CLIMATE INVESTMENT FUNDS © 2023 International Bank for Reconstruction and Development/The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory, or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. The World Bank encourages the dissemination of its knowledge; thus this work may be reproduced, in whole or in part, for noncommercial purposes, as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Cover photo: Shutterstock/robertonencini. SIERRA LEONE Climate and Health Vulnerability Assessment CLIMATE INVESTMENT FUNDS CONTENTS Acknowledgments................................................................................................................................................ vi List of Abbreviations............................................................................................................................................ vii EXECUTIVE SUMMARY................................................................................................................. ix SECTION I. INTRODUCTION...........................................................................................................1 Country Context......................................................................................................................................................1 Aims of this assessment and conceptual framework.....................................................................................2 SECTION II. CLIMATE CHANGE: OBSERVED TRENDS AND PROJECTIONS.......................... 7 Sierra Leone’s Geography ..................................................................................................................................8 Observed and Projected Climatology and Sea-Level Rise...........................................................................8 Climate-Related Hazards..................................................................................................................................... 11 SECTION III. CLIMATE-RELATED HEALTH RISKS.......................................................................17 Nutrition risks........................................................................................................................................................ 18 Vector-borne disease risks................................................................................................................................ 21 Malaria.................................................................................................................................................................... 21 Waterborne disease risk.................................................................................................................................... 22 Heat-related risks................................................................................................................................................ 25 Air quality risks.................................................................................................................................................... 27 Mental health risks.............................................................................................................................................. 27 SECTION IV. ADAPTIVE CAPACITY OF THE HEALTH SYSTEM..............................................33 Health System Overview................................................................................................................................... 33 Leadership and governance............................................................................................................................. 35 Health workforce................................................................................................................................................. 40 Health information and disease surveillance................................................................................................ 43 Essential medical products and technologies ..............................................................................................47 Health service delivery ..................................................................................................................................... 48 Financing............................................................................................................................................................... 52 SECTION V. RECOMMENDATIONS TO ENHANCE HEALTH SYSTEM RESILIENCE TO CLIMATE CHANGE........................................................................................................................57 Component 1: Leadership and Governance.................................................................................................. 57 Component 2: Health workforce..................................................................................................................... 59 Component 3: Vulnerability, capacity, and adaptation assessment......................................................... 59 Component 4: Integrated risk monitoring and early warning.................................................................... 60 Component 5: Health and climate research................................................................................................. 60 Component 6: Climate-resilient and sustainable technologies and infrastructure............................... 61 Component 7: Management of environmental determinants of health.................................................. 62 Component 8: Climate-informed health programs...................................................................................... 63 iv | Climate and Health Vulnerability Assessment: Sierra Leone Component 9: Emergency preparedness and management.................................................................... 63 Component 10: Climate and health financing............................................................................................... 64 ANNEXES........................................................................................................................................65 Annex A. Methods for the estimation of mosquito suitability under RCP 8.5 in Sierra Leone........... 65 Annex B. Water points in Sierra Leone........................................................................................................... 68 Annex C. Adaptive Capacity Rapid Assessment.......................................................................................... 69 Annex D. Health Adaptation Recommendations/Menu of Options.......................................................... 72 REFERENCES.................................................................................................................................75 LIST OF FIGURES Figure 1. World Health Organization’s (WHO) Operational Framework for Climate-Resilient Healthcare Systems....................................................................................................................................... 4 Figure 2. Administrative boundaries of Sierra Leone.................................................................................... 5 Figure 3. Physical features of Sierra Leone..................................................................................................... 8 Figure 4. Projected average monthly temperature and precipitation patterns in Sierra Leone under RCP 8.5................................................................................................................................................. 8 Figure 5. Average daily maximum temperature across Sierra Leone under RCP 8.5 during the 2050s................................................................................................................................................................ 9 Figure 6. Population flood risk in Freetown, by ward area.........................................................................12 Figure 7. Landslide risk in Sierra Leone........................................................................................................... 13 Figure 8. Drought risk in Sierra Leone ...........................................................................................................15 Figure 9. Stages of the food system that drive healthy and sustainable diets ......................................18 Figure 10. Food insecurity in Sierra Leone in under-5’s, by district, in 2020..........................................19 Figure 11. Prevalence of malaria in children aged 6–59 months, by district, in 2016...........................22 Figure 12. Comparison of Anopheles gambiae s.l. mosquito vector suitability across Sierra Leone under RCP 8.5 across three epochs: 1986–2005 (historical baseline), 2020–2039, and 2040–2059...................................................................................................................................................23 Figure 13. WHO’s Health System Building Blocks........................................................................................ 34 FIgure 14. WHO’s Operational Framework for Building Climate-Resilient Health Systems................58 Figure B1. Waterpoints in Sierra Leone..........................................................................................................68 LIST OF TABLES Table 1. Percentage of suitable habitat area, by region, for malaria vector species in Sierra Leone, under RCP 8.5, through the mid-century....................................................................... 23 Table 2. Two-week prevalence of diarrhea in children under 5 years in Sierra Leone, 2019............ 24 Table 3. Burden of mental disease in 2019, both sexes, all ages (percentage) .................................... 29 Table 4.CLIMATE CHANGE IMPACTS ON HEALTH OUTCOMES.............................................................. 30 Table 5. Assessment of key climate change and health-related policies ...............................................37 Table 6. Health workforce distribution per province and cadre ............................................................... 41 Table 7. Key governmental stakeholders involved in Early Warning System Implementation........... 45 Table 8. Number of healthcare facilities by type across provinces (per 10,000 population).............. 49 Table 9. Summary of the health system’s adaptive capacity gaps for Sierra Leone............................ 54 Table A1. Model parameterization and data sources for habitat characterization................................ 66 Table A2. Copernicus Global Land Cover Layers: CG:S-LC100 Collection 2 global landcover map classifications....................................................................................................................................... 66 Contents | v ACKNOWLEDGMENTS The authors are thankful to the Africa Climate Resilient Investment Facility (AFRI-RES) Trust Fund, the Climate Investment Funds (CIF) and the Climate Support Facility (CSF) for funding this work. This Climate and Health Vulnerability Assessment (CHVA) for Sierra Leone was produced by the Health- Climate, Environment and Disasters (HCED) program in the Health, Nutrition and Population (HNP) Global Practice of the World Bank, which is led by Tamer Rabie. The assessment is authored by April Frake, Christopher Boyer, Mikhael Iglesias, Claire Bayntun, and Stephen Dorey. The authors sincerely appreciate the valuable contributions provided by Judith Namanya, Ana Lucrecia Rivera-Rivera, Muloongo Simuzingili and Loreta Rufo. This work also benefited from the administrative support of Fatima-Ezzahra Mansouri and Julie Luvisa Bazolana, the editorial work of Kah Ying Choo, and the production of Sarah Jene Hollis. The authors are also highly grateful to the HNP management for their strong support of the HCED program and this product and would like to extend their thanks to Juan Pablo Uribe and Monique Vledder. vi | Climate and Health Vulnerability Assessment: Sierra Leone LIST OF ABBREVIATIONS AR6 IPCC Assessment Report 6 CCKP Climate Change Knowledge Portal [World Bank] CD Communicable Disease CFSVA Comprehensive Food Security and Vulnerability Analysis CHVA Climate and Health Vulnerability Assessment CHE Current Health Expenditure CMIP5 Coupled Model Inter-comparison Project Phase COVID-19 Coronavirus disease 2019 CRU Climatic Research Unit [University of East Anglia, UK] CVD Cardiovascular Disease DALYs Disability Adjusted Life Years DHIS District Health Information System DHS Demographic Health Surveys DRM Disaster Risk Management EPA Environmental Protection Agency EWS Early Warning System(s) FHCI Free Health Care Initiative FSMS Food Security Monitory System GCHA Global Climate and Health Alliance GCM General Circulation Model GDP Gross Domestic Product GEF Global Environment Facility GHG Greenhouse Gas [emissions] GIS Geographic Information Systems GFDRR Global Facility for Disaster Reduction and Recovery HARPIS-SL Hazard And Risk Profile Information System – Sierra Leone HISS Health Information Systems Strategy HRH Human Resources for Health HSS Health System Strengthening IHR International Health Regulations INDC Intended Nationally Determined Contributions IPCC Intergovernmental Panel on Climate Change LULC Land Use Land Change List of Abbreviations | vii MoH Ministry of Health MoHS Ministry of Health and Sanitation MOU Memorandum of Understanding NAP National Adaptation Plan NCD Non-Communicable Disease NDC Nationally Determined Contribution NDMA Sierra Leone National Disaster Management Agency NDP National Development Plan NHIS National Health Information Systems NGO Non-Governmental Organization NSCC National Secretariat for Climate Change OOP Out of Pocket (spending on health) PHC Primary Health Care PHU Peripheral Health Unit PM2.5 Fine Particulate Matter RCP Representative Concentration Pathway SLMet Sierra Leone Meteorological Agency SLR Sea-Level Rise SOPs Standard Operating Procedures SPEI Standardized Precipitation Evapotranspiration Index TBA Traditional Birth Attendant TtT Train-the-Trainer UHC Universal Health Coverage UNFCCC United Nations Framework Convention on Climate Change VBD Vector-Borne Disease WASH Water Sanitation and Hygiene WBD Water-Borne Disease WBGT Wet Bulb Globe Temperature WHO World Health Organization YLDs Years of Health Lost Due to Disabilities viii | Climate and Health Vulnerability Assessment: Sierra Leone EXECUTIVE SUMMARY Sierra Leone is among the most vulnerable countries in the world to the adverse effects of climate change such as extreme heat, droughts, wildfires, and floods. High population densities and inadequate housing, substantial economic dependence on agriculture, and poverty and lack of socioeconomic basic needs in the population, increases the risks in the face of climate change. The objective of the Climate and Health Vulnerability Assessment (CHVA) is to provide recommendations to enhance health system resilience to climate change, including health interventions and strat- egies for adaptation in Sierra Leone as well as assist decision makers in the country with planning effective adaptation measures to reduce climate-related health risks. Climate-related hazards and changes in the near- and mid-term temperature and precipitation affect the population in Sierra Leone. Sea level rise (SLR) threatens more than 2 million Sierra Leones in coastal communities and the low-lying coast. Catastrophic floods are increasing in frequency, having around 10 percent of Freetown’s population residing in high-risk zones, and around 28 percent of the population in the Western Area’s rural district and 34 percent of its urban district exposed to flood risks as well. Landslides are responsible for significant damage to homes and infrastructure and estimated to cause around USD 350,000 average annual direct loss to buildings by the 2050s under RCP 8.5. Wildfire events in the country are accelerating, most often affecting the northwest and eastern areas of the country, and the impact of future wildfires are likely to be exacerbated, given the projected declines in precipitation and increases in tempera¬tures. The interior provinces of Sierra Leone have been, and will continue to be, especially vulnerable to drought conditions during the dry season due to erratic rainfall, coupled with increasing temperatures. Temperature and precipitation changes affect directly and indirectly health risks in Sierra Leone, especially food security and nutrition, vector-borne diseases, water-borne diseases, heat-related morbidity and mortality, and air quality risks. Nutrition risks: Food insecurity is a chronic and worsening problem throughout Sierra Leone, with nearly 5 million people without adequate access to food. In the absence of adaptation, climate variability will substantially aggravate food insecurity and nutrition outcomes especially for populations in the Southern and Eastern Provinces, where demon- strated food insecurity and malnutrition rates already exceed those of other parts of the country. Vector-borne Diseases: Malaria has been the leading cause of premature mortality for over a decade, despite ongoing efforts to curb transmission. Malaria prevalence is nearly twice as high in rural areas (49 percent) than in urban areas (25 percent). The population in the Western Area will have the highest risk of malaria by the 2050s. ix Water-borne Diseases: Waterborne and water-related diseases occur throughout Sierra Leone because of inadequate water and sanitation systems, intense precipitation, drought conditions, and specific water contami¬nants. Coastal communities can be impacted through saline intrusions, as sea levels rise due to climate impacts, thus affecting the local groundwater. Heat-related Morbidity and Mortality: The health impacts of extreme heat are a growing concern in Sierra Leone, particularly in urban centers such as Bo and the capital Freetown. The whole of the country is exposed to medium to high levels of extreme heat index. Air Quality: In 2019, 98.8 percent of the urban population and 100 percent of rural populations had primary reliance on polluting fuels and technologies for cooking. Solid fuels are used in 97 percent of households, with 64 percent using wood. Sierra Leone has been developing policies that aim at addressing climate-related risks, having health risks and healthcare adaptation strategies being prioritized in national policies and plans, to