73 8.17% Sindh 187.27 198.89 6.20% 212.57 6.88% EXTREMELY HOT DAYS (>40°C) Pakistan 40.38 48.26 19.51% 58.47 21.16% Balochistan 34.76 44.83 28.97% 56.34 25.67% Federal Capital Territory 4.66 6.78 45.49% 11.18 64.90% Khyber Pakhtunkhwa 9.36 11.34 21.15% 14.36 26.63% Punjab 58.66 66.49 13.35% 78.26 17.70% Sindh 70.59 81.32 15.20% 96.31 18.43% TROPICAL NIGHTS (>20°C) Pakistan 146.69 156.35 6.59% 166.5 6.49% Balochistan 144.58 158.08 9.34% 170.91 8.12% Federal Capital Territory 123.25 133.57 8.37% 144.4 8.11% Khyber Pakhtunkhwa 72.65 79.4 9.29% 87.09 9.69% Punjab 185.29 192.84 4.07% 202.5 5.01% Sindh 220.79 230.6 4.44% 241.28 4.63% Source: World Bank Climate Change Knowledge Portal. Climatology | 17 TABLE 2. Projected extreme precipitation anomalies for Pakistan for the 2020–2039 and 2040–2059 periods, under SSP3-7.0, from the 1995–2014 reference period AVG 1-DAY 5-DAY CUMULATIVE 2030S 2050S 2030S 2050S Pakistan 2.6 3.49 14.28 22.05 Balochistan 1.5 2.86 13.8 17.03 Federal Capital Territory -0.28 -2.8 12.66 12.89 Khyber Pakhtunkhwa 1.84 1.44 7.95 14.11 Punjab 1.97 2.56 7.93 16.98 Sindh 7.52 9.32 30.88 51.4 TABLE 3. Landslide events from 1991 to 2020 HAZARD EVENTS NO. EVENTS NO. DEATHS NO. AFFECTED Avalanche 10 424 4,335 Landslide 9 222 29,707 Mudslide 1 12 12 Total 20 658 34,054 Source: [15]. 2.2.4 DROUGHTS is expected to increase from 17 percent between Pakistan is highly vulnerable to droughts due to 2020 and 2039 to 66 percent between 2080 and the erratic monsoon rainfall and rising tempera- 2099 [48]. Even as they increase in frequency, tures; moreover, the likelihood of severe droughts droughts are also projected to increase in severity is expected to increase. The duration of drought in all the provinces of Pakistan, according to the conditions can be considerable: the worst drought annual Standardized Precipitation Evapotranspira- in Pakistan’s history began in 1997 and lasted tion Index (SPEI). Currently, Pakistan encounters an through 2002. Historically, the southwestern areas annual median likelihood of experiencing severe of Pakistan, including Balochistan and the coastal belt of Sindh, have been particularly vulnerable meteorological drought, estimated at approxi- to drought conditions [18]. The annual mean mately 3%. This classification is based on when probability of severe meteorological droughts SPEI falls below -27. 7 The reported SPEI was extracted from the Climate Change Knowledge Portal, using the Coupled Model Intercomparison Project 5 (CMIP5) 18 | Climate and Health Vulnerability Assessment: Pakistan 2.3 KEY MESSAGES Historic Observations • Warming in Pakistan is accelerating and is strongly skewed toward the winter and post-monsoon months, most notably affecting Sindh, Punjab, and Balochistan. • Average annual rainfall in Pakistan has increased over the last half century, albeit with important subregional variations. Projected Climate • Projected temperature increases in Pakistan will redefine the magnitudes of extreme heat exposure. The historic summer season is projected to lengthen, compounded by rising nighttime temperatures. • An increasing trend in precipitation will be occurring until the mid-century, with projections characterized by high levels of uncertainty. Following this period, however, most regions will experience an increase in precipitation. Sea-Level Rises (SLR) • An average increase of 1.1 mm/year had been observed between 1989 and 2018, characterized by erosion impacts for Sindh’s coastline and a loss of 15–20 m of land per year in the Indus Delta. • Future SLRs will have the greatest risk in the low-lying coastal areas south of Karachi toward Keti Bander and within the Indus River delta. Climate extremes: • Extreme Heat: Across most of Pakistan, mean temperatures are already at, or very near, recognized extreme-heat thresholds, and rising. Northern regions are projected to experience the most substantial increases in extreme heat exposure during the 2030s and 2050s. • Extreme precipitation: Increases in total and extreme precipitation, combined with a westward shift of the Asian monsoon, are leading to severe flood risks that are affecting every province in Pakistan. This trend is predicted to continue to increase through the 2030 and 2050s. • Landslides: Increases in heavy-precipitation events, combined with populations and land-use factors, may result in increased landslide risks causing damage to homes and infrastructure, as well as significant losses of life in Pakistan. • Drought: Severe droughts already occurs and is expected to increase by 17 percent for the 2030s and by 66 percent by the end of the century. Climatology | 19 SECTION 3. CLIMATE-RELATED HEALTH RISKS Pakistan has demonstrated some important improvements in health status over the last two decades, albeit with persistent geographic disparities and an increasing burden of noncommunicable diseases (NCDs). Although the maternal mortality ratio (MMR) had halved from 286 deaths in 2000 to 140 per 100,000 live births by 2017, the rate remains high among global and regional comparisons [1]. During the same period, the infant mortality rate (IMR) declined from 84.4 to 58.9 per 1,000 live births, while the under-five mortality rate dropped from 107.5 to 71.6 per 1,000 live births [1]. Life expectancy at birth increased from 62.8 in 2000 to 67.2 in 2019 [19]. Despite these notable achievements, Pakistan the poor, rural populations, those living in informal is experiencing an epidemiological transition, urban settlements, women and young children, the characterized by a shift from communicable elderly, those living with pre-existing conditions diseases (CDs) to noncommunicable diseases and disabilities, as well as displaced populations. (NCDs). Although NCDs now account for about Investment in adaptation and mitigation measures 60 percent of all deaths, the burden of CDs is still must consider who directly benefits from by significant [20]. This is important, since many CDs adopted measures or who may be disadvan- and NCDs are climate-sensitive and will therefore taged by them. interact with the overall climate-related burden of disease. Other categories of health outcomes, such Pakistan’s CHVA assesses four climate-related as mental health, are also important to consider, health risk categories. These categories include when looking at the climate-related burden of heat-related risks, vector-borne disease (VBD) disease. In Pakistan, nearly 50 million people risks, waterborne disease (WBD) risks, and risks suffer from some form of mental illness; at the to nutrition. Each category is assessed in terms time of the preparation of this assessment, the of current and future risks, with considerations mental illness situation was also compounded for both national and subnational peculiarities by the impacts of the COVID-19 pandemic [21]. where possible. It is important to note that these risk categories represent only the most pressing Risks to health from climate change are not health risks to people in Pakistan. Other climate-re- evenly distributed in the population: some lated health risks have not been included in this groups are at greater risk than others. The factors assessment: they may incorporate, but are not that affect a population’s vulnerability to climate limited to, air quality and pollution as it relates change are often similar to those that affect health to respiratory health, the cross-cutting risks of more broadly [22]. However, climate change may ongoing climate change on mental health, along exacerbate health inequalities, especially among with direct injuries and mortalities associated certain vulnerable population groups, including with natural hazard events. 21 In particular, health risks related to poor air on record, especially in Karachi. This event has quality are recognized as a major environmental had an important impact on the population and health threat, globally and in Pakistan. The serves as a key reference point for most coun- South Asia region, including Pakistan, has the try-level studies on heat and human health. The worst air quality levels and a high air pollution-as- 2015 event affected the southern parts of the sociated health burden. In addition to already country in particular, resulting in approximately suffering some of the highest annual average 1,200 deaths in Karachi [15]. During this event, the fine particulate matter (PM2.5) exposures in the heat index rose to around 66°C [24], resulting in world, Pakistan is one of the few countries that a high number of patients, particularly the elderly, continue to experience increases in ambient air being admitted to emergency departments with pollution, with an increase in 3.0 micrograms per heatstroke. Residents of Karachi were approxi- cubic meter (ug/m3) between 2010 and 2019. The mately 17 times more likely to die of a heat-related five most populated cities in Pakistan (Karachi, cause during this event when compared with the Lahore-Johor Town, Peshawar, and Rawalpindi) previous year (for the same period). Residents with available air pollution data have annual mean with lower monthly incomes and lower education PM2.5 levels that are higher than the recommended levels were at a significantly higher risk of death WHO value of 10 μg/m³. The relationship among [25]. air pollution, climate change, and human health impacts is complex, but important. Although a Much of the information on morbidity also came comprehensive quantitative assessment of the from the 2015 event. A key study found that health impacts of air pollution in Pakistan is beyond among cases of heat-related illnesses admitted the scope of this CHVA, further investigation into to the hospital, heat stroke was the most common the gaps in evidence is recommended. and present in nearly two-thirds of the cases (64.2 percent), followed by heat exhaustion (35.8 percent), heat syncope (3 percent), and heat cramps 3.1 HEAT-RELATED RISKS (3 percent). Almost half of the patients needed The health risks of heat are wide-ranging, to be placed in high dependency units, with a including the effects on mortality, heat-re- mean hospital stay of 4 days [26]. lated injuries, along with mental health and wellbeing. Health effects caused by heat include Excess heat-related deaths in Pakistan are the direct effect of heat stress, along with heat very likely to increase under a high- emissions rash, cramps, exhaustion, and dehydration, as scenario. Routine statistics on annual heat-related well as the acute exacerbation of pre-existing deaths are not available in Pakistan. However, a conditions including respiratory and cardiovascular recent study demonstrated that all-cause mortality diseases. Longer-term mental health risks are also in Pakistan is significantly impacted by high an important effect to consider. In addition to the temperatures [27]. Based on the study findings, impacts on individuals, the whole-of-population the relative risk of mortality in Pakistan during exposure that occurs with an extreme heat event the 2000–2019 period increased by 27 percent, can lead to significant increases in hospitalizations, when comparing the number of deaths occurring thus imposing a strain on health system [23]. at monthly maximum temperatures of 35–40°C with those at monthly maximum temperatures Pakistan is known to experience regular of 25–30°C (considered to be the base point, heatwaves, with 2015 being one of the deadliest as the number of deaths is minimal). 22 | Climate and Health Vulnerability Assessment: Pakistan Further, and for the same time period, modeled 3.2 VECTOR-BORNE DISEASE annual heat-related deaths in South Asia are estimated at approximately 7 per 100,000 (VBD) RISKS (95 percent CI: 4–10) [28], which if extrapo- Weather and climate are the critical drivers of lated to Pakistan, would translate to a little spatiotemporal vector-borne disease (VBD) over 15,000 heat-related deaths annually. distribution and transmission dynamics. The Considering envisaged temperature increases epidemiology of VBDs is directly influenced by envi- under SSP3-7.0, the implications of a change ronmental factors that facilitate vector development in the maximum temperature on mortality in and survival. Climate variability causes vector Pakistan could lead to excessive deaths well and host ranges to expand or contract, shifting beyond the current estimate. Framed differently, disease distribution and seasonality, and/or facil- based on climate change projections (see Section itating the emergence or reemergence of VBDs II), Pakistan will likely experience increases in [30]. Although Pakistan is affected by other major the number of hot days (maximum temperature VBDs including chikungunya, leishmaniasis, and [Tmax] > 35°C) and very hot days (Tmax > 40°C), Crimean Congo hemorrhagic fever, along with with the highest increases in Sindh, Punjab, and the emerging threats of Zika, yellow fever, and Balochistan regions, especially during June, July, Japanese encephalitis (JE) [31], this assessment and August. For example, Sindh, under SSP3-7.0 focuses on mosquito-borne VBDs — dengue emissions scenarios, may experience 212.57 hot and malaria — given their burden or potential days (Tmax > 35°C) and 241.28 tropical nights in Pakistan. (minimum temperature [Tmin] > 20°C) a year by the 2050s. This may possibly expose nearly Investigating species distribution and seasonality 48 million people to potentially life-threatening of vectors is valuable to understanding plausible temperatures, with adverse implications on the VBD distributions and planning efficient, spatially health of those populations, particularly vulnerable targeted methods of control. Spatial models groups such as pregnant women, children under were constructed to demonstrate the plausible five years of age, and people over 65 years old. spatial distributions of the vectors of dengue and malaria to assess the risk propensity of these Future risks of increased temperature are also diseases. projected to reduce labor productivity, while increasing the risk of accidents and injury, as Nonetheless, it is important to recognize that well as heat stress in workers. The International spatial modeling results are limited by the input Labour Organization (ILO) estimates that Pakistan data’s spatial resolutions and dependent on the may lose more than 5.5 percent of working hours future extent of glaciers in the mountainous in 2030, owing to excessive heat; most of these areas. For further information on the modeling lost days are in the construction industry and the methodology and inputs, see Annex III. agriculture sector [29]. The risk of rising tempera- tures is and will be compounded by poor housing, urban and rural poverty, water insecurity, and an aging population, with the increased prevalence of NCDs. Climate-related health risks | 23 3.2.1 DENGUE to increase to 36 percent and decrease to 35 Dengue is the fastest-emerging arboviral threat percent, during the respective time periods having in Pakistan, with an 800-fold increase in cases around 61 million population being exposed. Sub between 1995–2004 and 2019.8 Dengue is nationally, however, differences in population transmitted by the bite of infected Aedes (Ae.) vulnerability will occur, having mountainous regions aegypti and, to a lesser extent, Ae. albopictus experiencing an increase in vector