strengthen its adaptive capacity. However, these strategies are diverse and lack specific details for implementation. Moreover, there is limited engagement of the health sector with coordination mechanisms to facilitate cross-sector action. Challenges in implementation are linked to lack of budgets that incorporate climate and health related risks, as well as not having resource allocation mechanisms for an integrated climate-resilient approach in the health sector. Regarding health workforce, the country faces an imbalance in number, skill mix and deployment, having an absent systematic approach for the capacity building of the workforce on climate-related health risks. On the other hand, health information and disease surveillance systems are not integrated with weather data or other environmental factors, likewise, there are no comprehensive climate-informed early warning systems in place. Furthermore, the health system’s facilities are under-resourced and hard to reach in rural areas, especially during extreme weather events, hindering the delivery of health services. Overall, Sierra Leone has not conducted a health infrastructure assessment, and has limited integration of climate-re- silient features in health facilities’ infrastructure. Moreover, strengthened disaster contingency plans are needed, especially at the community level, and climate change and associated impacts need to be mainstreamed into the operations of health programs at all levels. Additionally, laboratory capacities and other health technologies in Sierra Leone need further assessment to better understand the ability to manage current and projected climate-sensitive diseases, as well as guide allocation of resources. x | Climate and Health Vulnerability Assessment: Sierra Leone Recommendations for Strengthening the Resiliency of the Health System in Sierra Leone include: → Develop a Climate Change and Health National Strategy and action plan. This strategy should account for climate-related health risks and be closely aligned with the National Adaptation Plan to facilitate integration and enable multisectoral mechanisms for implementation. → Train health sector policy makers and planners to use climate information to inform the design of health sector programs and policies. → Support hospitals in updating their admissions and emergency case records to track heat-related morbidity and mortality, as well as other climate-sensitive diseases, starting with the Eastern and Northern Provinces, which are projected to experience significant tempera¬ture increases. → Develop and implement Standard Operating Procedures for drinking water and sanitation provision and launch a public awareness-raising campaigns on hygiene, particularly handwashing. → Develop and implement national building codes/permits for healthcare facilities, including to retrofit, refurbish, and maintain existing health infrastructure. → Enhance contingency planning for deployment and response at national, provincial, district, and community levels. → Improve laboratory capabilities for testing and diagnosis of endemic, as well as novel and reemerging diseases; develop a list of essential medicines needs for VBD outbreaks. → Facilitate the use of on-site renewable energy sources (for example, solar photovoltaic) in health care facilities, as well as promote the use of low-cost air quality sensor network to monitor dangerous air pollution levels. Executive Summary | xi SECTION I. INTRODUCTION COUNTRY CONTEXT 1. Sierra Leone is a developing country working to attain middle-income status, despite an undiversified, volatile economy. Fundamental to Sierra Leone’s economic growth is agriculture: it contributed to more than 60 percent of the country’s annual Gross Domestic Product (GDP) in 2020 [1]. Another significant sector of Sierra Leone’s economy is mineral production: it constituted approximately 7 percent of the GDP in 2019 [2]. However, Sierra Leone faced three major as a result of the COVID-19 pandemic. Poverty shocks between 2014 and 2021: the sharp rates in Freetown rose from approximately decline in the price of iron ore, the Ebola 18 percent in 2018 to 29 percent in 2020. epidemic, and the Coronavirus disease Even so, rural poverty (74 percent) is still 2019 (COVID-19) pandemic. The economic substantially higher than urban poverty (35 and fiscal impact of the Ebola epidemic was percent). In terms of geographical distribution, very significant, with the country’s real GDP the Northern Region has the highest incidence contracting by 20.6 percent in 2015. Although of poverty (74.2 percent), while the Western the country was in the process of rebuilding Area has the lowest (30.8 percent) [5]. Finally, slowly and recovering economically by 2019, income inequality is quite high throughout the occurrence of the COVID-19 pandemic the country, as evidenced by the Gini index nearly doubled its fiscal deficit in 2020 [3]. of 34 [5]. The cumulative output lost from 2020–2021 is SLL1.5 trillion (USD146.5 billion). While the 3. Population growth in Sierra Leone, which economy is projected to recover (with the is accelerating rapidly, is projected to GDP rising by 3 percent in 2021), it is likely increase to 8.8 million by 2025 [6]. In 2020, that the growth will be slower than prior to the population was over 7.9 million [6]. The COVID-19 [4]. population is disproportionately young: 40.9 percent are under 15 and only 3.5 percent 2. Despite the significant strides made in poverty are above 65 years [7]. Persons of working reduction, Sierra Leone suffers from rising age (15–64 years) represent 76.3 percent chronic poverty. In 2020, 58.9 percent of of the total population [8]. The most recent the population was impoverished, compared completed census, conducted in 2015,1 shows with 56.8 percent in 2018 [5]. Urban areas, in particular the capital city of Freetown, have 1 At the time of publication, results from the 2021 Mid-term Population experienced the largest increases in poverty, and Housing Census were unavailable. 1 an average annual growth rate of 3.2 percent outbreaks and susceptibility to natural between 2004 and 2015 (see [7]). In terms hazards. of population distribution, the Northern c. Substantial economic dependence Province2 is the most populated province on agriculture increases the country’s (over 2.5 million inhabitants); however, it has sensitivity to climate change and climatic the lowest population density (69.3/km2). The shocks, which affect agricultural produc- Southern Province is the least populated, with tivity and food security. approximately 1.4 million inhabitants and a d. Socioeconomic progress has recently been population density of 71.0/km2 [7, 9]. Most substantially hindered by the 2014–2016 of Sierra Leone’s population reside in rural Ebola outbreak and COVID-19, leaving areas (59 percent) [7]. However, the rate of Sierra Leone in a weakened position to urban population growth has been steadily address the impacts of climate change. increasing since the 1960s [10]. e. Poverty and the lack of socioeconomic necessities make it harder for the population 4. Sierra Leone is among the most vulnerable to cope with climate change-related risks. countries in the world to the adverse effects of climate change, although it is among 5. Sierra Leone is committed to meeting the the lowest contributors to greenhouse gas climate challenge through both adaptation emissions (GHGs). Coupled with human-in- and mitigation measures. Sierra Leone ratified duced health stressors, climate change has the Paris Agreement of the United Nations exacerbated existing health burdens and Framework Convention on Climate Change created new health risks in the country. (UNFCCC) on September 22, 2016: it aims to Compounding these challenges is the reality limit the global mean temperature increase to that the impacts of climate change on health well below 2°C, compared with pre-industrial and economic inequalities are not uniformly levels. Moreover, the Government of Sierra distributed, in terms of demographic, socio- Leone submitted two rounds of intended economic, geographical, and environmental nationally determined contributions (INDCs), factors, thereby further heightening population first in 2016 (see [2]) and then in 2021 (see [3]). health risks. They set out the measures Sierra Leone will take to respond to the climate crisis. Section Sierra Leone’s vulnerabilities are the result of IV of this assessment highlights the key steps several factors: adopted to meet its climate aspirations. a. The country’s geography renders the population vulnerable to a wide range of AIMS OF THIS ASSESSMENT AND extreme, climate-related events. CONCEPTUAL FRAMEWORK b. High urban population densities and 6. The objective of this Climate and Health population growth, coupled with inadequate Vulnerability Assessment (CHVA) is to assist housing, increase the likelihood of disease decision-makers with planning effective adaptation measures to deal with climate-re- 2 Statistics reported are from the most recent recorded census (2015), lated health risks. Where available, these prior to the re-drawing of provincial and district borders to include the Northwestern Province, along with the Falaba and Karene districts. measures are provided at a subnational level 2 | Climate and Health Vulnerability Assessment: Sierra Leone The objective of this Climate and Health Vulnerability Assessment (CHVA) is to assist decision-makers with planning effective adaptation measures to deal with climate-related health risks. to assist regional health planners. The recom- scenarios considered” [13]. Mitigation alone mendations of this CHVA are primarily aimed is no longer a sufficient strategy, regardless at the health sector, but they are also targeted of the pace with which governments and at other sectors that affect climate-related communities around the world act. Adaptation health risks, such as disaster risk management is now as critical a part of climate action as (DRM). mitigation. Therefore, while this report is focused on adaptation measures, it also 7. Adaptation priorities need to be accompanied includes recommendations for reducing GHGs by fundamental and urgent action to mitigate or facilitating the decoupling of emissions from climate change. It is important to illuminate progress toward human health goals, where the complexity of the climate challenge and possible. the difficulty of predicting with accuracy the severity of climate exposures populations will 9. The World Health Organization’s (WHO) face in the future. There are many factors that operational framework to build climate-resil- could slightly slow or significantly speed up ient health systems [14] has been adopted to rates of change, including positive feedback analyze the adaptive capacity for adequately effects and cascading climatological tipping dealing with current and future identified points, which are the most worrisome. For risks. this reason, mitigating existing GHGs, along with developing and implementing measures In accordance with this framework (Figure 1), to protect human health from the changing this CHVA is structured around the six climate, is of paramount importance. Health System Strengthening (HSS) building blocks. These six categories encompass the 8. Investing in adaptation strategies to assessment of current and future capacities proactively address the effects of climate and gaps. The CHVA then moves on to change on health outcomes is critical. This consider the 10 components of health system assessment outlines climate risks to health and climate resilience. health systems, the adaptive capacities in place to deal with these risks, and recommendations 10. This CHVA follows a stepwise linear approach. to meet identified gaps. The primary focus The first step characterizes the climatology in of this assessment is, therefore, on climate Sierra Leone, highlighting the observed and adaptation and resilience measures. future climate exposures relevant to health. The second step examines climate-related However, as the Assessment Report Six (AR6) health risks, including identifying vulnerable of the Intergovernmental Panel on Climate populations most at risk. The third and final Change (IPCC) makes clear, “Global surface step assesses the adaptive capacity of the temperature will continue to increase until health system by identifying gaps in order at least the mid-century under all emissions to manage current and future climate-related Introduction | 3 FIGURE 1. World Health Organization’s (WHO) Operational Framework for Climate-Resilient Healthcare Systems LIMATE RESILIENCE C hip & Heal eaders nce Workf th L verna orce Go V uln pac ation t Fin alth & A Ca pt en He ate era ity & Leadership As g da essm Clim cin bil & Governance Health s ity, an Workforce Financing Preparedness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential C li o r m e h Re ima & I n f a lt s Medical ma d C l a lt h se te Products & h He ra m Pro te a rc He Technologies - g Ma nt na Env ge m ent o 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: [14]. health risks. Together, these steps inform Leone is administered through five administra- a series of recommendations to reduce tive units, four provinces, and one area. The climate-related health vulnerability in Sierra provinces are the Eastern Province, Northern Leone. The CHVA is based on a review of the Province, Southern Province, Northwest published literature, national statistics, and Province, and Western Area (Figure 2). consultations with key counterparts in the These provinces are further subdivided into government including the Ministry of Health 16 districts. Freetown, the capital, is in the and Sanitation (MoHS). Western Area. New provincial and district borders were drawn in 2017, leading to the 11. The CHVA incorporates subnational consider- creation of the Northwest Province and the ations for health-related climate action. Sierra districts of Falaba and Karene. 4 | Climate and Health Vulnerability Assessment: Sierra Leone FIGURE 2. Administrative boundaries of Sierra Leone Source: World Bank Cartography Unit Introduction | 5 SECTION II. CLIMATE CHANGE: OBSERVED TRENDS AND PROJECTIONS 12. This section describes observed climatic changes and projected climate trends, highlighting priority climate-related exposures of human health risks in Sierra Leone. Climate information is taken from the World Bank Group’s Climate Change Knowledge Portal (CCKP; see [15]), while historical, observed data is derived from the Climatic Research Unit, University of East Anglia (CRU). Observed changes in the mean annual temperature, mean maximum temperature, as well as the mean minimum temperature and precipitation from CCKP, are derived from the CRU’s TS version 4.05 gridded dataset of the 1901–2020 period. In addition, model-based, climate projection Peninsula; and coastal swamps. The coastline data is obtained from the Coupled Model stretches for approximately 500 km along Inter-Comparison Project Phase 5 (CMIP5) the Atlantic Ocean [16]. There are nine major collection. CMIP5 is a standard framework river systems throughout the country that for analyzing coupled atmosphere-ocean range in length from 160 km to 430 km, and general circulation models (GCMs) and whose mean annual runoff is in the order of providing estimates of future temperature 160 km [17]. and precipitation scenarios. Projected changes are explored under the IPCC representative concentration pathway (RCP) 8.53 for the short OBSERVED AND PROJECTED (2030s; 2020–2039) and medium (2050s; CLIMATOLOGY AND SEA-LEVEL RISE 2040–2059) terms. 14. Sierra Leone has a tropical climate that is predominately hot and humid. As a function of topography, temperature increases, and SIERRA LEONE’S GEOGRAPHY precipitation decreases as one moves inland 13. Sierra Leone, situated on the west African from the coast. Mean annual temperatures coast, has a complex mosaic of landscapes range from 25°C to 28°C (Figure 4). There (Figure 3). There are four major physiographic are two distinct seasons — rainy and dry. The regions: the interior plateau and mountain rainy season occurs from May to November, range; interior lowland plains; the Sierra Leone driven by the movement of the Inter-Tropical Convergence Zone (ITCZ). Average rainfall 3 Raw data is provided for RCP 4.5 in Annex A of this report. For additional indicators, see The World Bank’s Climate Knowledge Portal during the rainy season exceeds 2,300 mm Data. Download at https://climateknowledgeportal.worldbank.org/ (1991–2020), with the Western Area experi- download-data. 7 FIGURE 3. Physical features of Sierra Leone Source: Natural Earth, ASTER Global Digital Elevation Model Version 3, WB Cartography, and AQUASTAT (FAO). FIGURE 4. Projected average monthly temperature and precipitation patterns in Sierra Leone under RCP 8.5 700 mm 30 ˚C 600 mm 29˚C 28 ˚C 500 mm 27 ˚C 400 mm 26 ˚C 300 mm 25 ˚C 200 mm 24 ˚C 100 mm 23 ˚C 0 mm 22 ˚C Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Precipitation Historical Reference Period, 1986-2005 2020-2039 2040-2059 Temperature Historical Reference Period, 1986-2005 2020-2039 2040-2059 Source: World Bank Climate Change Knowledge Portal 8 | Climate and Health Vulnerability Assessment: Sierra Leone encing more rainfall than any other parts of in the 2050s. As a consequence, average the country. The dry season is characterized daily maximum temperatures are projected by limited rainfall (less than 200 mm) and hot, to range from 28°C to 35°C in the 2030s dusty conditions from the Harmattan winds and 29°C to 36°C in the 2050s throughout blowing in from the Sahara [18]. the country (Figure 5). The Northern and Eastern Provinces will be the most vulnerable to both rising temperatures and heat index. TEMPERATURE Heat index (that is, the apparent or feels like 15. Mean annual temperatures across Sierra temperature) is a measurement that combines Leone have increased by 0.8°C over the air temperature and relative humidity. By the past half century, with the rate of increase 2050s, the Northern and Eastern Provinces accelerating more recently. There is little are projected to experience 98 and 105 days, variation in subnational temperatures. In all respectively, each year, during which the heat provinces, monthly maximum temperatures index will exceed 35°C. are at, or exceed, 30°C for nine months of the year. Monthly mean temperatures range Just as