suitability, mosquitoes. These species prefer biting humans as higher elevated areas will see an increase in over animals and are commonly found in urban temperature. Notably, Khyber Pakhtunkwa will and peri-urban environments. Vector feeding and experience the greatest increase of population habitat preferences, coupled with other factors exposed to dengue vectors (See Table 4). Overall, including climate and environmental changes, as while the population exposed at national level well as human population dynamics, in Pakistan, will remain relatively unchanged, the geographic have and will continue to influence the patterns distribution and vector suitability will be altered of the dengue transmission risk. due to changes in temperature and precipitation patterns. More than 62 million people are vulnerable to dengue in Pakistan, with the populations of Ongoing climate and infrastructural changes Punjab and Islamabad at highest risk. Suitability in Pakistan could promote the emergence of is largely concentrated in the north-central portion Zika, yellow fever, and Japanese encepha- of the country and within the Indus Basin. Model litis (JE). Vectors of dengue in Pakistan are the results of the historic period show that nearly 54 same mosquito species that transmit Zika and percent of Punjab is suitable for the dengue vector yellow fever — diseases that are endemic in species — approximately 16 percent of which neighboring China and India. Suitable areas for is populated by more than 31 million people. In dengue described above have the potential to Islamabad, nearly 80 percent of the total area become areas at risk for the transmission of Zika is suitable for dengue vectors: of this area, 16 and yellow fever. Punjab, and Sindh have sizable percent is populated by more than 350,000 people. populations of the JE mosquito vectors (Culex These findings are supported by 2019 statistics tritaeniorhynchus and Culex pseudovishnui) [31]. of dengue infection in Pakistan: 43 percent of In addition, the ongoing infrastructural changes, overall cases and 23 percent of dengue-attributable associated with the China-Pakistan Economic deaths occurred in the cities of Islamabad and Corridor (CPEC), could also facilitate Zika, yellow Rawalpindi, which are located in the Islamabad fever, and JE transmission. Along the eastern route and Punjab provinces, respectively [31]. Overall, of the CPEC, there is a large swine population 36 percent of Pakistan is suitable for dengue — the amplifier host of the JE virus [31]. Trans- vectors. portation via the CPEC from either China or India — endemic countries for JE — poses a significant Ongoing climate change will alter the geography threat to VBD emergence in Pakistan. While the of dengue transmission risk in Pakistan. On the national scale, overall suitability for dengue intention of this analysis aims to support dengue vectors will largely remain unchanged. In the control measures, findings may also be extrap- 2030s and 2050s, the suitable area is expected olated to assist in curtailing other VBD threats, including those transmitted by Ae. aegypti and 8 Dengue cases from 1995 to 2004: 699; dengue cases in 2019: 56,000. Ae. albopictus vectors. 24 | Climate and Health Vulnerability Assessment: Pakistan TABLE 4. Area of suitable dengue vector species habitat, by province, in Pakistan (percentage) PERCENT AREA POPULATED, SUITABLE OVERALL SUITABILITY VULNERABLE POPULATION Historic 2030s 2050s Historic 2030s 2050s Historic 2030s 2050s Sindh 7.63 7.63 7.63 51.93 51.93 51.88 12,920,689 12,920,689 12,920,689 Punjab 15.82 15.38 15.29 53.94 53.02 52.08 31,659,749 31,071,289 30,759,303 Khyber 8.62 8.75 8.68 43.74 46.56 45.68 11,885,363 12,083,359 12,042,013 Pakhtunkhwa Islamabad 31.97 31.97 31.97 78.94 78.94 78.94 358,759 358,759 358,758 Balochistan 1.37 1.37 1.37 21.93 21.93 21.93 2,379,293 2,379,293 2,379,293 TOTAL 59,203,853 58,813,389 58,460,056 Sources: Temperature (NASA, NEX-GDDP) Land Cover (Copernicus Global Land Service, Proba-V-C3), Water Resources (European Commission’s Joint Research Centre, GSW1_0), Flow Accumulation (World Wide Fund for Nature, HydroSHEDS), Population (European Commission’s Joint Research Centre, GHSL/P2016/POP_GPW_GLOBE_V 3.2.2 MALARIA of Punjab during the historic period was suitable for Over 60 million people live in high-risk areas the malaria vector species, this area is populated of malaria and nearly 50 million live in areas by more than 70 million people — 65 percent of of low to medium risk [32]. These figures were Punjab’s total population. More than half of all estimated in 2018 and show that malaria is an regions in Pakistan demonstrate a total suitable important cause of morbidity and mortality in area of greater than 50 percent for malaria vector Pakistan. Historically, Sindh have been among species. Model results across all time periods the regions with the highest number of malaria show that 100 percent of the Islamabad Capital cases across the country. Plasmodium vivax is Territory is suitable for malaria vectors, 51 percent responsible for more than 80 percent of cases, of which is currently populated by more than 1.4 while Plasmodium falciparum accounts for the million people (See Annex III for methodology remaining 20 percent [31]. Predominant malaria of model estimation). vectors in Pakistan are Anopheles (An.) stephensi and An. culicifacies. Notably, the species is also Shifting the suitability of malaria vectors in known to colonize irrigated areas [34], and Pakistan Pakistan will marginally change the subnational boasts the world’s largest contiguous irrigation geography of malaria transmission risk through system in the Indus Basin, irrigating over 2.5 2050 under high-emissions scenarios. Around million acres [35]. 37 percent of Pakistan will be suitable for malaria vectors during all the time periods assessed. The population living in Punjab is the most However, subnational variations and the vulnerable to malaria, albeit with decreasing populations impacted could potentially result vulnerability through 2050. While only 56 percent in fewer people being at risk. (See Table 5). Climate-related health risks | 25 Despite the strong correlation between VBD environmental conditions, the risk of VBDs could vectors and climate factors, climate is merely be quite substantial. one determinant in the VBD transmission risk. The future risk of these diseases will depend not only on changing climate conditions that define 3.3 WATERBORNE DISEASE RISKS vector suitability, but also environmental, social, The burden of waterborne diseases (WBDs) and economic conditions. For example, climate throughout Pakistan is significant, characterized change is arguably less of an immediate threat to by high rates of morbidity and mortality; WBDs the emergence of Zika, yellow fever, and JE than are especially deadly in the case of children under the increasing connectivity between Pakistan and endemic countries that is facilitated by the CPEC. five years of age. In 2019, diarrheal diseases were the fourth-leading cause of mortality in Pakistan In recent years, Pakistan has made notable [39]. Current drivers of WBDs throughout the progress in reducing malaria morbidity and country are attributable to many factors, including mortality. For example, Punjab, despite having sources, quality, and quantity of drinking water; the largest overall population at risk of malaria in sanitation facilities; and hygiene practices [40, terms of vector suitability, was recently declared 41] — each of which may be affected by weather malaria-free, along Islamabad [31]. However, without and climate change. comprehensive vector management strategies that give due consideration to both climate and TABLE 5. Area of suitable malaria vector species habitat, by province, in Pakistan (percentage) PERCENT AREA POPULATED, SUITABLE OVERALL SUITABILITY VULNERABLE POPULATION Historic 2030s 2050s Historic 2030s 2050s Historic 2030s 2050s Sindh 7.95 7.96 7.96 52.26 52.35 52.29 19,030,867 19,032,143 19,032,143 Punjab 16.91 16.81 16.40 55.68 55.96 54.43 71,468,706 71,511,284 67,265,162 Khyber 10.09 10.26 10.25 52.18 54.64 52.16 22,840,150 23,138,578 22,982,268 Pakhtunkhwa Islamabad 50.97 50.97 50.97 100 100 100 1,431,197 1,431,197 1,431,197 Balochistan 1.38 1.38 1.38 21.97 21.88 21.88 2,529,348 2,529,348 2,529,348 TOTAL 117,300,268 117,642,550 113,240,118 Sources: Temperature (NASA, NEX-GDDP) Land Cover (Copernicus Global Land Service, Proba-V-C3), Water Resources (European Commission’s Joint Research Centre, GSW1_0), Flow Accumulation (World Wide Fund for Nature, HydroSHEDS), Population (European Commission’s Joint Research Centre, GHSL/P2016/POP_GPW_GLOBE_V 26 | Climate and Health Vulnerability Assessment: Pakistan Understanding the historic burden and patterns drinking water [40] and estimates suggest that of diarrheal diseases in Pakistan is challenging in 30 percent of all diseases and 40 percent of all the absence of a dedicated surveillance system mortalities can be attributed to polluted water [41]. [42]. However, findings from the Demographic The decline in Pakistan’s surface water quality is Health Surveys conducted in Pakistan (PDHS) show attributable to contamination from sewage and that overall, the country had seen a downward industrial effluents, in addition to agricultural trend in the prevalence of diarrhea in children runoff to the water supply [40]. under 5 years of age in the two weeks prior to the survey, decreasing from 23 percent in Climate change can impact water quality through the 2012–2013 PDHS [43] to 19 percent in the temperature increases, which facilitate the 2017–2018 PDHS [44]. Prevalence rates were the proliferation of waterborne bacteria and algal same for children in urban and in rural areas (19 toxins, and through flood events caused by percent) in 2018, though children from urban areas the increasing intensity of precipitation and were more likely to receive advice or treatment glacial melting in some regions of Pakistan. [44]. Notably, regions such as Punjab and Khyber Floods not only damage sanitation infrastruc- Pakhtunkhwa have a prevalence of diarrhea above ture, but also carry pathogens, dissolved organic 20 percent (See table 6). pollutants, industrial effluents, and agricultural runoff into surface water and groundwater sources. Water quality is the most significant driver of Drought conditions also affect water quality and waterborne diseases (WBDs) in Pakistan. Only limited water quantity can force populations to 20 percent of the population has access to safe use contaminated water sources for drinking, TABLE 6. Two-week prevalence of diarrhea in children under 5 years in Pakistan, 2018 PERCENTAGE WITH DIARRHEA Region Sindh 14.4 Punjab 20.5 Khyber Pakhtunkhwa 21.3 Islamabad 19.7 Balochistan 18.6 SOURCE OF Improved 19.3 DRINKING WATER Unimproved 17.1 TYPE OF TOILET Improved 19.1 FACILITY Unimproved sanitation 19.1 Shared facility 22.4 Unimproved facility 18.7 Open defecation 16.5 Source: PDHS 2017–2018 [44] Climate-related health risks | 27 bathing, and agricultural irrigation. Limited data where sewer drains do exist, they are commonly make quantifying the direct risk of climate on open, with no treatment of effluents, which can the historic prevalence of WBDs in Pakistan lead to soil and water contamination in normal challenging. However, recent extreme weather conditions and present a significant risk to health events highlight the country’s vulnerability to WBD under flood conditions. risks. In 2010, heavy monsoons rains led to one of the worst flood events in Pakistan’s history, Alongside floods, increased temperatures with the reported laboratory confirmation of 99 due to climate change may lead to Sindh and cases of cholera from flood-affected regions [45]. Balochistan experiencing more frequent and / Likewise, floods in Karachi in August 2020 led or intense drought events, with the consequent to reports of cholera, typhoid, and hepatitis, as increased rates of diarrheal diseases driven water supply lines were compromised [46]. by insufficient water quality and inadequate quantity availability for hygiene practices. This Waterborne diseases (WBDs) are likely to would lead to outbreaks of E. coli and Salmonella increase in Pakistan in the face of a changing from the combination of contaminated food climate, with potentially more than 5 million sources and inadequate hygiene facilities. The people at risk. Despite the potential for significant impact of floods and droughts on WBD risks will health impacts, the research on the relation- be compounded by socioeconomic inequalities ship between climate change on water quality including poverty, level of education, access to and WBDs in Pakistan is insufficient to provide healthcare, age, and gender [50]. precise estimations of future projections of the WBD risk [47]. However, it is recognized that extreme weather events increase WBD risk, 3.4 NUTRITION RISKS such as through floods and droughts. Floods in Weather and climate are the foundational drivers Pakistan are projected to increase in frequency of healthy and sustainable diets. The mechanisms and intensity, with an additional population of by which climate change affects nutrition via the approximately 5 million potentially exposed to food system are profound, and include acute and extreme riverine floods by 2035–2044 [48]. chronic effects on agricultural production, storage, Likewise, the rate of glacial melting in South Asia processing, distribution, and consumption (Figure has increased, with consequent flood impacts 4). Nutritionally secure and stable diets not only for the population at risk [49]. Districts along the depend on agricultural production, but also on Indus River system will be the most vulnerable the complex interactions of demand, economics, to flood related WBD risks. legislation, conflict, food waste, nutrient losses, food safety, and access [51]. Climate variability is Taking historic flood events in Pakistan as an already contributing to increases in global hunger indication, the increase in future flood events and malnutrition [52]. could result in the breakdown of sanitation infrastructure, thus leading to the contamina- While a comprehensive analysis of climate tion of the drinking water supply and in turn change’s impact on the food system is beyond the increasing the rates of diarrheal diseases scope of this assessment, this CHVA examines including cholera, cryptosporidiosis, rotavirus, climate and nutrition linkages through a food typhoid, and paratyphoid. Evidence from the security lens in Pakistan, as they relate to the rural areas in regions such as Punjab show that weather and climate impacts on agricultural 28 | Climate and Health Vulnerability Assessment: Pakistan FIGURE 4. Stages of the food system driving healthy and sustainable diets Source: [54]. Healthy & Sustainable Diet Agriculture Storage Processing Distribution Consumption Production Unhealthy & Climate Change Post-harvest Loss Nutrient Losses Demand Culture Unsustainable Diet Land Use Mycotoxins Fortification Trade A ordable Water Use Nutrient Losses Waste Politics Accessible Waste Waste Legislation Economics Preferences Extreme Weather Nutrient Losses Nutrient Losses Legislation & Policies Waste Waste productivity. This is highly relevant, as agricul- but also through the interaction of several other tural productivity — a key determinant of food factors related to crop production, consumption availability — is affected by weather and climate and access to food, along with health, population in a multitude of ways, from short-term shocks growth, sanitation, and care practices [54]. (for example, natural disasters) to longer-term changes in agroecological conditions, which can Affordability is a critical determinant of proper drastically reduce yields or redefine spatiotem- nutrition across Pakistan. Food insecurity is poral patterns of crop suitability. strongly correlated with poverty. The average household in Pakistan spends nearly 51 percent Nearly 40 percent of the population in Pakistan of its monthly income on food [55] and more than is food-insecure, and the prevalence of child two-thirds of the households cannot afford a nutri- malnutrition — among the highest in the world tionally adequate diet [56]. Climate shocks (for — is increasing. Pakistan’s National Nutrition example, droughts and floods) affect agricultural Survey in 2018 shows that nearly 30 percent of production and yields, which in turn influence food all under-fives were underweight, 40 percent prices and profit. After the 2010 flood disaster, stunted, approximately 20 percent wasted, and the prices of wheat and rice increased by more more than half of children were anemic [53]. Malnu- than 80 percent in some region of the country trition in Pakistan is partially attributable climate [57]. High food prices, coupled with flood-related change, mainly through extreme weather events, losses of food stocks and sources, led to the Climate-related health risks | 29 severe deterioration of the food security status of hunger could increase by up to 30 percent in flood-affected areas and households, with in response to climate change [60]. The rise in poor food consumption rising from 13 percent food insecurity spurred by climate change will to 76 percent in Sindh and from 10 percent to have profound effects on nutrition outcomes, 45 percent in Punjab [57]. particularly in Balochistan, and lower Sindh— previously shown to be the areas of Pakistan Balochistan and Sindh have the highest rates that are most vulnerable to food insecurity as a of food insecurity and malnutrition, with an consequence of natural hazards [61]. estimated 3.8 million people at the crisis level. Of this group, 1 million people are classified under On the national scale, impacts to wheat and rice the status of “emergency” [58]. The ongoing production will be especially important to future COVID-19 pandemic has had severe impacts on nutrition outcomes. Wheat, milk, and rice make food security across the country due to the loss up approximately 50 percent of the caloric intake of income-generating opportunities. The Pakistan for the population [62]. Under RCP8.5, wheat Bureau of Statistics estimated that from April yields are projected to decline by 19 percent to July 2020, approximately 40 percent of all during the 2060s in the Punjab province [63], households were food insecure, compared with where 80 percent of Pakistan’s wheat production the 16 percent recorded in the 2018/19 Household takes place [64]. Projected risks of climate change Integrated Economic Survey [59]. on rice production are more complicated. Rising mean minimum temperatures have been shown In the absence of adaptation, climate change is to likely increase rice production in Pakistan [65]; likely to substantially aggravate food insecurity however, increases in precipitation by even 5 and worsen nutrition outcomes. While there is percent during the September-October period uncertainty on the precise number of people who could adversely affect rice production by nearly will be at risk of food insecurity because of climate 6 percent [66]. Notably, water-scarcity concerns variability, recent findings suggest that globally, could further limit rice production in favor of less between 2010 and 2050, the population at risk water-intensive crops. In the absence of adaptation, climate change is likely to substantially aggravate food insecurity and worsen nutrition outcomes. 30 | Climate and Health Vulnerability Assessment: Pakistan TABLE 7. Summary of climate change-related health risks RISK CATEGORY CURRENT RISK PROJECTED RISK Heat-related • Extreme heat is currently a significant • Excess heat-related deaths and impacts Risks climate-related health risk in Pakistan, on labor productivity in Pakistan are with most areas experiencing a high heat likely to increase under both high- and index. low-emissions scenarios. • The 2015 heatwave was one of the • Increases in the number of hot days deadliest in recent history and provides (Tmax > 35°C) and tropical nights (Tmin an illustrative example of the current risk. > 20°C) will exposure millions of people to dangerous temperatures, particularly in the Sindh, Punjab, and Balochistan regions, as well as urban centers such as Karachi and Lahore. Vector-borne • Dengue is the fastest-emerging arboviral • Increasing temperatures in Islamabad, Disease threat in Pakistan, with an 800-fold Punjab, and Sindh are likely to limit increase in cases between 1995–2004 to mosquito populations to only the areas 2019. that are most favorable for their survival. • More than 62 million people are vul- • Ongoing climate and infrastructural nerable to dengue in Pakistan, with the changes in Pakistan could promote the populations of Punjab and Islamabad at emergence of Zika, yellow fever, and highest risk. Japanese encephalitis (JE). • The population of Punjab is the most vul- nerable to malaria, albeit with decreasing vulnerability through 2050. Waterborne • Water quality is the most significant • Climate change-related extreme weather and Water- driver of waterborne diseases (WBDs) events, notably floods, are likely to drive related in Pakistan, with low baseline levels of increases in WBDs in Pakistan due to Diseases access to safe water and sanitation (that associated water contamination. is, roughly 20 percent of the population • Floods are projected to increase in has access to safe drinking water). frequency and intensity in Pakistan, with an additional population of approximately 5 million at risk of extreme riverine floods by the 2040s. Food Security • Pakistan’s National Nutrition Survey in • In the absence of adaptation, climate and Nutrition 2018 estimates that 33 percent of all change is likely to substantially reduce Deficiencies children were underweight, 44 percent agricultural yields, aggravate food insecu- stunted, 15 percent wasted, and 50 rity, and worsen poor nutrition outcomes. percent anemic. • Wheat yields are projected to decline by • Balochistan and Sindh have the highest 19 percent during the 2060s in the Punjab rates of food insecurity and malnutrition, province, where 80 percent of Pakistan’s with an estimated 3.8 million people at a wheat production takes place. crisis level. Climate-related health risks | 31 SECTION 4. ADAPTIVE CAPACITY OF PAKISTAN’S HEALTH SYSTEM 4.1 HEALTH SYSTEM OVERVIEW Pakistan’s health sector is decentralized — a mixed system that is legally and admin- istratively managed by provincial and local governments, involving public, private, civil society, and parastatal actors [67]. At the federal level, the Ministry of National Health Services and Regulations and Coordination (MoNHSRC) performs the national stewardship, regulation, and coordination functions. MNHSRC provides the overarching national health strategy that coordinates federal, provincial, and cross-sectoral actions through the Pakistan National Health Vision (2016–2025). With the 2010 devolution of power, the planning of healthcare delivery structures, programs, and services has become the responsibility of provincial health care authorities [67]. Pakistan suffers from several barriers impeding has been shown to increase household vulner- access to health services that may be further ability to health risks in flood-prone areas of exacerbated by climate change. Despite Pakistan [69]. government efforts to expand primary healthcare services, capacity is limited, leading to an overre- COVID-19 has had a significant impact on the liance on higher levels of care and on the private adaptive capacities of health systems. The sector, particularly in urban areas. This situation, emergence of the COVID-19 pandemic has combined with almost no risk pooling in public brought with it a focus on the preparedness and health financing, has resulted in high levels of capacities of health systems to manage emerging out-of-pocket (OOP) expenditures in Pakistan. public health risks of a large scale, including Moreover, access is further compromised during climate and global pandemics. Climate change, in and in the aftermath of extreme climate-related combination with COVID-19, has the potential to events. For example, the damage and loss of critical disrupt and overwhelm health systems, including infrastructure after the 2010 flood affected the healthcare facilities and staff. Meeting the dual population’s ability to seek and access adequate crises of COVID-19 and climate change will be an health care for multiple years [68]. In particular, the important challenge for Pakistan’s health system. lack of access to health facilities and information 33 The extent to which Pakistan’s health system 4.2 LEADERSHIP AND GOVERNANCE is prepared for and has the capacity to Pakistan is committed to meeting the climate respond to climate-related changes holds challenge through both adaptation and the key to modifying climate-related health mitigation measures, which are coordinated risks. In this assessment, Pakistan’s adaptive and implemented by the Ministry of Climate capacity9 to prevent and manage climate- Change and Environmental Coordination. Over related health risks is examined according the last decade, GoP has demonstrated its political to WHO’s six health system building blocks commitment and action to address climate change (Figure 5) [5]. Nevertheless, there are both data / challenges through several global and country-level information and methodology limitations that agreements and protocols — some of which are impede the ability of this assessment to compre- relevant to health. Nevertheless, the prioritization hensively review the resilience and adaptive of climate change and health risks, along with capacity of each aspect of the health system. the adaptation options, in national policies and The remainder of this section further elaborates plans (with a focus on both health and climate on the health system blocks in as much detail as change) remains mixed (see Annex IV for the possible, given these limitations. See also the summary table). Annex V for a summarized Adaptive Capacity and Climate Change-Related Health Risks Gap The evolution of the policy environment in Analysis. Pakistan to address climate change challenges over the last decade (2012–2021) has included FIGURE 5. several key policies and action plans. These WHO’s health system building blocks include, but are not limited to the following: Leadership Health 2012 & Governance Workforce • The National Climate Change Policy (NCCP) The NCCP informs climate policy in Pakistan Financing to mainstream climate change actions across Health BUILDING Information the entire economy through national and BLOCKS OF HEALTH Systems provincial implementation committees that SYSTEMS include representatives from the health Service sector. However, coordination mechanisms Delivery Essential are seemingly unclear. Medical Products & • National Disaster Management Plan (NDMP) Technologies The NDMP is a comprehensive plan that identifies macro-level hazards and includes Source: [5] risk assessments. It forms the basis for the development of the multihazard early warning system and identifies the roles and 9 Adaptive capacity is defined by IPCC as follows: “the ability of a system to adjust to climate change (including climate variability and extremes) responsibilities of stakeholders involved in to moderate potential damages, to take advantage of opportunities, or to cope with the consequences.” The related term, resilience, is disaster management. The plan encompasses the ability to prepare and plan for, absorb, recover from, and more successfully adapt to adverse events. People and communities with components related to human resource strong adaptive capacity have great resilience. This assessment makes development, community-based responses, use of the term adaptation and adaptive capacity to encompass both terms. and multihazard early warning systems. 34 | Climate and Health Vulnerability Assessment: Pakistan • National Monsoon Contingency Plan (July – acute crises or health emergencies. Although September 2012) – updated in 2023 there are no specific actions to address climate The National Monsoon Contingency Plan change in the Vision document, there are provides [70] critical information on monsoon several key activities that would support hazards, vulnerabilities, and resource mapping, adaptation and reduce the health risks of as well as offers gap analyses of provinces climate change. These are strengthening across Pakistan. environmental health protections; improving health information systems (HIS); as well as 2013 developing the core capacities to implement • Framework for Implementation of Climate International Health Regulations (IHR) and Change Policy (2014–2030) the Global Health Security (GHS) agenda. Produced as a follow-up of the NCCP, the • 1st Nationally Determined Contributions Framework for Implementation of Climate (NDCs) Change Policy serves as a catalyst for main- Pakistan’s first NDC outlines the country’s streaming climate change concerns into climate actions; however, climate-related decision-making to create enabling conditions health risks or the health sector’s adaptation for integrated climate-compatible development actions were not presented. processes. Although the framework highlights the need to enhance institutional capacity 2017 at provincial levels, progress on developing • Climate Change Act specific policies has been limited and actions The Climate Change Act supports a have been ad hoc, mostly due to the lack “whole-of-government” response to climate of resources and capacity to deliver policy change, leading to the establishment of the solutions (Parry 2016; Chaudhry 2017). Climate Change Council (CCC). CCC, headed • National Disaster Risk Reduction Policy (2013) by the Prime Minister, consists of several The National Disaster Risk Reduction Policy line ministries; however, to date, it does not aims to build resilience through a multihazard, include health. community-focused approach of reducing exposure to hazards. Specifically, the policy • National Action Plan for the Implementation calls for the integration of national capacity to of Bangkok Principles on Health Aspects identify and monitor climate change-related of the Sendai Framework for Disaster Risk vulnerability and hazard trends, as well as Reduction development planning that addresses disaster This is a 10-year action plan and roadmap risks alongside environmental and climate-re- guided by seven relevant principles that lated concerns. work to strengthen the health component of disaster management from relevant provincial 2016 perspectives. • Pakistan National Health