significantly, these increases in from approximately 25°C to 28°C, with interior daytime temperatures will be compounded provinces experiencing higher temperatures by escalating nighttime temperatures (that than coastal areas. is, tropical nights). A tropical night is char- acterized by nighttime temperatures that 16. Extreme temperatures will become the new do not fall below 20°C; this temperature is normal for Sierra Leoneans, as temperatures important, as the human body needs to cool continue to rise. Average monthly temperature down adequately, especially after experiencing increases will range from 0.8°C to 1.1°C across high daytime temperatures. Tropical nights are Sierra Leone in the 2030s and 1.4°C to 2.2°C already routine in Sierra Leone: in the Western FIGURE 5. Average daily maximum temperature across Sierra Leone under RCP 8.5 during the 2050s 37 ˚C 35˚C 33 ˚C 31 ˚C 29 ˚C 27 ˚C Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Eastern Western Northern Southern Western Area Source: World Bank Climate Change Knowledge Portal Climate Change: Observed Trends and Projections | 9 Area, there has historically been a maximum of the year, thereby encompassing nearly all of just two nights a year with temperatures below the dry season. The dry season is projected to 20°C. By the 2050s, the Western Province, become even drier throughout Sierra Leone the Western Area, and the Southern Province by the 2050s, with some slight increases will rarely experience nighttime temperatures in precipitation during the rainy season. By below 20°C. the mid-century, precipitation in the Western Area during the dry season will decline by 21 percent, amounting to only roughly 60 mm PRECIPITATION of rainfall. The decline in precipitation will 17. Rainfall has become increasingly more erratic trigger severe prolonged droughts especially throughout Sierra Leone, with a declining in the Western Area. trend in mean annual precipitation. Mean annual rainfall from 1991 to 2020 was 2,477 mm, a slight decline from the recorded 2,484 SEA-LEVEL RISE mm during the 1961–1990 period. The most 19. Sea-Level rise (SLR) is a phenomenon that notable change between the two periods is significantly threatens coastal communities what has been occurring during the month and the low-lying coast of Sierra Leone. More of August: monthly rainfall has increased by than 2 million Sierra Leoneans are at risk approximately 260 mm, nearly half of which of SLR [19], many with livelihoods that are has occurred in the Western Area. Over the dependent on coastal resources. SLR not past half century, stronger winds and more only has implications, in terms of population frequent rain and storms have occurred during displacement in coastal communities, but the pre-monsoon season, coupled with delays also poses significant risks to water quality, at the start of the annual rainy season. In incomes, food security, and nutrition, due contrast, the September–November period to two key reasons. The first is the loss of has become calmer and drier, deviating from coastal agricultural lands caused by erosion, what is typically a period of heavy rainfall inundation, or salinization, and the second is and convective activity [18]. An increase in the impact of SLR on coastal fish populations. precipitation intensity and storm surges along The erosion of sandy beaches, biodiversity the coast has exacerbated flood risk during loss, and compromised integrity to rocky coasts the rainy season especially in the Western have already been attributed to rising sea Area. levels [20]. As of January 2016, the average annual anomaly of coastal Sierra Leone was 18. Annual rainfall is projected to continue 126.48 mm. declining in Sierra Leone through the mid-century, albeit with marked seasonal Just as importantly, Sierra Leone does not differences. During 2030–2050, precipitation have a national sea-level observing system is projected to increase in all provinces from to monitor the mean SLR along the coastline, October to December, coupled with notable nor are there country-specific SLR projections. declines in precipitation during the first two However, global mean SLR is projected to rise months of the rainy season — May and June. between 0.63 and 1.322m by 2100 under RCP The overall net annual decline in precipitation 8.5 [21]. will be strongly skewed toward the first half of 10 | Climate and Health Vulnerability Assessment: Sierra Leone CLIMATE-RELATED HAZARDS in deforestation, stone mining on hills, the destruction of mangroves causing coastal 20. There are several climate-related hazards erosion, along with the buildup of wastes in linked to changes in baseline temperatures, drains and culverts, further compound flooding precipitation, and SLR, which are affecting risks [26]. population health in Sierra Leone. The most common climate-related hazards affecting The Western Area has historically been the Sierra Leone are flooding and landslides, but region that is the most vulnerable to flood wildfires and droughts also pose additional hazards: it has experienced more flooding risks. The overall impacts of such events in events over the past decade than any other Sierra Leone will not merely be attributable part of the country. Likewise, the percentage to changing environmental conditions, as of the population exposed to flooding in the they will also be compounded by anthropo- Western Area is higher than elsewhere in genic causes including rapid deforestation, Sierra Leone: 28 percent of the population coastal degradation, mining, urbanization, in the Western Area’s Rural district and 34 and inadequate housing. percent of its Urban district are exposed to flooding risk [27]. Other areas most substan- tially impacted by flooding are the Regent, FLOODS Port Loko, Kenema, Moyamba, and Kambia 21. The frequency of catastrophic flooding events districts [28]. in Sierra Leone is accelerating. Since 1990, 10 major flooding events have been recorded in 22. While annual net precipitation is expected the international emergency events database to decline in Sierra Leone, the intensity of (EM-DAT); nine of these events have occurred rainfall events during the rainy season is since 2004 [22]. The most recent catastrophic projected to increase, which can exacerbate flooding events occurred in 2019 and 2017, flood risk. By mid-century, the average largest both outside of Freetown. The 2019 event one-day precipitation totals will exceed 100 affected over 5,000 residents and claimed six mm in July and August. Likewise, the average lives, while the successive rainfall in August largest cumulative 5-day rainfall will increase 2017 led not only to a flooding disaster, but also by approximately 14 and 12 percent in June and triggered the Sugar Loaf Mountain landslide July, respectively, across Sierra Leone. The (see the following section on landslides) [23]. steep river valleys of the Western Area and the interior mountain region are at the highest Flash flooding occurs in urban and coastal risk of flooding due to shorter, intense flooding areas every rainy season [24], often triggered events during the July–August period. Flatter by heavy or sustained rainfall, high tides, areas will be more susceptible to flooding increasing river volumes, and insufficient or from the slower moving storm systems in blocked drainage infrastructure [25]. Beyond June and July. Compounding the flooding precipitation and rising sea levels, urban risk are rising sea levels, which will contribute development and policy has also contributed to the inundation of coastal areas and the to flood risk through a lack of zoning, city increased frequency of flooding events in planning, and building regulations. The coastal communities [28]. construction of homes on hill tops resulting Climate Change: Observed Trends and Projections | 11 23. Freetown is among the most vulnerable places deforestation in the upper catchment is to future flood risk. The hydraulic modeling expected to exacerbate flooding within these of flood risk highlights areas of high-hazard areas. Over 3,000 people are estimated to flood zones throughout Freetown (see [28]). be affected annually by flooding events with Areas of the highest flood risk include the an average of nine fatalities each year [28]. natural river channels within Regent-Lumley in The Lumley, Juba, Susan’s Bay, and Regent the northwest and Bathhurst-Hastings Village wards in Freetown are at the highest risk of area in the southeast; natural channels and flood-related fatalities, with Kroo Town and tributaries, such as from Thunderhill to Shell the Brookfield-Congo Market projected to and from Gloucester to Cline Bay; as well as have the highest number of people affected bay areas along the coast, including Kroo’s by flood events [28]. Bay, Susan’s Bay, and Cline Bay (Figure 6). By the 2050s, the average annual direct losses Approximately 10 percent of Freetown’s to buildings from flooding is estimated to be population reside in high-risk zones, where at more than USD2.5 million. FIGURE 6. Population flood risk in Freetown, by ward area Flood Risk Data Sources: World Bank 2018. Flood inundation data source: Integrated Geo-information and Environmental Management Services (INTEGEMS), United Nations Development Report (UNDP). 12 | Climate and Health Vulnerability Assessment: Sierra Leone LANDSLIDES The Sugar Loaf Mountain landslide of 2017 was one of the worst disasters to have taken 24. Landslides are responsible for significant place on the African continent. On August damage to homes and infrastructure, along 14, 2017, after three days of heavy rain in the with substantial losses of life, in Sierra Leone. Freetown area, a section of hillside collapsed. The climate of Sierra Leone, which exacerbates Homes were swept away and waterways the extensive tropical weathering of the became blocked. There were more than 1,100 bedrock, in combination with the country’s fatalities, including hundreds of children, due high relief and heavy precipitation during to the direct impacts of the mudslide [29]. The the rainy season, increases the country’s extent of the tragedy was further exacerbated vulnerability to landslide events. Landslide by deforestation and the poor planning of the and mudslide-prone areas of Sierra Leone built environment: approximately 15 percent of include the mountainous Western Area and the dense forests in the area had been converted high-elevation areas of the central highlands into built-up areas of housing from 1986 to (Figure 7). 2015 [30]. FIGURE 7. Landslide risk in Sierra Leone Data Source: INTEGEMS, UNDP. Climate Change: Observed Trends and Projections | 13 25. Ongoing climate change will aggravate the the impact of wildfires in Sierra Leone, even landslide risk around the steep hills of the as the climate continues to change. Freetown Peninsula and the mountainous areas of the central highlands. While rainfall Nonetheless, it is reasonable to assume that is the primary trigger of landslide events, the increasing temperatures the country will deforestation and unmanaged urbanization experience, coupled with a higher likelihood has weakened slope stability and signifi- of drought conditions (see below for further cantly compounded the risk. Freetown is information), could exacerbate wildfire risk. highly vulnerable to the landslide risk, given Notably, the lengthening of the wildfire season, the projected increases in the intensity of as has already been documented, can be precipitation events in the Western Area attributable to climate change [34, 35]. (see discussion on projected precipitation and flooding risk above for further details), deforestation along the area’s lower slopes, DROUGHT and ongoing, unregulated construction [31]. 27. The interior provinces of Sierra Leone are Estimates of average annual direct loss to especially vulnerable to droughts due to buildings are over USD350,000 as a direct erratic rainfall, coupled with increasing result of landslides in Freetown during the temperatures. In the northeast, droughts have 2050s under RCP 8.5 [28]. slowly become prevalent from February to March in recent years, as declining rainfall averages have been attributed to the longer- WILDFIRES than-normal dry spells experienced in the 26. Wildfire events in Sierra Leone are acceler- region [36]. Long-term patterns and trends ating, most often affecting the northwest of drought occurrences in Sierra Leone are and eastern areas of the country [32]. Histor- unavailable due to a lack of surveillance data ically, the wildfire season in Sierra Leone, [37]. occurring from January to March, coincides with the dry season [33]. However, climate Projected increases in temperature across change, manifested in temperature increases Sierra Leone, as well as declining precipitation and rainfall variability, can further exacerbate during the first half of the year, are likely to wildfires. increase the risk of drought events. The annual Standardized Precipitation Evapotranspiration At the same time, attributing the rise in wildfire Index (SPEI) statistics in the 2050s show a events in Sierra Leone to climate change is predicted negative water balance (-.21), but a challenging, at best, as information on wildfire very low overall likelihood of severe drought incidents throughout the country is scarce, at the national scale. Subnationally, the north- including whether individual wildfire events eastern districts of Koinadugu in the Northern are natural or human-induced events. Further, Province, along with Kono and Kailahun in fire is often used as a tool in agricultural and the Eastern Province, are likely to be the hunting practices throughout the region. No most vulnerable to future drought conditions studies have been conducted on predicting (Figure 8) [36]. 14 | Climate and Health Vulnerability Assessment: Sierra Leone FIGURE 8. Drought risk in Sierra Leone Data Source: INTEGEMS, UNDP. Climate Change: Observed Trends and Projections | 15 KEY MESSAGES Mean annual temperatures across Sierra Leone have increased by 0.8°C over the past half century. By the 2030s, extreme temperatures will become the new normal for Sierra Leone. Rainfall has become increasingly more erratic, with a declining trend in mean annual precipitation. Through the mid-century, annual rainfall will continue to decline, most notably from January to June. SLR threatens coastal communities and the low-lying coast of Sierra Leone significantly. However, without a national sea-level observing system, it is difficult to project and subsequently prepare for the impacts of SLR on coastal communities. The frequency of catastrophic flooding events in Sierra Leone is accel- erating, with the population of Freetown at the greatest risk of future flood-related impacts. Landslide risk is projected to increase in Freetown and the interior mountainous areas as a result of the increasing intensity of rainfall events, especially during the rainy season. There has already been a marked lengthening of the wildfire in season in Sierra Leone. The impacts of future wildfires are likely to be exacerbated, given the projected declines in precipitation and increases in tempera- tures throughout the wildfire season. The interior provinces of Sierra Leone have been, and will continue to be, especially vulnerable to drought conditions during the dry season due to erratic rainfall, coupled with increasing temperatures. 16 | Climate and Health Vulnerability Assessment: Sierra Leone SECTION III. CLIMATE-RELATED HEALTH RISKS 28. Sierra Leone faces a multitude of health challenges from communicable diseases (CDs) and non-communicable diseases (NCDs), many of which are climate sensitive. In 2019, the crude death (11.5 per 1,000) [38], under-5 mortality (109.2 per 1,000) [39], and neonatal mortality rates (31.18 per 1,000) [40] were higher in Sierra Leone than the regional averages in sub-Saharan Africa. In addition, the maternal mortality ratio is the third-highest in the world (1.1K per 100,00 live births) [41]. Though life expectancy is increasing, it remains low (54.6) [42]. Malaria is the leading cause of morbidity and in adaptation and mitigation measures must mortality across the country. In 2020, WHO carefully consider groups who would directly estimated the incidence of between 1.4 and 4.4 benefit from, or may be disadvantaged by, million cases of malaria across the country that adopted measures. resulted in an estimated 6,000–10,000 deaths [43]. CDs, maternal, neonatal, and nutritional 30. Sierra Leone’s CHVA assesses six climate-re- diseases constitute seven of the top 10 causes lated health risk categories. They include risks of death [44]. Of these, lower respiratory to (a) nutrition, (b) vector-borne disease (VBD), infections, diarrheal diseases, tuberculosis, (c) water-borne disease (WBD), (d) heat-related and meningitis are climate sensitive. risks, (e) air quality, and (f) mental health. Risk categories were selected from the literature 29. Climate-related risks to health outcomes review on climate and health risks to Sierra are not evenly distributed in the population, Leone, including the published literature of with some groups at greater risk than others. Sierra Leone’s MoHS. The factors that affect a population’s vulner- ability to climate are often similar to those Each category is assessed in terms of that affect health more broadly [22]. However, current and future risk, with considerations climate-related factors may exacerbate of both national and subnational peculiar- health inequalities, especially among certain ities, wherever possible. It is important to vulnerable population groups, including note that these risk categories represent the poor, rural populations, those living in only the most pressing climate-related health informal urban settlements, women and risks to the population of Sierra Leone. Other young children, the elderly, those living with climate-related health risks can include, but pre-existing conditions and disabilities, and are not limited to, direct injuries and mortality displaced populations. Therefore, investments associated with natural hazard events. 