Vision (2016–2025) • Karachi Heatwave Management Plan: A The National Health Vision aims to increase the Guide to Planning and Response health system resilience to disasters through The Karachi Heatwave Management Plan the implementation of mitigation responses outlines strategies for government and and the continued provision of services during non-government agencies to execute prior to, Adaptive capacity of Pakistan’s health system | 35 during, and after heatwave events to prevent In addition to the above, the NDC proposes heat-related illness and deaths in Karachi. adaptation actions in other sectors that are likely to positively impact health, including 2018 agriculture, water resources, disaster prepared- • Joint External Evaluation (JEE) – updated ness, and water sanitation and hygiene (WASH). in 2023 • National Climate Change Policy (NCCP) 2021 A JEE assesses Pakistan’s capacity to prevent, detect, and rapidly respond to public health risks Pakistan’s updated climate change policy, and identify critical gaps to enhance prepared- keeps prioritizing health as a key sector for ness and response. Through this process, the climate-related policy measures, including development of the National Action Plan for the following: Health Security was executed. However, actions • Assess the health vulnerabilities at for reducing the health risks of climate change, community level; including potential security threats, were not • Ensure integration of climate-related explicitly included in this plan. measures in national health plans; 2021 • Capacity building for health personnel about climate and health issues; • 2nd Nationally Determined Contributions (NDC) • Ensure preventive measures for essential Pakistan’s second NDC lays out a compre- medical products and resources availability hensive set of health sector-specific adaptive during extreme weather events; measures, including the following: • Upgrade and extend disease outbreak • Enhancing research on the impacts of monitoring and forecasting systems; climate change on health; • Improve data recording, reporting and analysis of climate-sensitive diseases; • Increasing monitoring and forecasting systems for pandemic and disease • Assess the impacts of climate change on outbreaks; vector/water borne and nutritional diseases; • Collating health co-benefit data to inform • Identification of technology and infrastruc- policy; ture options for WASH resilience; • Adopting the One Health approach; • Explore public-private partnerships to resolve the issue of financial access for • Conducting a geospatial analysis to identify WASH services; and hot spots and inform the implementation of adaptive climate-related measures for • Adopt water and sanitation safety plans health; for rural and urban areas. • Developing standardized emergency 2023 procedures; • National Adaptation Plan (NAP) • Moving toward a system of stockpiling Pakistan’s NAP includes health within the essential medicines; and human capital sector as a priority for adaptation • Adopting a Health in All Policies (HiAP) to climate change. The NAP highlights direct approach. health impacts from extreme weather events, 36 | Climate and Health Vulnerability Assessment: Pakistan heat stress, VBDs, WBDs, Nutrition, WASH, health focal point to support actions to build climate and reproductive health as key health risks resilience; however, at the time of this assessment, being affected by climate change. In this it is unclear if this position still exists, or if further sense they focus on 3 main objectives for adequate resources have been provided to support addressing the climate-related health risks: the effective implementation of identified climate 1. Mainstreaming climate adaptation in health change and health activities. policies by assessing climate change impact on public health, improving data collection and analysis, upgrading disease 4.3 HEALTH WORKFORCE outbreak monitoring and forecasting, and Climate change influences workforce capacity, integration adaptation measures in national putting additional strains on the overall health and sub national health policies. system performance. First, climate-related changes 2. Enhancing climate resilience through in population health needs increase demands Disaster Emergency Preparedness and on the health system, thus altering the number Response. This includes activities such of staff required. Similarly, climate-related health as: develop a communication and dissem- burdens influence the case mix, thus altering the ination strategy, issue timely alerts and skill requirements of the health workforce. Finally, advisories on climate-related hazards, climate-related extreme events may impact the capacity building for government officials health of those working in the sector themselves, at federal, provincial and district level, therefore affecting their levels of productivity. ensure family planning services available amid extreme weather events, expand As one of the 57 Human Resources for Health climate-resilient infrastructure for WASH (HRH) crisis countries,10 [71] Pakistan is already services. facing numerous health workforce challenges. There are an estimated 1.4 skilled health profes- 3. Build workforce capacities to address sionals per 1,000 population, well below WHO’s climate risks. Activities include: developing minimum threshold for achieving universal health a climate change curricula at secondary coverage (UHC) — 4.45 per 1,000 [72]. There is also schools and offer specialized courses in a shortage of allied health professionals. Projected colleges and universities; and develop climate-related health burdens can be expected occupation and vocational training; among to further increase demands on the number of others. skilled health professionals required. Moreover, Pakistan faces several notable challenges with Limited coordination mechanisms exist to respect to its HRH capacity, particularly pertaining facilitate cross-sector action on climate change to the lack of a proper skill mix, the quality of and health. There is no climate change and health education, standards and accreditation, poor working group within the government to bring absorption capacity, immigration — both internal together the multiple sectors involved in strength- and external, and career structure challenges. ening the adaptive capacity to respond to climate change-related health risks and prevent them. As of 2015, the Ministry of National Health Services and Regulations and Coordination (MoNHSRC) 10 The 2006 World Health Report [85] identified the countries facing critical health workforce shortages (for example, less than 22.8 skilled has identified a designated climate change and health workers per 10,000 population). Adaptive capacity of Pakistan’s health system | 37 The health workforce varies significantly lack comprehensive information on understanding across districts, with particular concentrations and reducing the health risks of climate change. observed in urban areas, across both private and Climate change has so far not been prioritized in government health sectors. These urban-rural human resource planning mechanisms, including discrepancies are particularly high for doctors, the National Human Resources for Health Vision. with 14.5 physicians per 10,000 population in urban areas, compared with 7.6 in rural areas Although some training materials have been [73]. In the case of midwives, the distribution developed for certain climate-related health risks, between urban and rural areas is less pronounced, they are far from being universal. Knowledge though it still skews toward urban centers, with on the health impacts of extreme heat is a good 3.6 midwives to 10,000 population in the urban example of where materials have been developed. areas compared with 2.9 in rural areas [73]. The Many healthcare professionals are cognizant of availability of skilled health personnel varies across heat-health risks due to the Heat Emergency province and district levels, leading to gaps in Awareness and Treatment (HEAT) manual and health promotion and protection activities. the accompanying treatment algorithm created to train them in the delivery of care during heat Despite its critical importance, the coverage of wave events. However, evidence points to the the Lady Health Worker (LHW) program does need for additional training and awareness raising not seem to be meeting its expected target to further expand knowledge of the signs and populations. LHWs are female outreach profes- symptoms of heat illnesses, as well as treatment sionals who have been recognized as government procedures [74]. Beyond extreme heat, more gaps health workers to bridge gaps between health on other topics exist, with some having relatively facilities and community members, especially simple solutions. For example, community health in rural and remote areas. The role of LHWs workers previously trained to deliver psychosocial is important, particularly in the face of climate interventions have not yet been trained to meet change and health threats, where remote and post-flood mental health needs [75]. rural populations are at particular risk. Despite the success of the LHW program, the number of LHWs is declining, total LHW coverage is currently 4.4 HEALTH INFORMATION AND less than 50 percent of its target population; moreover, the areas that are relatively remote and DISEASE SURVEILLANCE SYSTEMS disadvantaged are seeing the lowest coverage. Health information systems are currently Furthermore, climate change-specific guidance fragmented, and vertical coverage is insuffi- and tools have not so far been developed or cient. This coverage gap has been acknowledged integrated into the program. in the Pakistan National Health Vision (2016– 2025). Routine health information in Pakistan The absence of a systematic approach for is captured through a number of manual and capacity development on climate-related health electronic health and management information risks and emergency preparedness and response systems (MIS). Health facilities — at the primary is a key performance challenge for Pakistan’s and secondary level — relay information through health workforce. Both professional training the District Health Information System (DHIS). (for example, medical and nursing schools) and The DHIS has good coverage: established across continued professional development (for example, almost 90 percent of districts in the country, it on-the-job and in-service training) mechanisms has overall high reporting rates, with information 38 | Climate and Health Vulnerability Assessment: Pakistan collated on a monthly basis at the facility level. vulnerable areas to support a disaster response However, there are also simultaneous vertical and recovery. programs and functions of health services delivering information through their respective There has been no assessment of technologies MIS, thus resulting in duplicative efforts. to ensure that health equipment is resilient to climate change. The incorporation of new tech- Climate and weather information is not suffi- nologies to build resilience in the health sector to ciently integrated into the DHIS and early climate change needs further exploration, such warning systems (EWS) to inform the prevention as building designs that enhance cooling (that is, and management of climate-sensitive health increasing urban green spaces or painting roofs risks, as well as the early response to them. white) and the effective utilization of renewable Although EWS exist for some climate change-re- and sustainable energy sources within the health lated disasters, integration with the health sector. Even the application of innovative technol- sector is limited. This being said, the National ogies employed outside the health sector could Contingency Plan for Monsoons (2020) does, in be relevant, as they may have impacts on human fact, highlight the need for an active-disease EWS health, such as climate-smart food systems and in provincial health departments, when preparing agriculture. for disease outbreaks ahead of the monsoon season. Pakistan is also included in the Famine Early Warning System (FEWS) that provides an 4.6 SERVICE DELIVERY early warning of acute increases in malnutrition. The devolution of federal responsibilities for Although hospitals currently do not collect data health and population welfare to the provincial to track heat-related morbidity or mortality levels level has led to challenges in health service through admissions and emergency case records, delivery. These include increased fragmenta- there have, however, been efforts in Pakistan tion, reduced national institutional capacities and to map out urban heat islands in cities to help technical expertise, as well as the development locate hotspots and guide the establishment of of parallel vertical programs at the federal and first-response centers. Nonetheless, additional provincial levels. This is a likely reason for existing work is needed to expand these efforts. inefficiencies and compromised service quality. Moreover, the coordination of service delivery across a range of health care and public health 4.5 ESSENTIAL MEDICAL PRODUCTS programs, including those that are important to AND TECHNOLOGIES reduce risks related to climate change, is lacking Pakistan has a National Essential Medicines List in Pakistan. with policy measures and operative guidelines There have been no comprehensive reviews of for regulating essential medicines and labora- the current health care infrastructure in Pakistan tories; however, gaps exist between policy and to identify climate change-related vulnerabil- practice. Issues include frequent shortages and the ities. It is unclear to what extent infrastructure lack of drug inspectors, thus restricting the health assessments of the health sector have been system’s capacity to operationalize health tech- conducted, building designs have incorporated nologies and the delivery of medicines, including projected climate change impacts, and retrofit- for climate-sensitive diseases [76]. Stockpiles of ting measures have been carried out. This being essential medical supplies are also needed in Adaptive capacity of Pakistan’s health system | 39 said, a comprehensive approach for some climate such as Sindh, where hospitals are sited within change-related health risks to reduce the overall the 100-year flood extent.11 burden of disease have been identified. The Karachi Heatwave Management Plan, for example, highlights efforts to reform existing buildings and 4.7 FINANCING land use regulations in the city. However, the Public financing for health in Pakistan is low implementation of these actions has been slow and insufficient to meet public health needs. and national standards for sustainable cooling do Pakistan experienced a nominal fivefold not exist as yet. The National Disaster Reduction increase in government spending on health in Policy (2013) offers advice to provincial-level FY2017/2018 compared to FY2005/2006 [78]. disaster planning commissions in collaborating However, health public expenditure has not kept on infrastructure design to understand and reduce abreast with growing population and inflation. the disaster risks. The level of spending for health has averaged around 3 percent of GDP for the last 15 years, Baseline