17 NUTRITION RISKS While a comprehensive analysis of climate change’s impact on the food system is 31. Weather and climate are the foundational beyond the scope of this assessment, this drivers of healthy and sustainable diets. The CHVA examines climate and nutrition linkages mechanisms by which climate change affects through a food security lens in Sierra Leone, as it nutrition via the food system are profound, relates to weather and climate impacts on agri- and include the acute and chronic effects on cultural productivity. Agricultural productivity agricultural production, storage, processing, — a key determinant of food availability — distribution, and consumption (Figure 9). is affected by weather and climate in a Nutritionally secure and stable diets not only multitude of ways, from short-term shocks depend on agricultural production, but also (for example, natural disasters) to longer-term on the complex interactions among demand, changes in agro-ecological conditions, which economics, legislation, conflict, food waste, can drastically reduce yields or redefine nutrient losses, food safety, and access [45]. spatio-temporal patterns of crop suitability. In addition, climate variability is already contributing to increases in global hunger and malnutrition [46]. FIGURE 9. Stages of the food system that drive healthy and sustainable diets Healthy & Sustainable Diet Agriculture Storage Processing Distribution Consumption Production Unhealthy & Climate Change Post-harvest Loss Nutrient Loss Demand Culture Unsustainable Diet Land Use Mycotoxins Fortification Trade A ordable Water Use Nutrient Loss Waste Politics Accessible Waste Waste Legislation Economics Preferences Extreme Weather Nutrient Losses Nutrient Losses Legislation & Policies Waste Waste Figure source: [45] 18 | Climate and Health Vulnerability Assessment: Sierra Leone FIGURE 10. Food insecurity in Sierra Leone in under-5’s, by district, in 2020 Source: World Food Programme. 2021. State of Food Security in Sierra Leone: 2020 Comprehensive Food Security and Vulnerability Analysis 32. Food insecurity is a chronic and worsening food insecurity by 19 percent, 18 percent, and problem throughout Sierra Leone, with nearly 14 percent, respectively, from 2015 to 2020 5 million people without adequate access [47]. Conversely, the largest overall decline in to food. From 2010 to 2020, the prevalence food security during the same period occurred of food insecurity4 increased from 45 percent in Western Area Rural (-16 percent). In 2021, 1.7 to 57 percent. Amongst the food-insecure, million people were estimated to need food the proportion of households in severe food assistance throughout the lean season from insecurity5 rose from 7 percent to 12 percent June to August [47]. during the same period [47]. 33. Malnutrition has profound long-term conse- The highest rates of food insecurity are in quences on human capital, which can directly the Southern (65 percent) and Eastern (62 affect economic growth and development. percent) Provinces (Figure 10). The districts Access, including affordability, is a critical of Bo, Bonthe, and Moyamba in the Southern determinant of proper nutrition across Sierra Province saw increases in the prevalence of Leone, with food insecurity and malnutrition 4 “Exists when people do not have adequate physical, social, or economic access to food as defined above [110]” 5 Defined as, when a person either feels hungry and does not eat, or does not eat for an entire day, due to a lack of money or other resources Climate-Related Health Risks | 19 strongly correlated with poverty. Rice, oils, and In the absence of adaptation, climate 34. a limited number of vegetables are the dietary variability may substantially aggravate food staples in households across the country, insecurity and worsen nutrition outcomes in though the frequency of their consumption is Sierra Leone. While there is uncertainty on the dependent on the household income [47]. As precise number of Sierra Leoneans who will be dietary diversification is linked to purchasing at risk of food insecurity or rates of malnutrition power, it is limited by low income and rising because of climate change, recent findings food prices. Micronutrient deficiencies, in suggest that globally, between 2010 and 2050, particular Vitamin A and iron, are common the population at risk of hunger is projected to throughout the country, but are the most change by -91 percent to +30 percent [51]. In prevalent in rural areas. Only 45 percent and 15 Sierra Leone, the most vulnerable populations percent of rural households consume Vitamin to climate-related food insecurity and poor A and iron-rich foods daily, respectively [47]. nutrition outcomes are those in the Southern and Eastern Provinces, where demonstrated Children are especially vulnerable to poor food insecurity and malnutrition rates already health outcomes from malnutrition. Globally, exceed those of other areas. 45 percent of deaths in children under five are attributed to malnutrition [48], and in Impacts to rice and wheat production will Sierra Leone, approximately 85 percent of be especially important to future nutrition under-5s do not consume a diet that meets outcomes on a national scale. Rice is the minimum dietary diversity. Under-5 mortality staple food throughout the country, regardless in Sierra Leone is already among the highest of income level, with per capita consumption in the world (109.2 per 1000 live births in 2019 among the highest in sub-Saharan Africa [39]): from 2017 to 2020, the rate of acute [52]. Despite being cultivated throughout malnutrition in under-5s increased from 2.6 the country, rice production is insufficient to percent to 6.7 percent across the country meet the existing needs of Sierra Leone’s [47]. Further, 14 percent of under-5s were population. By 2020, rice produced in Sierra considered underweight and 30 percent Leone was available in only 52 percent of stunted, according to the 2019 Demographic markets, with most households dependent Health Survey (DHS) [49]. The prevalence of on imported rice [53]. stunting is highest in the Northwestern and Southern Provinces (32 percent) and the Rice self-sufficiency is a core priority of Sierra lowest in the Eastern Province (25 percent) Leone’s Ministry of Agriculture and Forestry [49]. The consequences of ongoing malnutri- now; this will likely be the case, as climate tion to Sierra Leone’s economic growth and continues to change [54]. Rice development development could be substantial. Undernu- is directly affected by increases in ambient trition in early childhood is associated with temperature and the availability of water decreased physical growth and cognition, resources. Likewise, warmer temperatures workforce productivity and skill attainment, as will encourage pests and disease, which well as a higher likelihood of developing NCDs. will negatively impact yield. Despite these This phenomenon is more pronounced in the concerns, no empirical studies on the impact of case of stunting, which has been shown to climate change on the current rice production have longer-term, intergenerational impacts [50]. system in Sierra Leone have been conducted. 20 | Climate and Health Vulnerability Assessment: Sierra Leone Nonetheless, if findings from nearby Côte of Anopheles gambiae s.l.7 mosquitoes D’Ivoire are any indication, irrigated and according to environmental suitability during rainfed rice yields will decline from -0.13 to the primary malaria transmission season in -0.28 [55]. Sierra Leone (May–November). Here, suitable areas are defined as those that facilitate the development of malaria mosquitoes through VECTOR-BORNE DISEASE RISKS the production and persistence of oviposition sites and where temperatures do not exceed or 35. Climate is a critical driver of vector-borne fall below thermal tolerances for the species. It disease (VBD) distribution and transmis- can be assumed that where the suitability for sion dynamics. Climate variability causes malaria vector species is the greatest, so too is vector and host ranges to expand or contract, the malaria transmission risk, in the absence thereby shifting disease distribution and of interventions. For further information on seasonality, and/or facilitating the emergence the modeling methodology and inputs, see or re-emergence of VBDs. Investigating species Annex A. distribution and the seasonality of vectors is valuable to understanding plausible VBD distributions and planning efficient, spatial- ly-targeted methods of control. VBDs in Sierra MALARIA Leone include malaria, dengue, chikungunya,6 38. Malaria is endemic in Sierra Leone, posing lymphatic filariasis (LF), onchocerciasis, and significant risks of morbidity and mortality. schistosomiasis (SCH). The disease has been the leading cause of premature mortality for over a decade, despite 36. This assessment focuses on malaria, in light ongoing strides to curb transmission [44]. The of its significance for morbidity and mortality most recent DHS Malaria Indicator Survey in Sierra Leone. The country’s vast swampland (MIS) demonstrated that prevalence is nearly and irrigated rice agriculture provide ideal twice as high in rural areas (49 percent) as breeding sites for these Anopheline vectors. compared with urban areas (25 percent). The predominant malaria vectors in Sierra Prevalence according to microscopy was Leone are Anopheles gambiae sensulato (s.l.) 40.1 percent at the national level in children mosquitoes [57]; of these mosquitoes, the aged 6–59 months, ranging from 6.3 percent Anopheles gambiae s.s. are highly efficient in the Western Area Urban to 58.5 percent in malaria vectors, given their preference for Port Loko district in the North West Province feeding on human blood, tendency for indoor [56]. By DHS region, malaria prevalence is the feeding behavior, and susceptibility to the highest in the Northern Region (52 percent), Plasmodium parasite [58]. compared with the Eastern and Southern Regions (40 percent in both) and the Western Spatial models were constructed to 37. Region (21 percent) (Figure 11) [56]. demonstrate the plausible distributions 7 Anopheles gambiae s.l. refers to a complex of eight sibling species. In the absence of detailed entomological surveillance information that 6 Reports of Dengue virus (DENV) and Chikungunya virus (CHIKV) morphologically distinguishes and reports distributions of Anopheles in Sierra Leone have been published (see [111–113]). However, gambiae s.l. species throughout Sierra Leone, this assessment focuses these viruses are not often considered in patients presenting with on Anopheles gambiae s.s. (Giles 1902) and Anopheles coluzzi, as non-specific, febrile illnesses; this may have contributed to their un- reported from entomological surveillance in Freetown by Zhao et al. der-reporting in Sierra Leone and the wider region [112]. (2019). Climate-Related Health Risks | 21 FIGURE 11. Prevalence of malaria in children aged 6–59 months, by district, in 2016 Figure source: [56]. The shifting suitability of malaria vector 39. mid-century (Table 1); as such, populations species in Sierra Leone will profoundly residing in the Western Area will be the most change the subnational geography of malaria vulnerable to transmission risks, in the absence transmission risk through the mid-century of preventative measures. At the same time, (Figure 12). Suitability for the malaria vector it is important to note that, despite the strong species is likely to decline sharply throughout correlation between VBD vectors and climate the country, especially the Eastern Province. factors, climate is merely one determinant Essentially, 4.6 million people are projected of the VBD transmission risk. The future risk to reside in areas that will likely be too warm of these diseases will depend not only on for these mosquito vectors. These changes changing climate conditions that define vector are the result of projected increases in the suitability, but also on environmental, social, monthly maximum temperatures between and economic conditions and responses. the 2030s and 2050s, which will exceed the thermal tolerance of malaria vector species beyond the coastal areas. Regional models WATERBORNE DISEASE RISK also demonstrate the declining suitability 40. Climate change impacts both the availability for Anopheles species across the region of water and its quality, with direct effects under an RCP 8.5 scenario, using the mean on water-related illnesses and waterborne temperature (see: [59]). Only the Western infectious diseases. Climate change, including Area will increase in suitable area by the changes in precipitation and temperature, can 22 | Climate and Health Vulnerability Assessment: Sierra Leone impact the quantity and quality of fresh and hepatitis A, and typhoid. Drivers of WBDs marine water through urban, rural, and agricul- throughout Sierra Leone are attributable to tural runoffs. This can lead to the contamination the consumption of contaminated drinking of drinking water, recreational water, as well water, inadequate sanitation facilities, and as fish and shellfish. Contaminated water and unhygienic practices, each of which may be poor sanitation are linked to the transmission of affected by weather and climate change. diseases, such as cholera, diarrhea, dysentery, FIGURE 12. Comparison of Anopheles gambiae s.l. mosquito vector suitability across Sierra Leone under RCP 8.5 across three epochs: 1986–2005 (historical baseline), 2020–2039, and 2040–2059 Note: The maps above were developed by the authors using data from various sources. See Annex A. TABLE 1. Percentage of suitable habitat area, by region, for malaria vector species in Sierra Leone, under RCP 8.5, through the mid-century PERCENT AREA POPULATED, SUITABLE OVERALL SUITABILITY VULNERABLE POPULATION REGION Historic 2030s 2050s Historic 2030s 2050s Historic 2030s 2050s Eastern 42.69 40.12 0.05 100 97.13 1.27 1,435,825 1,364,909 700 North-West 33.30 28.96 2.17 98.34 68.36 6.73 1,078,898 908,124 85,571 Northern 11.11 9.95 0.94 100 78.35 11.55 1,092,166 952,627 82,959 Southern 26.06 26.06 8.31 97.96 97.96 30.18 1,445,068 1,445,068 255,478 Western Area 62.48 62.48 62.57 95.37 95.37 95.51 1,193,931 1,193,931 1,193,931 TOTAL 6,245,888 5,864,659 1,618,639 Note: The table above was developed by the authors using data from various sources. See Annex A. Climate-Related Health Risks | 23 Diarrheal disease continues to be a leading animal wastes, along with agricultural and cause of child mortality in Sierra Leone [60]. other pollutants. In addition, flood waters Findings from the DHS 2019 showed that lead to the proliferation of flies and other among children under five years of age, pests, thereby heightening the risk of food approximately 7 percent of all participants had contamination. Similarly, under both flooding diarrhea in the two weeks prior to the survey, and drought conditions, bacterial pathogens with the largest proportion residing in the North attach themselves to leafy vegetables, such as West Province (9.2 percent) (Table 2) [60]. The lettuce, increasing the risk of food poisoning Northern Province had the lowest percentage and bacterial infection outbreaks including of under-5 children with diarrhea (4 percent). Salmonella Escherichia coli (E. coli) [62]. Prevalence rates were higher for children in rural areas (7.2 percent) as compared with the Drought conditions can also affect water urban areas (6.9 percent). quality and limited water quantity, thereby causing WBD outbreaks. This is because 41. Water quality is a significant driver of WBD limited water supply can force populations risk in Sierra Leone. Only 2 percent of the to use contaminated water sources for population has access to readily available, drinking, bathing, and agricultural irrigation. safe drinking water [61]. Climate change can The Northern and Eastern Provinces suffer impact water quality through temperature from extreme heat and drought conditions increases, which contribute to the prolif- in the dry season (November–April), with eration of water-borne bacteria and algal an estimated 40 percent of the recognised toxins, and through flood events caused “water points” experiencing water shortages by increasing precipitation intensity. Flood [26]. See Annex B for a map of water points waters can be contaminated with human and across Sierra Leone. TABLE 2. Two-week prevalence of diarrhea in children under 5 years in Sierra Leone, 2019 INDICATOR CATEGORY PERCENTAGE WITH DIARRHEA Province Eastern 8.7 Northern 4.0 North West 9.2 Southern 5.9 Western Area 7.8 Source of Drinking Improved 7.5 Water Unimproved 6.3 Type of Toilet Improved 6.9 Facility Unimproved sanitation 6.8 Open defecation 7.9 Data Source: DHS in Sierra Leone 2020. 24 | Climate and Health Vulnerability Assessment: Sierra Leone 42. The climate change impacts on algal blooms risk of water-related illnesses and WBDs. and eutrophication pose ongoing health The country’s poor WaSH infrastructure is risks to the population of Sierra Leone, reflected by the fact that it has one of the particularly in the coastal communities. As highest infant and child mortality rates in temperatures increase, algal blooms, which the world, along with high rates of malaria, flourish in both coastal waters and inland cholera, and typhoid. freshwater sources, will contaminate shellfish and fish. The various types of algae/blooms In the recent history of Sierra Leone, climate can cause paralytic and neurotoxic shellfish change-related hazards have caused mass poisoning, resulting in symptoms of nausea mortality and morbidity events. As Section and vomiting, as well as impacting the liver, III of this report has shown, Sierra Leone will skin, neurological and digestive systems [63], continue to experience increases in ambient [64]. In 2011 and 2012, major outbreaks of temperatures, which will lead to increased food poisoning were reported in the Freetown episodes of diarrheal diseases, seafood area, where shellfish and fish — a major food poisoning, and increases in dangerous source of the region — were contaminated. pollutants. Warmer waters will contribute to toxic algae blooms and increased cases of An added consideration is the impact of food poisoning from affected aquatic foods, eutrophication on coastal communities. This thus resulting in outbreaks such as hepatitis phenomenon, characterized by the excessive A, campylobacter, salmonella, and typhoid. enrichment of minerals and nutrients, specifi- Projected increases in the intensity of rainfall, cally nitrogen and phosphorus, has led to the with consequent floods, landslides, and inundation of Sargassum — a floating brown mudslides, will have the sequelae of WBDs, seaweed — on beaches in Sierra Leone since such as outbreaks of cholera. 