information is lacking on key envi- compared to 9.8 percent globally. The current ronmental determinants of health, including allocation of the healthcare budget, at the federal WASH coverage in healthcare facilities. Climate and provincial levels, for services and human resource development is not sufficient to meet change impact studies on water quality and quantity the strategic goals of the Pakistan National Health are also important information gaps in Pakistan. Vision (2016–2025). Approximately 4 percent Projected increases in intense rainfall, coupled of the total expenditure was allocated to health with encroachments in sewerage channels, [78] — below the recommended 15 percent of may also lead to urban flooding in major cities, the total budget required to strengthen health especially Karachi, Lahore, Rawalpindi, Quetta, and systems according to the Abuja declaration. Hyderabad. There is a need to build climate-resil- Although the current health expenditure per ient water and sanitation systems and infrastructure capita has increased from 15.58 percent in 2000 in both rural and urban areas. This includes efforts to 39.5 percent in 2019 [79], the health sector to promote education and social awareness in in the country remains under-resourced to meet confronting and controlling water pollution, as the needs of the people. Accordingly, a nominal well as waterborne and water-related diseases, 10 percent increase per annum in public health particularly at the subnational levels, by creating expenditure is required to meet population health and supporting water regulatory authorities. demands [78]. Minimum standards for climate-sensitive Pakistan’s historically low public financing healthcare infrastructure have not been on health has led to significant out-of-pocket developed, thereby increasing the vulnerability (OOP) payments, therefore increasing poverty, of existing facilities. The 2010 flood damaged especially in light of ongoing climate-related over 500 healthcare facilities [77]. To illustrate their risks. Financing for health comprises OOP expen- ditures, taxes, and employee contributions, as vulnerability to flood events, hospital facilities were well as community and private insurance [80]. overlaid with 100-year flood extent data to identify OOP payments are the largest source of health facilities located in flood-prone areas. Results show that 13 percent (535 of 4,046 hospitals) 11 Analysis of hospitals within the 100-year flood extent uses an outdated are vulnerable, especially facilities in provinces administrative boundaries map. 40 | Climate and Health Vulnerability Assessment: Pakistan financing in Pakistan [81]. In 2018, total health health insurance, funded through contributions expenditures from public sources constituted 40.9 to private schemes [81]. percent, while private expenditures were 58.5 percent, of which 88 percent fell under the OOP Pakistan has health insurance programs, but risk expenditure category. The OOP expenditure level pooling does not seem to account for climate and is higher than the recommended WHO threshold health-related risks. In general terms, illnesses of 20 percent, significantly increasing the risks and health care costs are not evenly distributed, of impoverishment and vulnerability for poor with some population groups facing higher health households. Although public hospitals provide risks, which may be exacerbated by climate change. free access to services, the facilities are under-re- Climate change can augment underlying health sourced in the face of high demand [81]. In fact, in burdens, while increasing the potential and size 2015, it was estimated that close to 5 percent of of certain catastrophic financial health risks, households spent more than 10 percent of their especially among the most vulnerable. Although incomes on health — the largest share of which Pakistan has health insurance schemes, they only was spent on medicines (67 percent). Medicines, account for 5 percent of the population [80], for instance, are purchased privately, accounting and potentially exclude the poor and climate-vul- for 50 percent of the OOP expenditure [81]. This nerable populations. Risk pooling can address is of particular concern in the case of large-scale this challenge. However, risk pooling through disasters such as those related to climate change. health insurance in Pakistan is poor, due to the fragmented insurance system and the lack of a Health financing sources include general taxes coordinated system to allocate resources across and mandatory health insurance, but resources public facilities [81]. are not earmarked exclusively for health. General government taxation is the second-largest source of Strategies to mobilize health funds will, to health finance in Pakistan [81]. It comprises primarily a large extent, determine the mechanisms indirect taxes, as there are no earmarked taxes for and ability to pool resources to address such the health sector. General taxation is channeled in risks. General revenues are most suited for annual development plans and includes external pooling risks, if health services are accessible sources of funds from donors [80]. Unlike most to the entire population, or for subsidizing the developing countries, the health sector in Pakistan premiums of high-risk groups. As the country has is not heavily reliant on donor financing [80]. In low public health expenditure and relies heavily 2012, for instance, external resources for health, on the private sector for the delivery of health as a share of total health expenditure, represented services, the limited risk pooling in public health 4.7 percent [81]. Additionally, the revenue collection financing has resulted in OOP expenditures being for health includes mandatory and voluntary health high [78]. Non-government pools of funding for insurance, constituting approximately 7 percent health include private health insurance and social of health financing. Although not earmarked only security funds. Further, as previously noted, OOP for health, mandatory financing includes social expenditure, which constitutes the largest share security contributions through employers and the of total health expenditures, is not pooled at private sector, as well as deductions from private any level. Finally, these arrangements do not savings (known as Zakat) [81]. Approximately 1 take into account any considerations for pooling percent of total private expenditure is voluntary funds for climate-related risks, thereby falling Adaptive capacity of Pakistan’s health system | 41 short of providing any form of financial protection for the poor and vulnerable populations affected by climate and health-related risks. Pakistan is resource-constrained, with a limited fiscal space for financing climate-resilient activities to promote health. Pakistan was ranked seventh on the list of the most vulnerable countries, in terms of climate finance resources to manage the outcomes of climate change [82]. Due to its limited climate financing capacity, the country primarily relies on donors to cover the gap. To enhance climate adaptation, Pakistan requires USD7–14 billion a year; however, the total grants received by the country has not reached that level [82]. Consequently, climate-related health issues receive limited finance. Limited experience with strategic purchasing in the Pakistan health sector precludes climate and health results from being appropriately achieved. Prioritizing basic health services and preventive programs is the most effective approach that governments can adopt to strategically purchase health services. The shift from passive budgeting to strategic purchasing can ensure improvements in health outcomes while strengthening governance and accountability mechanisms. Further, it is incumbent upon governments to embrace an equity lens to assure pro-poor healthcare service delivery. The selection of providers, using public funds, should take into consideration capacity, quality, and price. To this end, considerations for different provider payment mechanisms need to be given due attention to incentivize provider behaviors that are geared toward achieving strategic objectives. Finally, dimensions related to regulation, provider autonomy, and competition are fundamental for successful strategic purchasing arrangements. In Pakistan, there is limited experience with strategic purchasing, along with the insufficient coor- dination of benefits and the adaptation of programs to cover the vulnerable. This being said, one example where new strategic purchasing interventions were proposed is within the Sindh Health Strategy [83]. This Strategy articulated two result areas that are aimed at improving strategic purchasing for priority services as well as enhancing strategic planning, budgeting, and financial management. In this respect, it outlined steps toward strengthening contract management capacity, introducing results-based financing mechanisms, and supporting innovative methods to finance human resources. In addition, it stipulated strategic steps to prioritize and rationalize health financing while improving public budgeting and overall public financial management. While there are no current considerations for climate in the thinking on strategic purchasing in Pakistan, this should be prioritized moving forward to ensure that climate and health results are appropriately addressed. 42 | Climate and Health Vulnerability Assessment: Pakistan TABLE 8. Summary of the adaptive capacity gaps of the health system for Pakistan as they relate to climate change HEALTH SYSTEM SUMMARY OF GAPS IN BUILDING BLOCK ADAPTIVE CAPACITY Leadership and • Pakistan is committed to meeting the climate challenge through both adaptation Governance and mitigation measures; however, the coordination mechanism to facilitate cross-sector action on climate change and health is limited. Health Workforce • The number of skilled health professionals is well below the WHO minimum threshold for achieving UHC, and with notable urban-rural discrepancies. • There are existing HRH capacity issues, pertaining to the lack of a proper skill mix, low quality of education, the lack of standards and accreditation, poor absorption capacity, immigration — both internal and external, and career structure challenges. • There is no systematic approach for capacity development on climate-related health risks, and emergency preparedness and responses constitute a key challenge for Pakistan’s health workforce. Health Information • Health information and surveillance systems are currently not integrated; moreover, and Disease they do not include climate / weather data or information on other environmental Surveillance Systems factors. • There is no comprehensive climate-informed health EWS. Essential Medical • There are important gaps between policy and practice for essential medical Products and products and technologies, including frequent shortages and the lack of drug Technologies inspectors. • There has been no assessment of technologies to ensure that the health equipment is resilient to climate change. Health Service • Health service delivery is challenging in Pakistan, stemming from fragmentation, Delivery reduced national institutional capacities and technical expertise, along with the development of parallel vertical programs at the federal and provincial levels. • There has been no comprehensive review of the health care infrastructure in Pakistan to identify climate change-related vulnerabilities. • Minimum standards for climate-sensitive healthcare infrastructure have not been developed, thereby increasing the vulnerability of existing facilities. Financing • Pakistan’s historically low public financing on health has led to significant OOP payments, thereby increasing poverty, especially in light of ongoing climate-related risks. • Risk pooling in Pakistan does not account for climate and health-related risks. • Limited experience with strategic purchasing in Pakistan precludes climate and health results from being appropriately achieved. Adaptive capacity of Pakistan’s health system | 43 SECTION 5. RECOMMENDATIONS TO ENHANCE HEALTH SYSTEM RESILIENCE TO CLIMATE CHANGE This section describes recommendations to enhance health system resilience to climate change, including health interventions and strategies for adaptation. The recommendations, produced by the reflection on the findings of this assessment, are guided by the 10 components of WHO’s operational framework for building climate- resilient health systems (Figure 6). It also draws on consultations with key stakeholders in Pakistan and the draft Pakistan Climate and Health Policy / Action Plan. See also Annex VI for relevant line ministries for each of the described key recommendations, Annex VII for examples of “No-Regrets” recommendations for climate change and health in Pakistan, and Annex VIII for the menu of health adaptation options organized by climate-related health risk. FIGURE 6. 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 apt men He ate era ity & Leadership As g d ess Clim cin bil & Governance Health s ity, an Workforce Financing Preparedness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential C li r m e h Re ima & I n f a lt s Medical ma d C l a lt h se te o Products & h He ra m Pro te a rc He Technologies - g Ma t na ien Env ge m ent o t e Re s il f C li m a l e ir o n in a b D et m ental & S u st a gies ri m e o l o of H n ts Techn ct u re e a lt h s tr u & Infra Source: World Health Organization, 2015, Operational Framework for Building Climate Resilient Health Systems. 