2011 [65]. It has been damaging the fragile coastal and coral ecosystems [66]. Moreover, Finally, SLR and coastal storm surges have hydrogen sulfide gas, a product of the resulted in significant erosion in Konkridee, decomposing Sargassum, has been associated Lakka, Hamilton, and Plantain Island, with with cardiovascular and respiratory impacts, reports documenting 4–6 m of shift in the irritation to the upper airways and eyes, as well coastline. Saline intrusions in coastal areas have damaged the quality and quantity of as neuro-behavioral effects and neurological ground water sources, making it unusable, thus symptoms [67]. There are additional concerns exacerbating the shortages of clean water [17]. about Sargassum’s carcinogenic properties, These occurrences are projected to increase, and the health risks associated with its accu- with climate change rendering these areas mulation of heavy metals, particularly arsenic highly vulnerable to clean water shortages. and cadmium, although this has yet to be fully proven by evidence [68]. 43. Sierra Leone is extremely vulnerable to HEAT-RELATED RISKS climate shocks, particularly due to a lack 44. The health risks of heat are wide-ranging, of resilience in its water, sanitation, and including effects on mortality, heat-related hygiene (WaSH) infrastructures and systems, injuries, mental health, and wellbeing. Several thereby placing its population at increased factors influence mortality and morbidity in Climate-Related Health Risks | 25 relation to extreme heat events: the magnitude analysis reported that heat-related non-optimal of the impacts associated with the timing, temperatures in sub-Saharan Africa between duration, and intensity of the temperature 2000 and 2019 were associated with over event; levels of acclimatization (an individual’s 18,000 deaths (roughly 4 percent of the adaptive response to a hot environment); the total excess deaths) [73]. Moreover, globally, built environment (for example, the urban heat more than one-third of deaths related to heat island effect8), the adaptive capacity of the exposure (nearly 10,000 deaths a year) have affected populations, and the resilience of been attributed to climate change [74]. infrastructure and institutions, among others [69]. Both the increases in average seasonal 46. temperatures as well as the frequency and Health effects caused by heat include the intensity of heatwave events are projected direct effect of heat stress, as well as heat rash, to increase the health risks globally in a cramps, exhaustion, and dehydration, along changing climate [75–77]. These trends are with the acute exacerbation of pre-existing expected across many countries in Africa, conditions including respiratory and cardio- with increasing exposure to dangerous heat vascular diseases (CVDs). Longer-term projected in cities due to a combination of mental health risks are also an important climate and population factors [78, 79]. Based effect to consider. In addition to the impacts on the climate change projections described in on individuals, the exposure of the entire Section II, the Northern and Eastern Provinces population to an extreme heat event can lead in Sierra Leone are expected to experience to significant increases in hospitalizations, thus the most substantial temperature increases in putting a strain on health systems [70]. 2030 and 2050 under RCP8.5, including an increasing number of very hot days (>35°C) 45. The health impacts of extreme heat are a and tropical nights (>20°C). Although not growing concern in Sierra Leone, particularly as densely populated as other parts of the in urban centers such as Bo and the capital, country, approximately 1.6 million and 2.5 Freetown. The whole of the country is exposed million people in the Eastern and Northern to medium to high levels of extreme heat Provinces, respectively, would potentially be (see Section II of this report for a complete exposed to these temperature increases. They discussion on extreme temperatures). However, include vulnerable groups such as children estimating heat-related mortality and morbidity (ages 0–14), who make up 41 percent and remains a challenge due to limitations in the 85 percent, as well as persons over 65 availability and quality of vital health statistics years of age, who make up 3 percent and 4 [71], as well as the under-reporting of extreme percent, of the populations in the Eastern and heat events on the continent [72]. In West Northern Provinces, respectively. Moreover, as Africa, the risk of heat-related health effects mentioned, urban centers such as Freetown has been highlighted, especially for children and Bo, may also experience increased risk of and agricultural workers; yet, in Sierra Leone, extreme heat-related morbidity and mortality, heat-related mortality and morbidity have due in part to the urban heat island effect not been quantified. Nonetheless, a global and higher population density. 8 An urban heat island is a metropolitan area that’s a lot warmer than the rural areas surrounding it. 26 | Climate and Health Vulnerability Assessment: Sierra Leone AIR QUALITY RISKS levels of ozone and particulate matter, thus impacting health acutely and chronically 47. Ambient and indoor air pollution from through damage to the cardiovascular and wildfires, dust storms, and other air pollutants respiratory systems. Moreover, the extended poses a considerable risk to the health of dry season will prolong exposure to coarse Sierra Leoneans. Wildfire smoke, for example, particulate matter from dusty roads, industry contains carbon monoxide, nitrogen oxides, and dust storms, as there will be no rains to volatile organic compounds, as well as the settle the fine and coarse particles to the particulate matter of coarse and fine sizes ground. [80]. The entry of fine particulate matter (PM2.5) and other toxins into the deeper sections of the lungs and the blood stream not only exerts an acute impact on health, but also MENTAL HEALTH RISKS contributes to the development of severe 49. The association between climate change-re- chronic health conditions. Although the country lated events and mental health can be direct saw a decrease in PM2.5 concentrations to or indirect, short-term or long-term. Acute 17.7 micrograms per cubic meter from 2012 to events (such as floods and other extreme 2014, it rose to 22 by 2015 [82] and remained weather events) in the short term can relatively the same at 21.6 in 2017. precipitate a psychopathological pattern similar to a traumatic stress experience. Exposure to Acute impacts include eye, throat, and lung extreme or prolonged weather-related impacts irritation; shortness of breath and asthma may result in delayed mental impacts, such as attacks; and precipitation of cardiac symptoms the symptoms of post-traumatic stress in the in those at risk (chest tightening and pain future or psychological impacts on younger due to myocardial infarction). Those who generations. Individuals with lower resilience, are particularly vulnerable to particulate air including populations such as those in Sierra pollutants include those with known asthma, Leone, are anticipated to be most at risk of chronic obstructive pulmonary disease (COPD), negative impacts on their mental health and children, and emergency responders such as wellbeing in the face of climatic changes. firefighters of wildfires. Pregnant women are another group who can be adversely impacted, 50. Globally, research on the effects of mental with resultant impacts on the development of health outcomes related to climate change babies, such as low birthweight, where the lags behind research related to physical acute damage done could produce adverse health. As such, to evaluate mental health long-term effects [81]. in the context of climate change in this assessment, the full spectrum from “mental 48. Projected increases in temperatures, coupled illness” to psychological and social wellbeing with longer, drier seasons, are likely to result or “psychosocial health” is considered. Such in air quality deterioration in Sierra Leone. an approach allows for the incorporation of In built-up, densely populated areas such as considerations of wellbeing and resilience Freetown, increased temperatures will result [83], which encompasses the diverse psycho- in ‘heat island’ effects, characterized by the logical and social strains of climate change increased risk of smog formation where the impacts. Examples include housing, water air stagnates. The smog contains increased and income insecurities, as well as living in Climate-Related Health Risks | 27 physically uncomfortable drought or humid associated with higher risks of depression conditions. Adopting such an approach is and anxiety [88]. particularly relevant in Sierra Leone, as the • Alcohol and Illicit Drug Use. Figures from population is experiencing such strains. 2008 estimated that approximately 90 Moreover, there are limited opportunities percent of psychiatric patient admissions for the population to receive psychological were related to drug use in Sierra Leone or psychiatric assessment and diagnoses [89]. It has been reported that the use of in order to inform any potential analyses of marijuana and tramadol had been rising climate and health links. [90]. Alcohol consumption is higher in males than females, with no written national 51. Mental health outcomes are byproducts policy or national action plan for alcohol of biological and genetic, psychological, consumption. However, the consumption cultural, and social factors. Important societal has been declining at a regionally high considerations, with regard to Sierra Leoneans’ level in the period since the civil war [91]. mental health outcomes, are set out below: • Civil War. Sierra Leone suffered through a violent civil war from 1991 to 2002. A survey • Migration — Ongoing, dynamic migration conducted by WHO following the end of between Sierra Leone, Liberia, and the civil war revealed that 2 percent of the Guinea, predominantly rural to urban. population was psychotic, 4 percent had The migration process itself, coupled with severe depression, and 4 percent engaged the myriad push and pull factors associat- in substance abuse. Subsequently, WHO ed with migration, can negatively impact advocated for the establishment of com- mental health and wellbeing [84]. munity-based mental health services to • Ethnicity, Dialects, and Culture. Sierra meet mental health needs, particularly for Leone has 18 major languages [85], with those living in remote areas [92]. distinct cultural beliefs and practices that • Ebola. Sierra Leoneans are continuing to can affect community support networks and recover from the socioeconomic devas- relationships among community members. tation and loss of more than 11,000 lives Further, mental health perceptions vary by from the Ebola outbreak in 2014–2016 [93]. culture. Mental illness is highly stigmatized • Sugar Loaf Mountain Landslide. The Sugar in some cultures of Sierra Leone, with the Loaf Mountain Landslide of 2017 resulted individual and their relatives often viewed in the loss of more than 1,100 lives and as having done something to cause the destroyed hundreds of buildings. “curse” [86]. • COVID-19. The ongoing COVID-19 • Poverty. Most of the population in Sierra pandemic continues to affect Sierra Leone’s Leone are poor (GDP per capita of USD653), population, both in terms of morbidity and with 53 percent living below the poverty mortality associated with the infection, line. Poverty and mental illness have a along with the economic impacts of the bidirectional, causal relationship [87]. global COVID-19 situation. • Food Security. Food security is a chronic and worsening problem throughout the 52. Climate change is a considerable threat to country (see the “Nutrition” subsection of mental health in the 21st century. Nonetheless, this report). Food insecurity is significantly analyzing the link between climate and the 28 | Climate and Health Vulnerability Assessment: Sierra Leone resulting mental health and well-being in Sierra The country lacks the capacity to train health Leone is challenging. A lack of mental health workers to meet with the psychosocial needs and well-being monitoring, service provision, of the population. Sierra Leone has only 20 and assessment, as well as a high level of mental health nurses and the only facility psychological stressors experienced by the for patients needing psychiatric care — the population (see above), makes determining Sierra Leone Psychiatric Hospital — has a the actual burden of mental health disease maximum capacity of just 150 patients. Yet challenging, at best. no official budget line has been allocated to mental health according to the MoHS (see Estimates have placed the mental health [65]). Eighty-eight percent of individuals who treatment gap in Sierra Leone at 98 percent do access psychiatric services have previously for those with severe mental disorders. Based been seen by an unregulated traditional healer, on available data, mental diseases contributed of which there are estimated to be 37,000 in to approximately 3 percent of total disability the country. adjusted life years (DALYs) and 21 percent of total years of health lost due to disabilities (YLDs) in 2019 in Sierra Leone (Table 3). TABLE 3. Burden of mental disease in 2019, both sexes, all ages (percentage) CONTRIBUTION TO CONTRIBUTION TO DEATHS PER MENTAL DISEASES TOTAL DALYS (%) TOTAL YLDS (%) 100,000 Anxiety disorders 0.59 3.59 Mental disorders are Depression 1.01 6.23 ranked 21st for their con- tribution to deaths. Even Idiopathic developmental intel- 0.084 0.51 if their impact remains lectual disability weak compared to other Schizophrenia 0.18 1.15 groups of diseases, the burden of mental diseases Autism spectrum disorders 0.11 0.65 has strongly increased Bipolar disorder 0.18 1.08 during the two decades (1990–2019). Conduct disorder 0.16 0.99 In 1990: 0.000333 deaths Headache disorder 0.96 5.84 per 100,000 Eating disorder 0.036 0.22 In 2019: 0.000777 deaths Other mental disorders 0.14 0.85 per 100,000 Total contribution to the burden 3.45 21.11 of diseases Even if their impact is relatively weak, in terms of DALYs (3.45 percent), the contribution, in terms of total YLDs, is one of the highest in the world. Data Source: [109]. Climate-Related Health Risks | 29 53. It is challenging to project the magnitude of psychological traumas that challenge of the global, much less country-specific, previously existing assumptions about mental health outcomes in relation to climate self, others, and the future change. In Sierra Leone, there is a need for improved surveillance and diagnostics, as On the other end of the projection spectrum, well as specialist training and services, to researchers in China have projected levels meet the mental health and wellbeing needs of heat-related excess mortality for mental of the population. disorders, modeled under different climate change scenarios. Based on the findings that Many factors can influence mental health and suicide rates increase by 0.7 percent and 3.1 wellbeing, and the nature of resilience is not percent, respectively, for a 1°C increase in fully understood. For example, following a monthly average temperature, they projected climate change-related extreme weather event, that unmitigated climate change would result trauma may not be an inevitable outcome; in a combined 21,770 (95 percent CI, 8,950– rather, it could present an opportunity for 39,260) additional suicides by 2050 [94]. While post-traumatic growth (PTG), as described these estimates may not transfer directly to the by Tedeschi and Calhoun (1995): context of Sierra Leone, the trends between significant beneficial changes in cognitive increasing temperatures and associated and emotional life beyond levels of mental disorder have also been found with adaptation, psychological functioning, or regard to self-harm and suicide rates, using life awareness that occur in the aftermath data from the US and Mexico. TABLE 4. CLIMATE CHANGE IMPACTS ON HEALTH OUTCOMES CATEGORY CURRENT RISK PROJECTED RISK Food Security & • Food security is a chronic and worsening • The effects of climate change on food Nutrition problem throughout Sierra Leone. security and nutrition, and their impacts • From 2010 to 2020, the prevalence on health outcomes for Sierra Leoneans of food insecurity9 increased from 45 will depend primarily on changes to rice percent to 57 percent; 4.7 million people agriculture. Rice is the staple food of do not have adequate access to food. Sierra Leoneans, regardless of income • The highest areas of food insecurity are in level. the Southern and Eastern Provinces. • No empirical studies of the impact of • Malnutrition is primarily attributable to climate change have been conducted limited access to nutritionally diverse for rice agriculture in Sierra Leone. As a foods. basis of comparison, yield is estimated to decline by 0.13–0.28 in nearby Côte d’Ivoire. 9 “exists when people do not have adequate physical, social, or economic access to food as defined above.” 30 | Climate and Health Vulnerability Assessment: Sierra Leone CATEGORY CURRENT RISK PROJECTED RISK Vector-borne • Malaria has been the leading cause of • The shift in the suitability of malaria vector Disease premature mortality for over a decade, species in Sierra Leone will profoundly despite ongoing strides to curb transmis- change the subnational geography of sion. malaria transmission risk through the • •Malaria prevalence is nearly twice as mid-century. high in rural areas (49 percent) than in • By mid-century, approximately 4.6 million urban areas (25 percent). people will reside in areas that are too • Prevalence of malaria in children age warm for malaria mosquito vectors. 