45 Strengthen a climate-health policy environment and community health workers is fundamental to at the national and subnational levels. While operationalizing key interventions at the program- Pakistan has ratified a number of international matic level. As a first priority, the focus on the agreements and developed national policies management of extreme heat exposure risk is and strategies related to climate change, the essential. This is especially significant in regions majority of them do not include a specific health such as Sindh, Punjab, and Balochistan, where focus. As such, GoP would be well-advised to the most substantial increases in heat exposure ensure that health is featured prominently in its are projected and capacity may be limited for national adaptation plans and strategies. To this addressing related health risks. end, the integration of climate-related health risks into the next iteration of the Pakistan National Furthermore, building the capacity of lady health Health Vision would be a critical step. Subnational workers (LHWs) would be ideal to enable this plans for certain climate risks exist, but they important and efficient cohort to manage climate are far from comprehensive. In light of this, it is and health risks at the community level, thus recommended that subnational adaptation plans focusing on preventive and promotive health that are further developed are modified to provide services. Realizing the intended objectives of the specific climate-related health actions. A good proposed capacity development actions requires example is the Karachi Heat Health Action Plan, two cardinal steps: (a) introduce formal pedagogical which could be rolled out for all major population training on climate change and health, as part centers, with prioritization for cities in vulnerable of medical, paramedical, and nursing curricula, areas such as Lahore and Islamabad. at higher-education and vocational institutions; and (b) develop training and awareness raising Enhance coordination mechanisms for climate materials tailored for health providers and and health action. In the first instance, this would community health workers on climate change, involve the designation of a national climate and health risks, and adaptation responses. health focal point to liaise with stakeholders at different levels. Establishing coordination Develop an intersectoral platform to monitor mechanisms with key actors both inside and climate-related health risks and support the outside the health sector, including with line establishment of a climate-informed disease ministries of climate change, agriculture, planning early warning and response system. Under the and development, and transportation, among patronage of the Ministry of Climate Change and others, would be beneficial. Environmental Coordination, it is recommended that the surveillance of key climate risks, as Develop health workforce capacity to manage they relate to health, be conducted to inform climate and health risks. Climate information the operationalization of the Ministry of National presented in this assessment could be used to train Health Services and Regulations and Coordina- policy makers and planners in the health sector tion programs (MoNHSRC). This is important for to inform the design of health sector programs the broader understanding of health risks that is and enhance day-to-day service delivery, as informed by real-time climate information. well as during and after extreme weather events (for example, heatwaves and floods). Beyond Further, expanding health surveillance to capture capacity development efforts at the policy level, spatiotemporal patterns of climate-sensitive a more intensive training for service providers diseases and determine population health risk is 46 | Climate and Health Vulnerability Assessment: Pakistan imperative. Building on prior efforts to strengthen tandem and feeding into the proposed national the disease early warning system (DEWS), it is risk register, the government would be well- recommended for the scope of such a system advised to develop seasonal climate outlooks. to be further expanded in order to incorporate They would serve to inform disease control and / climate-sensitive diseases. This would require or prevention programs as well as facilitate a multi- intersectoral collaboration with existing DRM sectoral response to climate-related health risks efforts related to respective EWS around disasters (involving first-responders, disaster management (that is, for floods and heatwaves) to enable the authorities, rural support agencies, and LHWs). real-time analysis of subsequent health impacts to inform a timely health response. Pool health funds to cover climate-related health risks and include climate risk considerations Climate-proof health infrastructure and technol- in strategic purchasing. With the exception of ogies. Here, the vulnerability of health facilities is OOP payments, all revenues for health are pooled analyzed in relation to potential structural damage through public and private health insurance and in from climate-related hazards (that is, flooding). central and provincial government budgets, and However, the assessment of the existing infra- then transferred to providers. It is important for structural characteristics — encompassing building the health system to provide financial protection design and construction (including retrofitting) for the vulnerable to maintain access to health — is beyond the scope of this assessment, and services for climate-related health needs, while therefore, warrants a further in-depth analysis. also preventing financial hardship. This could The same can be said of the contribution of include the consideration of a pre-payment healthcare facilities to increasing urban tempera- mechanism that provides such financial protection tures (that is, the urban heat island effect), which for climate-related health impacts through the needs to be further studied. In light of findings pooling of resources. Moreover, this could involve a stemming from these proposed assessments, the bold move toward a provider payment mechanism government may wish to revisit building codes that incentivizes healthcare providers to focus on to ensure that they are climate-smart and that climate-related health outcomes. In this respect, appropriate consideration is given to the likely a strategic purchasing mechanism that pays for impacts of climate-related hazards. In addition, climate results would need to be designed and energy efficiency should be considered as part implemented across the provinces of Pakistan, of these building codes, including sustainable particularly those most vulnerable to climate-re- cooling options for health facilities and medical lated health risks. warehouses for vaccines and drugs. Establish a national risk register for climate- health risks in Pakistan, with seasonal climate outlooks to inform health-sector programming. The aim of this register would be to ensure that GoP is prepared to manage health emergencies from climate-related hazards. The register would cover the likelihood, scale, and extent of such emergencies affecting the population to help inform the government’s emergency response. In Recommendations to enhance health system resilience to climate change | 47 REFERENCES [1] World Bank. 2021. World Development Indicators. Washington, [19] World Bank. 2021. 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ASSUMPTIONS ON THE COURSE OF FUTURE GLOBAL CLIMATE CHANGE Predicting the future climate of any country requires several assumptions to be made about the direction of the future global climate. World Bank’s Climate and Health Vul- nerability Assessments (CHVAs) uses climate information from the World Bank Group’s Climate Change Knowledge Portal (CCKP). Observed changes in mean annual, mean maximum, and mean minimum temperatures and precipitation are presented on CCKP for the period 1901—2021. Climate data in the World Bank Group’s CCKP is derived from the Coupled Model Intercomparison Project, Phase 6 (CMIP6), the foundational data used to present global climate change projections in the Sixth Assessment Report (AR6) of the Intergovernmental Panel on Climate Change (IPCC). CMIP6 relies on the Shared Socioeconomic Pathways (SSPs), which represent possible societal devel- opment and policy scenarios, which are used to represent the climate response to different plausible future societal development storylines and associated contrasting emission pathways to outline how future emissions and land use changes translate into responses in the climate system. For the purposes of the World Bank’s vulnerability assessments, this assessment uses the SSP3-7.0 scenario, being business-as-usual. In addition to selecting the most likely scenario of future global climate, it is also useful to define a baseline period to represent the current climate within which observed health impacts have occurred. It is also useful to define future time periods that can be used as a comparison against this baseline, and for which assumptions or models can be used to predict changes in future climate-re- lated disease burdens. The World Bank’s CHVAs use two 20-year time periods that together cover the next four decades to show imminent and medium-term climatic changes in a given country. The baseline period covers 30 years, since this has conventionally been the length of time over which climatic conditions are measured to reduce noise from annual or other cyclical variations. Looking to the future, 20-year time periods are used because of the accelerating pace of change of global climate; moreover, doing so enables climate-related threats to be analyzed over a sufficiently proximate timescale. • 2030s: This 20-year period extends from 2020 to 2039, with 2030 as the chronological mid-point. The 2030s can be seen to represent the immediate upcoming years to which countries and their governments need to respond with the utmost urgency. • 2050s: This 20-year period extends from 2040 to 2059, with 2050 as the chronological mid-point. The 2050s can be seen to represent a medium-term period — still well within the lifetime of current populations for which countries and governments have sufficient time to make profound changes in preparation for expected threats. 53 ANNEX II. NET CHANGE IN FUTURE MONTHLY PRECIPITATION ACROSS PAKISTAN JAN FEB MAR APR MAY JUN JULY AUG SEPT OCT NOV DEC Balochistan 2030s 1.92 -1.98 1.32 0.13 0.3 1.34 5.37 5.34 1.6 0.0 -0.09 0.94 2050s 0.12 -3.16 -0.4 0.42 0.31 1.81 5.93 5.57 1.92 0.03 -0.11 -0.45 Federal Capital Territory 2030s 5.46 -8.18 1.88 -7.01 5.75 12.46 17.51 12.38 8.38 1.35 -2.32 8.24 2050s -0.61 -0.43 -3.81 2.18 6.29 8.5 26.77 28.45 13.72 1.96 -1.58 3.47 Khyber Pakhtunkhwa 2030s 3.47 -2.39 7.17 -4.49 5.27 8.17 3.92 4.15 4.13 -1.49 -2.45 4.61 2050s 1.14 1.29 0.47 3.19 5.23 5.41 10.44 15.17 3.68 1.09 2.2 2.55 Punjab 2030s 0.76 -2.33 0.69 -1.15 2.15 6.81 6.73 8.47 7.89 0.43 -0.48 1.35 2050s -0.35 -2.12 -1.01 1.54 2.54 9.43 14.49 14.44 12.22 1.32 -0.54 0.1 Sindh 2030s 0.0 -0.02 0.0 0.0 0.0 2.59 10.19 17.01 7.27 0.04 0.0 0.0 2050s 0.0 -0.03 -0.02 0.01 0.0 3.34 15.62 21.84 10.65 0.44 0.0 -0.01 Source: Climate Change Knowledge Portal Note: Figures above are in millimeters (mm) 54 | Climate and Health Vulnerability Assessment: Pakistan ANNEX III. METHODS FOR THE ESTIMATION OF MOSQUITO SUITABILITY, UNDER RCP 8.5, IN PAKISTAN Predicted spatiotemporal distributions of Anopheles (An.) stephensi, An. culicifacies, Aedes (Ae.) aegypti, and Ae. albopictus were determined, using a raster-based suitability model that is constructed with Google Earth Engine through the adaptation of methodology presented by Frake et al. (2020) [84]. This methodology uses abiotic variables specific to the thermal tolerances of vector species and biotic variables that consider the species’ habitat preferences. Suitable areas are defined as those geographic areas that would support vector survival. At the outset, four models were constructed to define suitability for each mosquito species. For each model, parameter thresholds for all input variables were selected, based on a literature review of the species’ thermal tolerance and habitat characteristics (see Table 1). Thresholds were then used to create binary maps for each predictor (that is, suitable [1] or unsuitable [0]) that were combined, using Boolean logic, to produce suitability for each target species. To demonstrate malaria and dengue vulnerability as a function of vector suitability, Boolean logic was again used to combine suitability maps for An. stephensi and An. culicifacies for malaria vulnerability, and Ae. aegypti and Ae. albopictus for dengue vulnerability. Population vulnerability was demonstrated by spatially overlaying vulnerability maps for malaria and dengue, with population data from the Global Human Settlement Layers (2015) used 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 information. The output spatial resolution of products was set at 1000 m. TABLE A1. Data sources and thresholds for vector species’ thermal tolerance and habitat characteristics CHARACTERISTIC DATA SOURCE PRODUCT SPATIAL RESOLUTION THRESHOLD Temperature NASA NEX-GDDP 0.25 degrees An. stephensi Min: 15°C Max: 36°C An. culicifacies Min: 12°C Max: 41°C Ae. agypti Min: 15°C Max: 35°C Ae. albopictus Min: 20°C Max: 30°C Land Cover Copernicus Global Land Proba-V-C3 100 m See Table 2* Service Water Resources JRC GSW1_0 30 m > 0% water occurrence Flow Accumulation WWF HydroSHEDS 500 m > Q2** Population JRC GHSL/P2016/POP_ GPW_GLOBE_V1 * The table providing information for each species, by land cover type, is forthcoming. ** Quartiles 1–4 of the precipitation range are presented to identify areas of varying water inundation potential. Annex | 55 ANNEX IV. KEY CLIMATE CHANGE AND HEALTH-RELATED POLICIES IN PAKISTAN POLICY OR PLAN RELEVANCE FOR CLIMATE CHANGE AND CLIMATE CHANGE AND HEALTH RISKS HEALTH National (climate change and health) Health and Climate Action It will be the first national action plan specific Vector-borne diseases (VBDs) (dengue Plan (under draft) to climate change and health. and malaria); waterborne, airborne and foodborne diseases (including pollen allergies); health effects of extreme heat; nu- trition-related diseases; injuries; and mental illnesses will be discussed. National (Climate Change) Nationally Determined Con- The updated NDCs (2021) include health as Priority risks may VBDs, waterborne tributions (NDC) (2021) a key priority for climate change action. diseases (WBDs), nutrition-related diseases, air pollution / air quality, and extreme weather events such as heatwaves, floods, and droughts. 2nd National Communica- This document Includes a section on health VBDs (dengue and malaria); waterborne, tion to the UNFCCC (2018) vulnerabilities and adaptation needs in airborne, and foodborne diseases (including relation to climate change. pollen allergies); health effects of extreme heat; nutrition-related diseases; injuries; and mental illnesses are discussed. National Climate Change This policy includes a description of health VBDs (dengue and malaria); heat-related Policy (NCCP) Framework for adaptation actions across five strategies. mortality; injuries and deaths related to Implementation (2013) extreme weather events; diarrheal diseases; and mental health are discussed. NCCP (2021) Health is included as a priority sector and Injuries related to extreme weather event policy measures of interest - including as- such as flooding; WBDs related to changing sessment of health vulnerabilities, integra- rainfall patterns; VBDs (dengue and malaria); tion of climate-related measures in health and mental health are discussed. national plans, capacity building of health personnel, preparedness measures for ensuring essential medical products, sur- veillance and information systems, among others. National (Health) Pakistan National Health This plan mentions building health system There is no discussion of specific climate- Vision (2016–2025) resilience to disasters (including climate related health risks. change) as a strategic priority. Provincial Provincial Disaster Manage- Provinces and districts have contingency Health is mentioned to varying degrees, ment Plans and disaster risk management (DRM) plans, including disease early warning systems with a specific focus on monsoons and (DEWS), the protection of healthcare facili- flooding events. ties, and enhanced health service delivery. Municipality level Karachi Heat Action Plan This plan focuses on the prevention of Extreme heat-related health risks and adap- (2018) health risks related to heat. tation options are discussed. 