6-59 months by microscopy was 40.1 • The Western Area will be the most vulner- percent in 2016. able area to malaria transmission risk by • Malaria prevalence is highest in the the 2050s. Northern Province (52 percent), as compared with the Eastern and Southern Provinces (40 percent in both) and Western Province (21 percent). Waterborne • Waterborne and water-related diseases • Coastal communities can be impacted and Water- occur throughout Sierra Leone as a through saline intrusions, as sea levels Related result of inadequate water and sanitation rise due to climate impacts, thus affecting Diseases systems, intense precipitation, drought the local groundwater, as well as toxins conditions, and specific water contami- from algal blooms that proliferate in nants. response to increases in surface water • Contaminated water, such as through temperatures on the coast and inland flooding, results in the transmission waterways. of diseases such as cholera, diarrhea, • Climate change patterns will influence dysentery, hepatitis A, and typhoid, with the expanded ecosystem opportunities, poor sanitation systems contributing to the growth and transmission rates, as large and rapid outbreaks of disease. well as the persistence and virulence of • More intense droughts in the north and pathogens. east have been linked to the reduced availability of freshwater, a deterioration in water quality, stagnation, and disease outbreaks. Heat-related • The health impacts of extreme heat are a • Increases in average seasonal tempera- Morbidity and growing concern in Sierra Leone, particu- tures and an increase in the frequency Mortality larly in urban centers such as Bo and the and intensity of heatwave events are capital, Freetown. projected to increase health risks globally • The whole of the country is exposed to in a changing climate. medium to high levels of extreme heat, as • Both increases in the average seasonal defined by the daily maximum Wet Bulb temperatures and an increase in the Globe Temperature (WBGT). frequency and intensity of heatwave • Estimating heat-related mortality and events are projected to increase health morbidity remains a challenge due to risks globally in a changing climate. limitations in the availability and quality • The Northern and Eastern Provinces are of vital health statistics,10 as well as the expected to experience the most substan- under-reporting of extreme heat events tial temperature increases in 2030 and on the continent. 2050 under RCP 8.5, including an in- creasing number of very hot days (>35°C) and tropical nights (>20°C). 10 Dann Mitchell, 2021, “Climate Attribution of Heat Mortality,” Nature Climate Change 11 (6): 467–8. Climate-Related Health Risks | 31 CATEGORY CURRENT RISK PROJECTED RISK Air Quality and • Ambient and indoor air pollution poses a • Northern and Eastern Sierra Leone are Respiratory considerable risk to the health of Sierra projected to experience increasing tem- Health Leoneans. Mean annual PM2.5 exposure peratures and longer, drier seasons that in 2017 was 21.6 micrograms per cubic may result in increasing risks of air quality meter. deterioration associated with droughts • Deaths attributable to household air and wildfires. pollution are significantly higher in Sierra • An extended dry season will also result Leone as compared with other regions, in longer exposures to coarse particulate due to the use of unclean cooking fuels matter from dusty roads, industry, and and the lack of suitable ventilation. dust storms, as there will not be rains to • In 2019, 98.8 percent of the urban popula- settle the fine and coarse particles to the tion and 100 percent of rural populations ground. had primary reliance on polluting fuels and technologies for cooking [95]. Solid fuels are used in 97 percent of house- holds, with 64 percent using wood. Mental Health • Important societal considerations with • It is challenging to project the magnitude and Wellbeing regard to Sierra Leoneans’ mental health of mental health outcomes in relation to outcomes include migration, ethnicity, climate change. In Sierra Leone, there is a dialects, and culture, poverty, food need for improved surveillance and diag- security, civil war, Ebola, the Sugar Loaf nostics, as well as specialist training and Mountain landslide, and the ongoing services, to meet the mental health and COVID-19 pandemic. wellbeing needs of the population. 32 | Climate and Health Vulnerability Assessment: Sierra Leone SECTION IV. ADAPTIVE CAPACITY OF THE HEALTH SYSTEM HEALTH SYSTEM OVERVIEW 54. Sierra Leone’s health system is diverse, comprising the government, religious missions, local and international non-governmental organizations (NGOs) and the private sector. The public health delivery system comprises three levels: (a) peripheral health units (PHUs) (community health centers, community health posts, along with maternal and child health posts) for primary health care (PHC); (b) district hospitals for secondary care; and (c) regional/national hospitals for tertiary care. In 2016, the country was served by roughly 19,030 health workers of different cadres (WHO 2017).There are pronounced inequalities in the geographical distribution of clinical health workers between districts with a high 20.28 health workers per 10,000 population in Western Urban and a low 3.75 health workers per 10,000 population in rural Kailahun [98]; however, 9,120 are volunteers [97]. Traditional healers and traditional birth attendants (TBAs) provide a significant amount of healthcare services across the country [96]. 55. The health system has been weakened by 56. While there have been significant reforms devastating outbreaks. Among them is the in the health sector in Sierra Leone since Ebola virus disease outbreak in 2014–2016 that 2010, the efficient financing of the various devastated Sierra Leone, severely straining components of the health system remains the health system and the ability of the health a key challenge. Even though the health workforce to deliver services. It resulted in expenditure is 16.06 percent of the total 8,706 laboratory cases and 3,956 deaths [102]. government expenditure in 2018 [99], signifi- There were 296 infections among frontline cantly over the target of 15 percent in the health workers and 221 recorded health worker Abuja Declaration, the government is heavily deaths. reliant on donors and partner organizations. 33 They support its health programs, with funds and susceptibility will determine its resilience flowing through budget support or directly in coming decades. In this assessment, Sierra to the MoHS and its implementing partners. Leone’s adaptive capacity11 to prevent and Out-of-pocket (OOP) expenditure represents manage climate-related health risks is 45 percent of the current health expenditure examined according to WHO’s six health [100]. system building blocks, as shown in Figure 13. See also Annex C for the Adaptive Capacity 57. The occurrence of the COVID-19 pandemic Rapid Assessment and a summarized Adaptive has brought with it a focus on the country’s Capacity and Climate Change-Related Health health and health systems, specifically the Risks Gap Analysis that informs this section. capacity to manage emerging public health risks. Climate change, as with COVID-19, has It should be noted that several factors 59. the potential to disrupt and overwhelm health outside the scope of the health sector can systems, including healthcare facilities and also drive reductions in the adaptive capacity healthcare staff. This is especially important of Sierra Leone’s institutions and people in settings that may already have weak health with regard to managing the health risks of systems, including leadership challenges, lack climate change. These factors include the of resources, and/or limited capacity. country’s economic challenges, changing demographic patterns, and slowly improving During the first wave of the pandemic (Q1 social conditions. The promotion of equity and Q2 2020), hospital utilization in Sierra as a cross-cutting theme for enhancing the Leone decreased by 14.7 percent. According to Sevalie et al. (2021), this development can be attributed to the health systems’ inability FIGURE 13. to maintain the core functions and protection WHO’s Health System Building Blocks of health services (see [101]). The economic costs of the pandemic have been substantial Leadership with significant impacts on growth: -2.3 to & Governance Health Workforce -4.0 percent (2020) and 4 percent (2021), as compared with the pre-COVID-19 projected Financing growth rate of 5.4 percent. With the state Health of emergency, characterized by a partial BUILDING Information BLOCKS OF lockdown and restrictions on movement, Systems HEALTH SYSTEMS the disruption of economic activity has also Service heightened social tensions, increased poverty Delivery and the crime rate. Essential Medical Products & The extent to which the capacity of the 58. Technologies health system in Sierra Leone is prepared to manage changes in hazards, exposure, Source: [14] 11 Adaptive capacity is defined by IPCC as “the ability of a system to adjust to climate change, moderate potential damages, take advantage of opportunities, and cope with the consequences” (IPCC AR5). The related term, “resilience,” is the ability to prepare and plan for, absorb, recover from, and more successfully adapt to adverse events. People and communities with strong adaptive capacity have greater resilience. [[This assessment makes use of the terms, “adaptation” and “adaptive capacity,” to encompass both terms 34 | Climate and Health Vulnerability Assessment: Sierra Leone adaptive capacity and resilience to the health data, along with processing and disseminating risks of climate change is also critical. Adaptive information and related services to end-users. capacity is likely to be greater when access → 2012 — Under EPA, the National Secretariat to resources within a community, nation are for Climate Change (NSCC) was established more equitably distributed. and the National Climate Change Policy was developed. NSCC hosts a multistake- holder committee that provides guidance LEADERSHIP AND GOVERNANCE on all national climate change matters, 60. The Government of Sierra Leone is acutely including cross-cutting issues related to aware of the potential negative impacts of DRM, agriculture, infrastructure, and health. climate change, given the country’s already It is the key mechanism for building institu- dire economic situation. As a result, the tional links across governmental agencies and government has been actively developing other actors, such as NGOs and universities, policies and plans to support mitigation and though the extent of the involvement of the adaptation actions. Among sector policies and MOHS is unclear. plans relevant to climate change and health, → 2015–2016 — The National Climate Change there is a special emphasis on community Strategy and Action Plan was developed in engagement and capacity building at local 2015, which includes a section that describes levels (including the use of community-based both the impacts and potential adaptation volunteers, see “Health Workforce”), which is options for human health. This was followed important for addressing subnational needs. by the submission of the country’s INDC to For example, MoHS works closely with district- UNFCCC in 2016 (see [11]). Other existing level stakeholders to develop operational strategies that are important for specific climate plans that ensure bottom-up approaches for change-related health risks include the Malaria key health programs. A similar district-focused Control Strategic Plan (2016–2020) (see [103]) emergency operations model is used for DRM. and the National Environmental Health and Sanitation Strategy (2016-2020) (see [104]). 61. The evolution of the climate change and However, for the most part, these plans, while health policy landscape in Sierra Leone acknowledging the increasing adverse effects since 2007 can be summarized as follows of climate change, lack substantial information (see also Table 5 for a snapshot assessment on potential risk pathways for health, as well as of climate change and health policies and any adaptation activities to improve resilience plans): and reduce vulnerabilities. → 2007 — Following the development of the → 2017 — The National Health Sector Strategic National Adaptation Programme Action Plan (2017–2021) is well-informed: it includes (NAPA), the Environmental Protection sections on climate change-related health Agency (EPA) was established in Sierra issues, such as environmental health and Leone. EPA is responsible for all issues sanitation. However, it lacks adequate concerning the environment and climate information on climate change and health change. The Meteorological Department risks and does not identify climate change as of the Ministry of Transport and Aviation is a current or future threat to human health. It the body responsible for collecting weather outlines the vision of a well-functioning national Adaptive Capacity of the Health System | 35 health system delivering efficient and high- downscaling models for environmental quality healthcare and ultimately contributing to and climate change-related health risks. the socioeconomic development of the country → 2019 – Sierra Leone’s Medium-Term National across eight pillars. They mirror the six-health Development Plan (NDP) (2019–2023) system building blocks, as well as ‘health highlights the building of climate and disaster security and emergencies’, and ‘community resilience as a national goal and core element. engagement, and health promotion’. Although climate risks are outlined throughout → 2018 — The 3rd National Communication the NDP, including the increasing magnitude to UNFCCC provides the most comprehen- of extreme weather events, food insecurity, sive review of climate change-related health and coastal erosion, they are not explicitly impacts and adaptation options in Sierra linked to human health. Leone. Using a Strengths, Weaknesses, → 2019 — At the municipality level, Freetown’s Opportunities, and Threats (SWOT) approach three-year plan — the Transform Freetown with key stakeholders, the communication Strategy (2019–2022) — aims to transform the review assessed the country’s climate change capital into a productive, livable, and resilient and health vulnerability and adaptation. It also city by improving urban governance and included a description of the current climate planning and investing in resilient infrastructure change-related health impacts, a discussion of and greening. After two years, implementation future risks, a best practice recommendation has begun on several projects relevant for specifically for malaria, and the identification of adaptation options. Examples of prioritized enhancing adaptive capacity for the reduction actions include the following: of climate change and health risks. These projects include tree planting initiatives, flood • Adapting to the increased incidence of mitigation measures, climate action planning, malaria and rodent-related diseases, par- strengthening of disaster risks reduction efforts, ticularly in the design and procurement upgrading of informal settlements, city-wide of safe water storage containers and the sanitation improvements, and enhanced water development of an early warning system supply in PHUs, as well as numerous COVID-19 (EWS), response activities. • Instituting better water monitoring and management through improvements at → 2021 — Sierra Leone provided an update to the National Water Resources Authority their Nationally Determined Contributions to reduce the risk of WBDs, (NDC). The revision includes a section on • Improving the capabilities of the Disaster the health impacts of climate change and Management Department to develop EWS describes the potential of improving population for climate-related hazards, health by building climate resilience in other • Improving the data-gathering capabilities sectors, such as water, waste management, of the Meteorological Office’s technical agriculture, and infrastructure. Additional support staff for monitoring climate priority adaptation actions include enhancing variables and warning about climate and health delivery services, improving the supply health risks, such as flooding and air quality, of safe drinking water and sanitation, increasing • Strengthening collaboration among research funding to the health sector, developing an institutions involved in pollution control, as EWS, strengthening meteorological and well as supporting regional and statistical hydrological institutions, and providing coastal 36 | Climate and Health Vulnerability Assessment: Sierra Leone infrastructure. However, although identified as Development Programme (UNDP) and the a cross-cutting issue, health is not included as United Nations Environment Programme a “priority sector.” Moreover, the health-specific (UNEP) [106]. adaptation action, described as “mainstream • The NAP plans to focus on (a) agriculture climate change into the health sector” in the and food security; (b) water resources and NDC, is broad and lacking in adequate detail. energy; (c) coastal zone management, → 2021 — Notably, Freetown appointed the including fisheries and coastal ecosys- first Chief Heat Officer in Africa. The role tems; (d) infrastructure, including water, involves coordinating across agencies and sanitation, and transportation; along with stakeholders to develop new policies, with a (e) environment, including tourism, land focus on the health impacts of extreme heat and forestry, and disaster management. and broader climate change and health risks • Documents to support the development of facing Freetown. Freetown is also planning to the NAP have been released recently: they include a Climate Change Communications develop new standard operating procedures Strategy Under the NAP (2020) and the (SOPs) for disaster response, as well as National Adaptation Plan Framework (2019), establish minimum training requirements for both of which mention human health, albeit local councilors and disaster managers [105]. with limited details. The NAP will build on → Forthcoming — Sierra Leone is currently the two foundational climate change plans, developing a National Adaptation Plan namely the National Climate Change Policy (NAP), although it is unclear how health (2012) and the National Climate Change will be integrated and/or prioritized. The Strategy and Action Plan (2016), both of government is working alongside the Global which highlight the current and potential Environment Facility (GEF)-funded National impacts of climate change on human health, Adaptation Plan Global Support Programme, particularly in relation to WBDs, VBDs, and being implemented by the United Nations undernutrition. TABLE 5. Assessment of key climate change and health-related policies POLICY OR RELEVANCE FOR CLIMATE CLIMATE CHANGE AND DATE PLAN CHANGE AND HEALTH HEALTH RISKS National (Climate Change) 2007 National Adaptation Health mentioned throughout Injuries and disruption of health service Programme of Action in detail, including impacts and delivery related to extreme weather (NAPA)a priority adaptation measures events such as flooding, WBDs related to changing rainfall patterns, and VBDs 2012 National Climate Change Health is mentioned as a key WBDs, food insecurity, and respiratory Policyb sector, although details are limited. diseases 2015 National Climate Change Includes sections on health that WBDs, undernutrition, respiratory Strategy and Action Planc describe impacts and adaptation illnesses, and NCDs actions Adaptive Capacity of the Health System | 37 POLICY OR RELEVANCE FOR CLIMATE CLIMATE CHANGE AND DATE PLAN CHANGE AND HEALTH HEALTH RISKS 2016 Intended Nationally De- Health mentioned under one Not specified termined Contributions of seven strategies, in terms of (INDCs)d benefits related to improved waste management 2018 3rd National Communica- Completed a health vulnerability Vector-borne (dengue and malaria) tion to UNFCCCe and adaptation assessment, which and rodent-borne diseases; food and includes recommendations for waterborne diseases; health effects of prioritizing adaptation options for extreme weather events including heat, the health sector floods, and droughts; nutrition-related diseases; and NCDs 2019 National Adaptation Plan Highlights the Ministry of Health Not specified Frameworkf and Sanitation (MoHS) as a key stakeholder 2020 Climate Change Communi- Sector-specific messages are WBDs and impacts related to adverse cations Strategy Under the described briefly, including for effects on fisheries National Adaptation Plang health 2021 Nationally Determined Includes a section on health Risks mentioned include undernutrition, Contributions (NDC) (first impacts and one strategy for im- WBDs, and extreme weather events submitted in 2016 — plementing adaptation actions in such as floods, and droughts updated in 2021)h relation to the health sector Forth- National Adaptation Plan Highlights the Ministry of Health Not specified coming (NAP) and Sanitation (MoHS) as a key stakeholder National (Health) 2017- National Health Sector Impacts of climate change on Not specified 2021 Strategic Plani health and health systems not mentioned Municipality Level 2019- Transform Freetown Prioritizes group in four cluster Focuses on water- and sanitation- 2022 Strategyj areas: resilience, human devel- related risks; DRM, including from opment, healthy city, and urban extreme weather events; food security, mobility NCDs; and maternal health a Source: Government of Sierra Leone. 2007. National Adaptation Programme of Action (NAPA). https://faolex.fao.org/docs/pdf/sie175907.pdf b Source: Government of Sierra Leone. 2012. National Climate Change Policy. c Source: Government of Sierra Leone. 2015. National Climate Change Strategy and Action Plan. d Source: Government of Sierra Leone. 2016. Intended Nationally Determined Contributions (INDCs) e Source: Government of Sierra Leone. 2018. Third National Communication to UNFCCC. https://unfccc.int/sites/default/files/resource/FinalThird%20Nat.%20 Com.%20document%20111.pdf f Source: Government of Sierra Leone. 2019. National Adaptation Plan Framework. g Government of Sierra Leone. 2020. Climate Change Communications Strategy Under the National Adaptation Plan. https://napglobalnetwork.org/wp-content/ uploads/2020/10/napgn-en-2020-Sierra-Leone-Climate-Change-Communications-Strategy-under-the-NAP.pdf h Government of Sierra Leone. 2021. Updated Nationally Determined Contributions. https://unfccc.int/sites/default/files/NDC/2022-06/210804%202125%20 SL%20NDC%20%281%29.pdf i Government of Sierra Leone. 2017. National Health Sector Strategic Plan. https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_ repository/sierra_leone/sierra_leone_nhssp_2017-21_final_sept2017.pdf j Freetown City Council. 2019. Transform Freetown. https://fcc.gov.sl/transform-freetown/ 38 | Climate and Health Vulnerability Assessment: Sierra Leone GAPS IN ADAPTIVE CAPACITY 62. The prioritization of climate change and health risks varies across policies, strategies, and plans in Sierra Leone. For example, key international climate change documents, such as the NDCs and the 3rd National Communication, have highlighted health as a key sector (see Table 5). To this end, a recent analysis of NDCs, which assessed the extent to which governments’ commitments reflect the linkages between climate change and health, gave Sierra Leone a score of 9 out of 15 — one of the higher scores among African countries (GCHA 2021). Sierra Leone also received high marks for acknowledging the diversity of health impacts related to climate change, as well as the need for adaptation. However, it had gaps in the description on the health co-benefits of climate change mitigation policies, as well as resource mobilization and the costing of adaptation actions. 63. Despite health being identified in climate change policies and plans, there seems to be a disconnect with the health sector, including limited engagement from MoHS and ineffective coordination mechanisms for supporting climate change and health actions. The mainstreaming of climate change into MoHS’ strategic planning remains absent, with no national climate change and health-specific strategy or action plan having been developed. Moreover, there is no designated department or focal point designated within MoHS to lead and coordinate climate change activities. The Environmental Health and Sanitation Directorate would be the suggested leading department, but this link has not yet been formally established with EPA or NSCC. 64. Coordination and collaboration on climate change and health issues across sectors and agencies have not been assessed. Although a mechanism for cross-sector stakeholder engagement exists within EPA, the utility of the mechanism and the involvement of MoHS representatives are unclear. In many cases, even though health decision-makers have demonstrated an awareness of the health impacts of climate change, engagement with climate change, DRM, and agriculture coun- terparts has been slow in general. As a result, progress on the necessary improvements needed to ensure greater level of resilience and preparedness has been limited. 65. Although several plans have been developed, including the updating of the NDC, the implemen- tation of the actions identified in the plans remains limited, in part due to resource constraints and continued exposure to climate and non-climate shocks. A review of the public health adaptation measures in the National Communications of 21 African countries found that Sierra Leone was considering several climate change and health adaptation measures, such as EWS, public awareness, and improved infrastructure; however, few of these have been implemented (Nhamo et al. 2019). 66. At the subnational level, the development and implementation of policies and plans to address climate-related health risks are lacking — a situation that is exacerbated by funding resource Adaptive Capacity of the Health System | 39 constraints. Although MoHS has developed district-level operational plans, climate change and health in these sub-national plans, so far, have not been well-integrated into local-level planning initiatives. In Freetown, there has been considerable activity related to climate change, but challenges remain, particularly related to sustained funding streams and human resource constraints. Similarly, city councils across Sierra Leone face several barriers related to their fiscal sustainability and investment capacity, thus constraining their ability to deliver services to their residents and undermining the ability to tap into economic growth potential. There is also a need to reinforce national-district coordination for DRM, including for climate change-related hazards. Where progress has been made, as with the appointment of the Chief Heat Officer, it is unclear whether adequate resources will be provided to maintain these positive efforts. HEALTH WORKFORCE 69. Labor conditions for health workers curtail health workforce capacity — a concern that 67. Sierra Leone has made progress in improving is interrelated with the absence of a unified its health workforce, but challenges remain, educational strategy. The unsalaried workforce particularly in the public sector. Although of approximately 9,120 health workers (48 the health workforce has increased since the percent of the health workforce), active in the introduction of the National Free Health Care government health facilities, are the same in Initiative (FHCI), insufficient staffing levels and number as the formally employed workers. other health workforce-related challenges Although there have been efforts to increase remain.12 They include urban-rural maldistribu- salaries for the formal workforce, this remains tion; a lack of proper skill mix; the low quality a challenge for retaining the human capital of education; poor absorption capacity; rural within the health system. retention issues; international out-migration; as well as insufficient and irregular salary At the same time, most of the unsalaried payments. workers have limited training and/or are lower- skilled, with no regulations on their education 68. Sierra Leone has a shortage of healthcare or role within the health workforce. This lack of personnel. In 2018, the country had an a unified educational strategy has contributed estimated 0.74 medical doctors and 7.525 to the shortage of qualified health profes- nurses and midwives per 10,000 population. sionals, thereby increasing risks for health This number is below the WHO’s minimum challenges such as maternal mortality, whose threshold of 44.5 per 10,000 for achieving rate is among the highest in the world (HRH universal health coverage (UHC) (WHO 2016). 2016). In total, there are an estimated total of 566 registered doctors and 5,757 nurses. Moreover, there is a shortage of allied health professionals. For example, in 2011, there were only 183 medical pathologists and laboratory scientists, along with 201 environmental and 12 Sierra Leone is one of the 57 Human Resources for Health (HRH) crisis occupational health and hygiene profes- countries (WHO 2006). It is important to note that, in general, data on HRH is scarce, particularly with regard to the private health sector. sionals, who play a vital role in reducing climate 40 | Climate and Health Vulnerability Assessment: Sierra Leone change-related health risks. This also includes patterns of climate-sensitive diseases, thereby only 0.041 psychiatrists working in the mental potentially preventing health professionals health sector per 100,000 in 2017 (WHO 2017). from being able to respond to them in a timely The shortage is worsened by the out-migration manner (WHO 2020). of medical doctors and nurses due to a lack of adequate labor conditions. 72. The health workforce and its professional expertise are also affected by uneven 70. The health sector’s health education institu- distribution, with the level of awareness tions tend to be underfunded, characterized of climate change and health risks among by insufficient qualified educators, materials, health workers unknown. The health and infrastructure. In 2016, Sierra Leone workforce, particularly doctors and nurses, reported the existence of 25 health training are more concentrated in urban areas, with institutions that imparted 56 programs, ranging 70 percent of medical staff located in urban from certificates to master’s level degrees. health facilities, leaving 30 percent of medical Large programs like the State Enrolled staff in rural areas where 62 percent of the Community Health Nurse certificate produce population lives (HRH 2016). There is also an around 900 cumulative new graduates per uneven distribution of the health workforce year, while the medical officer program has across provinces, with the majority of highly about 40 recent graduates (HRH 2016). Each skilled professionals stationed in large tertiary institution manages its own curriculum and hospitals or administrative offices in Freetown training program. (Western area, see Table 6). On the other hand, midwives and community health officers 71. Climate change can further exacerbate are better distributed in more rural districts. challenges faced by the health workforce Overall, 74 percent of the health workforce due to changes in the frequency and intensity is concentrated in 10 percent of the facilities, of extreme weather events. Such changes mainly hospitals (57 percent) and community may affect a facility or the workers’ ability health centers (21 percent) (HRH 2016). to reach the facility. They may also alter the TABLE 6. Health workforce distribution per province and cadre PER 10,000 POPULATION COMMUNITY MEDICAL NURSES HEALTH OFFICERS/ (HIGHER OFFICERS/ AREA CADRE SPECIALISTS CADRES) PHARMACISTS MIDWIVES ASSISTANTS Bombali 0.1 0.38 0.03 0.41 0.56 Kambia 0.06 0.29 0.06 0.44 0.84 Northern Koinadugu 0.05 0.17 0.05 0.32 0.44 Port Loko 0.1 0.2 0.03 0.39 0.52 Tonkolili 0.06 0.11 0.02 0.26 0.68 Adaptive Capacity of the Health System | 41 PER 10,000 POPULATION COMMUNITY MEDICAL NURSES HEALTH OFFICERS/ (HIGHER OFFICERS/ AREA CADRE SPECIALISTS CADRES) PHARMACISTS MIDWIVES ASSISTANTS Kailahun 0.08 0.06 0.04 0.15 0.69 Eastern Kenema 0.08 0.18 0.07 0.34 0.93 Kono 0.08 0.12 0 0.26 0.42 Bo 0.1 0.45 0.03 0.47 2.4 Bonthe 0.2 0.2 0.05 0.3 1.05 Southern Moyamba 0.13 0.28 0.06 0.5 1.01 Pujehun 0.06 0.38 0.03 0.35 0.95 Western Area 0.27 0.25 0.02 0.32 0.63 Rural Western Western Area 1.1 1.92 0.5 1 0.96 Urban Source: MoHS 2016. GAPS IN ADAPTIVE CAPACITY 73. Overall, the health sector faces an imbalance in the number, capacities, deployment of the health workforce, and inadequate resource allocation across different levels of health care when compared with global minimum thresholds. Improving workforce capacity would strengthen job satisfaction, human resources retention, salaries, work environment, and resource allocations. Previous experience with the Ebola epidemic has proven to be successful in increasing health workforce absorption capacities and deployment, thus providing a model for the integration of climate change and health training aspects. 74. There are significant disparities in the roles and types of health professionals at subnational levels, including substantial urban-rural divides on which climate change could impact. The presence of a massive unsalaried health workforce, coupled with the lack of a unified health training curriculum, has deepened the disparities and gaps in the workforce distribution and roles. Moreover, the reliance on private initiatives or NGOs, without strengthening and articulating efforts with the public sector, could further increase the vulnerabilities of the health workforce in a changing climate. Finally, the lack of climate change guidelines and tools in capacity-building programs undermines the development of the health workforce. 42 | Climate and Health Vulnerability Assessment: Sierra Leone 75. The absence of a systematic approach for health workforce capacity development for climate change, as well as for the integration of emergency preparedness and response courses, constitutes a vital bottleneck. Overall, climate change has not been prioritized in human resource planning mechanisms, starting with the Strategic Planning for the Development of Human Resources in the Health Sector for 2030, which is closely aligned with the WHO Global Health Workforce 2030. Sierra Leone’s health education system, which is managed by MoHS and the Ministry of Education, Science and Technology lacks a national training plan and does not prioritize climate change and health. Further, there are no national capacity-building programs in place to address the context of a changing climate and the capabilities of the health workforce to prepare for, prevent, as well as respond and adapt to, climate change-related health risks. International non-governmental organizations (INGOs), which have helped to supplement capacity building in the workforce, have not integrated climate change impacts on health into training programs to date. 76. The extent to which Sierra Leone’s health workforce possesses the adequate knowledge, technical capacity, and resources to prevent and manage current and future climate change-re- lated health risks remains unknown. There has been no assessment to establish the baseline understanding, knowledge, and technical needs of the health workforce in relation to climate change. Although climate change policies in the country prioritize climate change impacts on health, there are no programs within MoHS that integrate climate-related risks in the development of the health workforce capacities. HEALTH INFORMATION AND DISEASE climate-sensitive diseases; however, overall, there are challenges with data completeness SURVEILLANCE and quality. The National Health Information 77. Although progress is being made, Sierra System (NHIS) relies on a combination of Leone lacks a consistently functioning paper-based and electronic systems for the health information and surveillance system collection and management of most of its health infrastructure, as well as clear leadership data. Routine health information is collected and reporting mechanisms, thus leading through the District Health Information System to data quality and availability challenges. 2 (DHIS-2). Following the Ebola virus disease outbreak, there were efforts to develop an integrated A Health Information Systems Strategy (HISS), disease surveillance and response system; developed in 2017, focuses on building a user- however, the maintenance of equipment friendly system for collecting, accessing, and and continued technical support have been analyzing quality data at all levels of the health significant barriers. system to inform decision-making and improve service quality. Climate-sensitive diseases, 78. Health information and surveillance systems such as malaria, malnutrition, and diarrhea, are in Sierra Leone collect some information on captured routinely from health facility reports Adaptive Capacity of the Health System | 43 through DHIS-2, albeit with varying degrees civil war, has been slow to be rebuilt. This of completeness. Nevertheless, information has limited the country’s capacity to engage on emerging VBDs, such as dengue and in the accurate observation and monitoring chikungunya, is still lacking. of weather and climate events, as well as the issuance of predictions and warnings. 