56 | Climate and Health Vulnerability Assessment: Pakistan ANNEX V. ADAPTIVE CAPACITY AND CLIMATE CHANGE-RELATED HEALTH RISKS GAP ANALYSIS SELECTED CLIMATE CHANGE-RELATED HEALTH RISKS HEALTH SYSTEM HEAT-RELATED RISKS VECTOR-BORNE WATERBORNE AND FOOD SECURITY AND BUILDING DISEASES (VBDS) WATER-RELATED NUTRITION BLOCKS DISEASES Leadership A Heat-Health Action Climate change is The link with the Climate change inte- and Plan or Strategy was not considered in MoNHSRC needs to be gration into strategic governance developed in Karachi. The strategic planning for strengthened across planning, and interven- health impacts of extreme VBDs (for example, sectors to improve the tions for food security heat are not mentioned the National Malaria climate resilience of and nutrition are lacking. in climate change, or Strategic Plan). the water sanitation health sector policies or Dengue and chikun- and hygiene (WASH) planning. gunya are not high- infrastructure. Subna- lighted as emerging tional interventions are climate- sensitive lacking. The advocacy VBDs. role needs strengthen- ing to integrate climate change-related risks. Health Some training materials Training — linking A baseline understand- Climate change is not workforce exist, but the MoNHSRC climate / weather ing of WASH, as well as incorporated into training staff have not completed variables to VBDs, the climate relationship models across programs. training on the identifica- particularly epidemi- and interventions is tion of extreme heat and ology and the use needed. clinical responses for the of climate / weather condition. data at sub-national levels — should be provided. Health MoNHSRC does not Basic surveillance of Climate data is not Further assessment information record heat-attributable VBDs needs to be integrated into health is needed to under- and disease mortality. Some mapping improved. There is no information systems stand the relationships surveillance of urban hot spots to integration of climate (HIS). No risk assess- between climatic factors system identify at-risk populations / meteorological data. ments of WBDs and and nutrition / food have been done (that is, climate change have insecurity. Karachi). An evaluation of been done. No early the Heat-Health Warning warning systems (EWS) System in Karachi is for climate-sensitive needed. diseases exist. Essential Healthcare facilities have Laboratory, testing, The distribution of No baseline information medical not been assessed to and control capabili- essential medications on equipment / medica- products, determine potential risks ties need to continue (for example, vaccines) tion related to under- technologies, related to extreme heat, to be strengthened is lacking in rural / nutrition, including new and infrastruc- and cooling measures for effective malaria remote areas. technologies related to ture have not been implement- and dengue response sustainable agriculture, is ed. and elimination. available. Annex | 57 SELECTED CLIMATE CHANGE-RELATED HEALTH RISKS HEALTH SYSTEM HEAT-RELATED RISKS VECTOR-BORNE WATERBORNE AND FOOD SECURITY AND BUILDING DISEASES (VBDS) WATER-RELATED NUTRITION BLOCKS DISEASES Health service There are no extreme Climate change is Baseline information Nutrition programs in delivery heat programs in not incorporated into on safe WASH in remote, rural areas are MoNHSRC: extreme heat standard operating healthcare facilities and needed, particularly is not included in DRM procedures (SOPs) interventions needed before, during, and after plans / operations. for VBDs. Commu- to improve resilience drought and flooding nity-based interven- to climate change is events. tions / awareness lacking. building can include the link between VBDs and climate change. Financing Though extreme heat Surveillance of The distribution of funds Climate-smart agriculture is prioritized in some malaria and dengue, to improve WASH, systems, including water city-level budgets, it is not as well as the addi- especially in rural areas, harvesting and irrigation highlighted in heat-health tional analysis of the is needed. to manage rainfall vari- projects. VBD risk associated ability, are needed. with climate change, needs investment. 58 | Climate and Health Vulnerability Assessment: Pakistan ANNEX VI. KEY RECOMMENDATIONS AND RELEVANT LINE MINISTRIES IN PAKISTAN HIGH-LEVEL RELEVANT LINE MINISTRIES WHO'S CLIMATE AND HEALTH RECOMMENDATIONS OPERATIONAL COMPONENT Strengthen a climate-health Ministry of National Health Services and Leadership and governance policy environment at Regulations and Coordination (MoNHSRC); national and subnational Ministry of Climate Change and Environmen- levels. tal Coordination; Provincial Health Authori- ties; Municipality Health Authorities Enhance coordination MoNHSRC; MoCC (Climate Change Council mechanisms for climate and Climate Change Authority) and health action. Develop health workforce MoNHSRC; Ministry of Federal Education Health workforce capacity to manage climate and Professional Training; Pakistan Medical and health risks. Association; Pakistan Nursing Council Develop an intersectoral MoNHSRC; MoCC; Pakistan Meteorolog- Integrated risk monitoring and early warning platform to monitor climate- ical Department; Directorate of Malaria, related health risks and Dengue, and other Vector Borne Disease support the establishment Control; Ministry of National Food Security of a climate-informed & Research; National Disaster Management disease early warning and Authority response system. Climate-proof health infra- MoNHSRC; Ministry of Water Resources; Climate-resilient and sustainable technolo- structure and technologies. Ministry of National Food Security & gies Research; Ministry of Energy; Public Private Partnership Authority (PPPA); Ministry of National Food Security & Research; Ministry of Planning Development and Special Initia- tives Establish a national risk MoNHSRC; National Disaster Management Emergency preparedness and management register for climate-health Authority; Provincial Disaster Management risks in Pakistan with Authority; National Commission on the seasonal climate outlooks Status of Women to inform health sector programming. Pool health funds to cover MoNHSRC; Ministry of Finance; Water and Climate and health financing climate-related health Power Development Authority risks and include climate risk considerations into strategic purchasing. Annex | 59 ANNEX VII. EXAMPLES OF “NO REGRETS12” RECOMMENDATIONS FOR CLIMATE CHANGE AND HEALTH IN PAKISTAN COMPONENT 1: LEADERSHIP AND GOVERNANCE Options to strengthen leadership and governance include the following: National (Health) • The finalization of the Health and Climate National Action Plan should incorporate all available evidence and senior endorsements to facilitate implementation. • Integrate climate-related health risks into the Pakistan National Health Vision (2016–2025). • Develop and deliver climate and health-related workshops and national policy briefs aimed at senior health sector policymakers, as well as other key sectors, to advocate for and develop climate and health policies and plans at the national level. • Establish legal and coordination mechanisms within the MoNHSRC specific to climate change, including the designation of a national climate and health focal point. • Facilitate a memorandum of understanding between MoNHSRC and other key stakeholders at the national level, including other sectors such as agriculture, planning and development, and transportation. This could potentially include the establishment of a cross-governmental climate change and heath working group. Subnational • Develop subnational adaptation plans for climate and health to enable the prioritization of adaptation needs and ensure the allocation of sufficient financial resources for implementation at provincial levels. • Develop city-level policies and plans for climate-related health risks. As a first step, the heat health action plan developed for Karachi could be rolled out for all major population centers, with prioritization for particular cities in vulnerable areas such as Lahore and Islamabad. COMPONENT 2: HEALTH WORKFORCE Options to strengthen the health workforce include the following: • Conduct climate-health analytics to inform health workforce planning. Evidence to inform policy making is critical for developing a strategic health workforce plan that is aligned with Pakistan’s current and projected climate-related health risks. To this end, while this assessment has reviewed the Human Resources for Health (HRH) dimensions related to climate change, a more in-depth analysis is necessary to elicit the health workforce needs and knowledge that are tailored to the Pakistan context. This would include considerations of the size of the health workforce, the skill mix, and the geographical distributions of personnel necessary to meet expected health needs, including addressing urban-rural disparities. 12 “No-Regrets” Approach: “No-regrets” actions are actions by households, communities, and local / national / international institutions that can be justified from economic, social, and environmental perspectives, whether natural hazard events or climate change (or other hazards) take place or not. “No-regrets” actions increase “resilience,” defined as the ability of a “system” to deal with different types of hazards in a timely, efficient, and equitable manner.  Increasing resilience is the basis for sustainable growth in a world of multiple hazards [86], [87], [88]. 60 | Climate and Health Vulnerability Assessment: Pakistan • Make use of climate information to train the health sector’s policy makers and planners to enable them to inform the design of health sector programs and enhance day-to-day service delivery, as well as during and after extreme weather events. • Develop training and awareness raising materials tailored for health providers and community health workers on climate and health in Pakistan. In addition to the conventional areas of climate and health focus (for example, malaria and dengue), an emphasis on emerging diseases (for example, Japanese encephalitis [JE], yellow fever, and Zika) is also equally important, particularly for areas along the intended China Pakistan Economic Corridor (CPEC). A full range of climate and health risks, such as extreme heat and nutrition, would need to be incorporated. It is recommended that the delivery of such training occur at both the national and subnational levels, utilizing a training- of-trainers (ToT) approach. COMPONENT 3: VULNERABILITY, CAPACITY, AND ADAPTATION ASSESSMENT Options to strengthen vulnerability, capacity, and adaptation assessments include the following: • Establish mechanisms for the routine update of climate and health vulnerability assessments (CHVAs) to inform policy and programming. Building on this assessment, periodic updates of climate and health vulnerability as well as adaptive capacity assessments are necessary. Given the pace at which climate risks are developing and the associated disease burden, it is recommended that CHVAs for Pakistan are conducted every five years to capture new information and update the stakeholders on climate-related health risks. In addition, expanding the scope of the CHVA to include an in-depth, finer-scale quantitative analysis of climate-related health risks is essential for informing policy. For example, examining the causal pathways and impacts of climate change on water quality and waterborne diseases (WBDs) would be a valued addition to the provision of precise estimates of the projected WBD risk. Further, future CHVAs could potentially also incorporate economic modeling, capturing the costs of inaction and determining the cost-benefit of cost-effective adaptive measures. • Utilize modeling techniques, including climate, disease, and economic scenarios, to guide future vulnerability adaptation assessments. This could integrate outputs from tools currently under development by the World Bank, including the Climate and Health Economic Valuation Tool (CHEVT), as well as others. These tools could make use of the information collected in this CHVA and other CHVAs. COMPONENT 4: INTEGRATED RISK MONITORING AND EARLY WARNING Options to integrated risk monitoring and early warning systems include the following: • Support the expanded and enhanced coverage of health surveillance for climate-sensitive diseases, for example, in terms of geographic, population, and seasonal aspects. This would include linking with environmental / meteorological monitoring structures to develop climate-informed early warning systems (EWS) and response mechanisms. For example, air quality monitoring systems that are linked effectively to public health communication channels to disseminate education risk messaging can inform the public and reduce the adverse health outcomes related to air pollution. Addition- ally, hospitals should update their admissions and emergency case records to track heat-related morbidity and mortality levels. Annex | 61 • Introduce a systematic approach to the monitoring of climate and health vulnerabilities. It is imperative that climate and health-specific indicators are identified to enable the monitoring of climate-sen- sitive diseases while simultaneously assessing the impacts of intervention measures, especially for climate-vulnerable populations. For example, reestablishing diarrheal disease monitoring at district levels across Pakistan would be important to elucidate the impact of climate events on diarrheal disease. • Review the extent to which human, animal, and plant disease surveillance systems are integrated and incorporate climate factors to ensure that the One Health approach is utilized and strengthened. • Collect information to establish agreed-upon baselines for monitoring vulnerable populations / regions, and existing or new health-related human resource, technical, and health services delivery capacity. • Support the identification and / or development of indicators to measure climate change and health impact and integrate the response capacity into national and provincial monitoring systems. This would also support future vulnerability and adaptation assessments. COMPONENT 5: HEALTH AND CLIMATE RESEARCH Options to strengthen climate and health research include the following: • Develop research partnerships to conduct studies and projects on key climate change and health topics, such as modeling studies to quantify the current and projected burden of climate-sensitive diseases; economic analyses to better understand the healthcare costs related to climate change; the quantification of the health co-benefits of climate change mitigation actions; operational research to test and evaluate the implementation of evidence-based interventions, such as targeted resource deployment for extreme weather events; as well as the development and testing of contextualized climate change and health risk communication materials and dissemination approaches. • Additionally, research priorities have been identified for specific climate-related health risks, such as studies on climate-resilient crops and the analysis of water demands under different climate scenarios. COMPONENT 6: CLIMATE-RESILIENT AND SUSTAINABLE TECHNOLOGIES AND INFRASTRUCTURE Options to strengthen the climate resilience of health technologies and infrastructure include the following: • Conduct health technology assessments (HTAs) targeted at understanding the value and benefits of adaptation measures in the health sector in Pakistan. HTAs ensure a systematic evaluation of health technologies, with the aim of informing the policy on cost-effective options that can be adopted. To this end, GoP would be well-advised to conduct HTAs that consider climate adaptation in their design to identify value-for-money and to inform implementation. • Assess current laboratory capacities to diagnose current and future climate-related disease, particularly emerging and reemerging communicable disease (CD), as well as noncommunicable disease (NCD) burdens. • Establish and support the implementation of the use of national building codes that should also be extended to healthcare facilities. Importantly, this should include the incorporation of climate 62 | Climate and Health Vulnerability Assessment: Pakistan risk projections into these codes, for example, to include siting and construction, functioning and operation, energy and water supplies, as well as the sanitation services of healthcare facilities. • Establish procedures to implement the above building codes to also retrofit, refurbish, and maintain the existing health infrastructure. • Support the integration of new and innovative technologies for monitoring environmental change (for example, satellite imagery) to inform measures that will improve the performance of the health system, for example, to direct the support of local health capacity planning to respond to anticipated increases in NCD burdens due to heat impacts. Other examples would relate to droughts and nutrition, precipitation, heat, and humidity and VBDs, as well as the mapping of the air quality impact on health outcomes. Mental health services should also be considered. • Introduce sustainable cooling measures for healthcare facilities and laboratories, which would enhance energy efficiency, space cooling, and medical cold chains, and ensure sustainable refrigerant technologies. These measures should follow a hierarchy of interventions, starting from passive measures, such as building design and vegetative shading, to more active technologies, such as powered air conditioning as a secondary option. • Develop structures to integrate health and climate considerations into the urban design to reduce the threat of urban heat islands. This could involve strengthening health impact assessments through to specific initiatives, such as supporting urban tree planting, in large cities. Actions have also been identified that will contribute to enhanced sustainability and reduced GHGs in the health sector, such as the following: • Assess the carbon footprint of Pakistan’s health sector. • Health facilities could implement transportation planning to minimize air pollution and associated GHGs. • Prioritize sustainability in the selection of health system procurement strategies, procedures, and products. This would include the focus on the incorporation of low-carbon, energy-efficient tech- nologies, such as photovoltaic cells, solar-powered machinery, vaccine chains, and water pumps. • Promote modern energy cooking solutions (MECS), such as low emissions cookstoves, to reduce solid fuel use and household air pollution. • Promote and, where necessary, further develop regulations that support sustainable healthcare waste management. COMPONENT 7: MANAGEMENT OF ENVIRONMENTAL DETERMINANTS OF HEALTH Options to strengthen the management of environmental determinants of health include the following: • Develop improved national regulations and policies on key environmental health services and determinants (for example, drinking water, air quality, food system, housing, transport, energy, and waste management). • Increase research on climate and environmental determinants of health in Pakistan. Data linking climate to environmental determinants of health (for example, air pollution, as well as water quality and quantity) in Pakistan was not available at the time of conducting this CHVA. Therefore, it is recommended that further research be conducted to explore the linkages between climate and environmental determinants in Pakistan on population health outcomes. It may include under- Annex | 63 standing the climate impacts on WASH infrastructure and WBDs, climate-driven water availability on nutrition outcomes via a reduction in agricultural productivity, and the effects of climate change on air pollution and its subsequent impacts on health. • Map out areas using unsafe drinking waters and unimproved sanitation facilities, assess service delivery gaps, and invest in improved drinking water, sanitation, and the sewage infrastructure to improve water quality and reduce climate-driven exposures. • Support community-led efforts to improve sanitation practices and controls to prevent foodborne diseases. • Establish a climate and environmental health database to support the development of national regulations on the management of environmental health services (for example, water supply, sanitation, and food safety). • Integrate environmental health policies and services into national public health promotion and protection programs. • Increase support for focused interventions and integrate them with the non-health sector. Inter- ventions could include, for example, promoting sustainable irrigation practices by smallholder farmers, establishing a central repository of water data / analysis to be integrated with health information, and / or adopting innovative technologies to improve wastewater treatment and water efficiency through water reuse strategies. COMPONENT 8: CLIMATE-INFORMED HEALTH PROGRAMS Options to strengthen climate-informed health programs include the following: • Engage communities and strengthen primary health care (PHC) to create a climate-informed health system. Many of the recommendations proposed thus far feed into climate-informed health programming. As previously mentioned, moving toward a climate-informed health system requires cross-sectoral collaboration, given the multifaceted nature of climate-health risks. Further recom- mendations in this area include engaging community groups and leaders to support dialogues and the development of prospective climate and health programs and policy options, as well as to strengthen PHC in managing current and future climate-related risks. • Use mainstream and social media to spread awareness and issue warnings related to preventive measures in order to improve population health literacy related to climate-sensitive health risks. • Engage district-level community groups and leadership structures to support dialogues and the development of prospective climate and health programs and policy options, as well as their integration into the planning and support of health promotion programs directed toward climate-re- lated health threats. COMPONENT 9: EMERGENCY PREPAREDNESS AND MANAGEMENT Options to strengthen emergency preparedness and management for climate change-related disasters include the following: • Enhance contingency planning for deployment and response in relation to acute climate shocks at all administrative levels. These should include integrating health considerations for climate-related hazards, such as floods, droughts, heat waves, and consequent disease outbreaks, as well as longer-term climate stressors and sea-level rises (SLRs). This should include integrating climate-re- 64 | Climate and Health Vulnerability Assessment: Pakistan lated health considerations into provincial-level monsoon contingencies to support stakeholders in organizing activities related to the preparedness of emergency responses. Further, contingency planning should consider stockpiling and distribution plans to support the disaster response. To this end, scenario-based simulation exercises will be important for testing, identifying bottlenecks in implementation, and further refining future contingency planning. • Establish seasonal climate outlooks to inform a disease control / prevention program ahead of potential extreme weather events, and facilitate multisectoral engagement with first responders, disaster management authorities, rural support agencies, and lady health workers (LHWs) to conduct community outreach and awareness regarding climate-sensitive diseases. • Ensure climate-related health risks are integrated into stockpiling and distribution plans to support disaster response supplies (for example, water purifiers). COMPONENT 10: CLIMATE AND HEALTH FINANCING Options to strengthen climate and health financing include the following: • Support revenue collection for climate-related health risks. At the national level, it would be useful to allocate (that is, earmark) a proportion of the national health funding for adaptation and mitigation policies. This funding would need to be reflected in national health strategies and budget formu- lations and could come either from central treasury or other funds, including external sources. If a country is weak in raising revenue, it will tend to rely more on user fees for its revenue. • Explore and promote the financial benefits of the health co-benefits of climate action. There are economic benefits underlying the mobilization of financial resources in Pakistan to support the health sector in assessing the co-benefits of climate action in other health-determining sectors and in identifying climate actions that bring the greatest benefits to health. • Facilitate access to international and external donor funding opportunities and mechanisms. They should include the Green Climate Fund, the Global Environment Facility, and the Adaptation Fund for the allocation of funds toward health-based adaptation measures, the control of climate-sen- sitive diseases, research projects, and mitigation projects, including NDCs. Annex | 65 ANNEX VIII. MENU OF HEALTH ADAPTATION OPTIONS BY CLIMATE-RELATED HEALTH RISK COMPONENT HEAT-RELATED RISK VECTOR-BORNE WATER-RELATED NUTRITION, FOOD DISEASES (VBDS) DISEASES SECURITY, AND FOOD SAFETY Component 1: Develop and Implement a Promote the Incorporate climate Leadership and implement national National Action Plan creation of subna- change risks Governance heat health policy on VBDs. tional-level water into food safety and subnational regulatory author- standards. plans. ities and engage with communities on policy options. Component 2: Conduct heat-health Provide subnational- Raise the awareness Incorporate edu- Health workforce training for health level training of health workers on cational materials workers. Ensure to enhance the the climate change on climate change occupational heat capacity of dengue impact on water san- impacts on food exposures are prevention and itation and hygiene security and managed. control, as well as (WASH) and wa- nutrition into health the knowledge of terborne diseases worker training. climate change-re- (WBDs). lated factors. Component 3: Conduct assess- Conduct district- and Conduct vulnera- Conduct vulnerabil- Vulnerability, ments on high-risk community-level bility assessments ity assessment of capacity, and adap- groups at subnation- assessments to of water shortages, nutrition to climate tation assessment al levels and incor- better under- rainfall extremes, change. Assess the porate economic stand local risks unpredictable river nutrition benefits analyses. related to VBDs flows, and baseline of climate-smart and the capacity WASH coverage in agricultural interven- for managing healthcare facilities. tions. outbreaks. Component 4: Set up heatwave Building from health Integrate climate / Develop and include Integrated risk alert systems for information system, weather information long-term strategies monitoring and urban and rural pop- establish virus and with WBD surveil- for nutrition inter- early warning ulations. vector surveillance, lance systems to ventions into the as well as incor- forecast outbreaks. FEWS (famine early porate climate-in- warning system). formed seasonal outlooks. Component 5: Conduct studies to Conduct climate Model water security Analyze the Health and climate further explore the change modeling / demand projec- long-term effects of research impacts of extreme studies to estimate tions under different food insecurity on heat on health dengue risk projec- climate scenarios health and economy. systems, including tions and inform ad- and impacts on urban heat island aptation decisions. WBDs. mapping. 66 | Climate and Health Vulnerability Assessment: Pakistan COMPONENT HEAT-RELATED RISK VECTOR-BORNE WATER-RELATED NUTRITION, FOOD DISEASES (VBDS) DISEASES SECURITY, AND FOOD SAFETY Component 6: Cool down spaces in Improve labora- Improve WASH Improve drainage Climate-resilient healthcare facilities tory capabilities systems in health- systems in crop and sustainable to prevent overheat- for the testing care facilities to fields at risk of technologies and ing and protect IT and diagnosis of withstand extreme floods. Explore infrastructure and equipment. endemic as well weather events (for smart agriculture Energy-efficient or as novel and re- example, drainage and crop diversifica- passive measures emerging diseases. systems and health- tion practices. of cooling to reduce Develop a list of care waste manage- energy costs should essential medicines ment). be implemented. needs for VBD outbreaks. Component 7: Institute housing Conduct community Improve household Promote communi- Management of en- standards and urban awareness water security. ty-led efforts to map vironmental deter- planning (built envi- campaigns to Community-led total out food insecurity minants of health ronment) to reduce increase the sanitation should be and inform inter- heat risks. Ensure awareness of the promoted to achieve ventions to improve household water climate sensitivity of the “Open Defeca- the food system in a security. Set up VBDs and engage tion-Free” status. changing climate. occupational health vulnerable groups in management. outbreak prevention. Component 8: Ensure that heat Incorporate climate Standard Operating Implement inter- Climate-informed risks are incorpo- change information Procedures (SOPs) ventions involving health programs rated into maternal into VBD preven- for drinking water the establishment health guidance, tion and outbreak and sanitation of gardens or guidance for response standard provision. Public food-growing op- diabetes manage- operating proce- awareness-raising portunities. Com- ment, etc. dures (SOPs). campaigns should munity-mediated be conducted on delivery of nutrition hygiene, particularly services, including handwashing. screening, should be conducted. Component 9: Include heat into Include VBD Develop WASH-fo- Reinforce the food Emergency pre- disaster risk man- outbreaks into DRM cused emergency production and paredness and agement (DRM) plans at the national, preparedness and distribution chain to management operations. provincial, district, response plans, withstand impacts and community including a stockpil- from extreme levels. ing and distribution weather events. plan for supplies (for example, purifiers). Component 10: Finance sustainable Formulate proposals Allocate resources Invest in the dis- Climate and health cities / cool cities for external donors to build climate- semination of crop financing that address heat to support the resilient WASH in varieties and breeds risks. control of VBDs. provincial health adapted to changing Other interventions investment plans. climatic conditions. related to heat- health responses (for example, cool roofs) should be implemented. Annex | 67 APRIL 2024 CLIMATE INVESTMENT FUNDS 68 | Climate and Health Vulnerability Assessment: Pakistan