79. There are several cross-sectoral and partner- To address these challenges, the Sierra supported initiatives to improve health Leone Meteorological Agency (SLMet) was information and surveillance that could be established in 2017 to provide comprehen- utilized to build climate resilience. HISS has sive meteorological services. They include mapped out key governmental stakeholders climate services centered around sustain- and associated data sources including MoHS; ability planning and assessment, as well as the Ministry of Agriculture, Forestry, and Food the Climate Information, Disaster Management Security; and Statistics Sierra Leone (partly in and Early Warning System (CIDMEWS-SL) — charge of vital statistics). The Directorate of a GIS web-based mapping application that Health Security and Emergencies also supports enables the exploration of available climate surveillance efforts by providing leadership, information, disaster management, along with scientific, and technical situational awareness early warning data and information resources. and advice at the national level, including Additionally, there have been ongoing producing weekly epidemiological reports enhancements of early warning capacities, and risk communication materials. such as strategic investments in new remote sensing, hardware and software packages, as There are also supplementary initiatives well as the strengthening of the capacity of to improve health information and surveil- SLMet to assist in climate and oceanographic lance systems in Sierra Leone supported monitoring. by development partners. For example, → Disaster management. Ongoing institutional the Regional Disease Surveillance Systems reforms, as part of the recently approved Enhancement Project (REDISSE), funded by Sierra Leone National Disaster Management the World Bank, is designed to strengthen Agency (NDMA) Act (2020), provide an weak human health, animal health, and opportunity to strengthen the coordination disaster response systems in West Africa, for an all-hazard EWS, with the capability to including Sierra Leone, to guard against future promptly gather, process, and communicate epidemics. Although climate change is not at disaster information to local stakeholders and the center of this project, there are clearly vulnerable communities. Key stakeholders several co-benefits from this investment that involved in the development and implemen- is also being expanded in 2022 to support, in tation of a national EWS have been identified, part, a more climate-resilient health system. including potential roles and responsibil- ities for MoHS (Table 7). There have also 80. In Sierra Leone, there are other information been investments in data management and monitoring systems that are relevant for information technology (IT) systems, such as climate change and health: open data kits (ODK), phones, and tablets, → Meteorological services. The meteorological to improve data collection capacities in the infrastructure, largely destroyed during the context of DRM (AFRICAB, 2021). 44 | Climate and Health Vulnerability Assessment: Sierra Leone Nevertheless, the current early warning West African countries (FSMR 2020). FSMS services in Sierra Leone are constrained by also acknowledges the potential drivers of the weak technical capabilities and capacity food insecurity, including climate change-re- of the hydromet services providers. These lated shocks and stresses, such as shifting challenges restrict the granularity and rainfall patterns and flooding events. timeliness of warning provision, thus limiting Additionally, the 2020 Comprehensive Food the effectiveness of the warning services Security and Vulnerability Analysis (CFSVA) provided. conducted in Sierra Leone by WFP in → Food security monitoring. The Ministry of partnership with the government of Sierra, Agriculture, Forestry, and Food Security, MoHS, provides evidence on food insecurity using and Statistics Sierra Leone, in partnership a trend analysis. This analysis, conducted with the Food and Agriculture Organization every five years, could be used to track climate of the United Nations (FAO) and the United change-related impacts on food security. Nations World Food Programme (WFP), are collaborating to strengthen the Food → Air quality monitoring. Sierra Leone lacks a Security Monitoring System (FSMS) aspect robust national air quality monitoring system, of the national EWS. FSMS is implemented despite growing concerns related to outdoor twice per year — once in the immediate air pollution, especially in urban centers, and post-harvest period (January–February) and the potential impacts of wildfires. In 2015, again during the height of the “lean season” EPA conducted an ambient air quality study (August–September) — when access to and in Freetown to analyze the impact of urban availability of food is reduced. This is done traffic. However, the absence of consistent air in order to effectively monitor food security quality monitoring data makes evaluating the levels in Sierra Leone, better understand their health implications of air pollution in Sierra dynamics, and compare the situation with other Leone a significant challenge (EPA 2015). TABLE 7. Key governmental stakeholders involved in Early Warning System Implementation AGENCY ACTIVITIES Sierra Leone • Monitor and forecast the weather conditions in the country in relation to all socio- Meteorological economic activities requiring meteorological or climatology services Agency • Develop government policy in the field of meteorology, climatology, climate change, and other climate-related issues • Promote the use of meteorology in agriculture; food monitoring; the monitoring of floods, droughts, and desertification; along with other related activities • Establish, organize, and manage surface and upper air observational station networks • Provide meteorological information, advice, and warnings for agriculture; civil and military aviation; surface and marine transport; operational hydrology; manage- ment of energy and water resources; as well as search and rescue operations to mitigate the effects of adverse natural events, such as floods, storms, droughts, and disease outbreaks Ministry of Health • Monitor and manage disease outbreaks, with a focus on highly contagious and and Sanitation fatal diseases that have the potential of developing into epidemics Adaptive Capacity of the Health System | 45 AGENCY ACTIVITIES Ministry of Agriculture • Monitor and manage pest outbreaks of crop and animal husbandry and Forestry Environmental • Provide information on environment and forestry disaster situations, such as Protection Agency excessive pollution and fire outbreaks Government • Provide information on the number of beds, nurses, and doctors available for Hospitals emergency response in disaster situations Source: World Bank Disaster Risk Management Diagnostic Note Sierra Leone 2020. GAPS IN ADAPTIVE CAPACITY 81. Health information and surveillance systems are currently not integrated and do not include climate/weather data or other environmental factors. Integrated risk monitoring refers to the use of tools and epidemiological surveillance for early detection, in conjunction with direct and remote sensing technologies for the surveillance of the environmental determinants of health. They include water and air quality, variability in ambient temperature and humidity, or the incidence of extreme weather events. While there are potential monitoring systems (for example, meteo- rological, all-hazards, and food security) in place that could be useful for better understanding climate change-related health impacts, these systems currently work in silos. Further, there has been no baseline analysis to date of climate change relationships with health outcomes specific to Sierra Leone, in part due to the limitations of the health information and surveillance systems. 82. Sierra Leone has not conducted a comprehensive national assessment of climate change impacts, vulnerability, and adaptation for health. The current assessment helps to fill knowledge gaps, but additional work is needed to conduct more advanced analyses of future climate change-related health risks, explore subnational impacts, and support the prioritization and evaluation of adaptation options. While the 3rd National Communication includes a section on climate change and health-re- lated vulnerabilities and adaptation options, it lacks any analysis of associations between climate and health outcomes, projections of future risks under different climate scenarios, the assessment of targeted vulnerable groups, and a detailed description of interventions across health risks. 83. A comprehensive climate-informed health EWS is also lacking in Sierra Leone. This includes the utilization of current disaster/environmental monitoring systems. Generalized warnings of major climate/extreme weather events are of limited value for effective preparations and response, which require the identification of specific areas and communities likely to be impacted, along with the understanding of when the impacts might occur and the potential impacts, for timely and effective decision-making. Key challenges include limitations in monitoring equipment, technology, administrative and human resources, as well as specialist technical personnel for the analysis and forecasting of hazardous climate/weather events, risk communication, and targeted public health interventions. Building from the improvements within SLMet, there are also opportunities to support climate services targeted at the needs of public health decision-makers and practitioners. Climate 46 ||Climate and and Health Health Vulnerability Vulnerability Assessment: Assessment: Sierra Sierra Leone Leone ESSENTIAL MEDICAL PRODUCTS AND estimated 1,200 laboratory facilities across Sierra Leone. While community health units TECHNOLOGIES are able to deliver testing services, including Stock-outs of essential medicines in 84. for climate-sensitive diseases like malaria, an healthcare facilities remain an issue in assessment done by MoHS in 2016 found that Sierra Leone. In 2016, the country reported only 13 percent of the 184 lab facilities samples having no stock-out situations of 75 percent were able to conduct essential basic tests for oral rehydration solutions, 23 percent for (including rapid diagnostic test for malaria) zinc, 75 percent for oxytocin injection, and (MoHS 2016). Further, poor supply chains, 78 percent for magnesium sulfate. However, including high vulnerability to extreme weather data on essential drugs is limited, which has events such as flooding, result in a lack of complexified the assessment of the adequacies of drug stocks and resource allocation for basic needs (for example, water and electricity) health facilities and related planning. and contribute to stock-outs of laboratory reagents, consumables, and equipment. Lastly, 85. Laboratory capabilities in Sierra Leone face there are no SOPs, accreditation, or registra- several challenges, in relation to testing tion licensing systems in place for laboratory services, the transport of specimens, quality facilities in Sierra Leone, thus contributing to management, and regulations. There are an inadequate quality control measures. GAPS IN ADAPTIVE CAPACITY Healthcare facilities, including preventive and critical care, along with dispensaries, are 86. ill-equipped, thus increasing health risks and contributing to a lack of management of the health system’s needs. Most hospitals are under-resourced, with stock-outs of medications and supplies often affecting rural health centers and PHUs. These gaps and vulnerabilities in equipment and supplies exacerbate the impact of climate-related health risks, such as disease outbreaks. Further, stockpiles of essential medicines and emergency supplies, particularly in rural areas, are needed to adequately prepare for extreme weather events. 87. Laboratory capacities and other health technologies in Sierra Leone need further assessments to better understand their abilities to manage current and projected climate-sensitive diseases. This includes the fundamental strengthening of laboratory capabilities to ensure access to essential medicines, testing, and equipment, as well as specialized protective equipment (for example, insecticide-treated bed nets and rapid diagnostic testing) to reduce climate change-related health risks. Adaptive Adaptive Capacity Capacity of of the the Health Health System|| 47 System HEALTH SERVICE DELIVERY Health infrastructure in Sierra Leone is 90. impacted by several climate change-related 88. Sierra Leone suffers from several barriers hazards, most notably floods and landslides. that impede access to health services, which Hazard And Risk Profile Information System – can be exacerbated by climate change. At Sierra Leone (HARPIS-SL) (2017) identified baseline, remote rural areas in Sierra Leone 81 out of 1,317 (6.7 percent) health facilities have seen slow change in access to key as being at risk of flood inundation. Kailahun elements of health coverage. During climate and Bombali are the only districts that do change-related emergencies such as floods not have health facilities at risk of flooding. (coastal and inland), access to health services Floods (coastal and inland) and landslides and health workers is particularly difficult. (notably near urban centers) are unlikely to Moreover, a lack of access to health services recede given current projections (GFDRR), and information has been shown to increase with potential damages to health infrastruc- household vulnerability to health risks in flood ture including healthcare facilities, especially prone areas. Even as access to services is those in remote areas, likely to be observed improving in Sierra Leone, the adequate in a changing climate. delivery of quality of health care remains a recurrent challenge (WHO 2017). In Sierra Leone, where most healthcare facilities are public, services are delivered 89. Low quality of services increases the risk of through hospitals and PHUs (see Table 8 for poor health outcomes. Sierra Leone’s health health facility density per province). They are system is divided into three tiers of health reported to be understaffed, understocked, service delivery: PHUs with extended support and lacking in adequate infrastructure (WHO provided by community health workers; district 2016). hospitals; and referral hospitals providing 91. Rural access to healthcare infrastructure is secondary and tertiary patient care. The complicated by a lack of transportation and National Health Sector Strategic Plan (2017–21) the distance patients must travel due to the pinpointed several key challenges with health limited number of health facilities within a service delivery, including inadequacies in 5-mile radius. For the majority of Sierra Leone’s the following areas: accessibility to health population (67 percent) living in rural areas, it facilities, often due to geographic reasons is difficult to access healthcare facilities. As and lack of transportation; affordability caused there are no facilities near every community, by high OPP expenditures; the availability of the distance increases for the patients to get basic and specialized services; and quality to other communities’ healthcare facilities. This issues. This reality is further reflected by the results in 15.3 percent of the total population 2020 International Health Regulations (IHR) (roughly 1.2 million people) living farther than capacity progress indicator of the country’s 5 miles from health facilities. health service provision: implementation status of just 40 percent implementation 92. Climate change is not integrated in health status compared with 46 percent and 64 sector planning and programming. When percent regionally and globally, respectively discussed in climate change policies and plans, (IHR 2020). as in the case of the 3rd National Commu- 48 | Climate and Health Vulnerability Assessment: Sierra Leone TABLE 8. Number of healthcare facilities by type across provinces (per 10,000 population) PROVINCE HEALTH FACILITY DENSITY Western Area Urban 0.44 Western Area Rural 1.07 Kailahun 1.49 Kono 1.64 Bombali 1.64 Koina Dugu 1.64 Port Loko 1.68 Tonkilili 1.90 Kambia 1.95 Kenema 1.96 Bonthe 2.16 Pujehun 2.17 Bonthe 2.75 Moyamba 3.08 Sierra Leone 1.64 Source: Government of Sierra Leone. 2016. Annual Health Sector Performance Report 2016. https://www.afro.who.int/sites/ default/files/2017-08/Sierra%20Leone%20Health%20Sector%20%20Performance%20Report%202016.pdf nication, the only health-related programs health issues in relation to climate change. being promoted are related to vector control For example, Sierra Leone faces a number and epidemic disease (Nhamo et al. 2021). of barriers regarding environmental health As for Sierra Leone’s NAP, there are projects and sanitation due to cultural (for example, and programs that address different needs open defecation) and resource-dependent indirectly affecting health, along with efforts factors (for example, its WaSH infrastruc- regarding coastal communities and climate ture and environmental health officers). The risk management, biodiversity conservation National Environmental Health and Sanitation and watershed management, and climate- Strategy (2016–2020) outlines several detailed smart agriculture. However, strategies set out strategies to manage environmental deter- for improving nutrition or water and waste minants of health, including integrated waste management are insufficient, considering management, integrated vector control, WaSH, Sierra Leone’s experiences with waterborne and food safety. Moreover, the One Health and water-related diseases, as well as under- National Emergency Risk Communication nutrition (MoHS 2017; NDMA 2020). Strategic Plan similarly outlines important actions that could build resilience to climate 93. National environmental quality standards change by strengthening collaboration among have been defined for air, drinking water, human, animal, and environmental health and noise; however, these standards are sectors. limited and not up to date, given emerging Adaptive Capacity of the Health System | 49 Longer-term strategies on DRM, such as 94. Management Committees in each chiefdom, incorporating climate change trends, have and private initiatives, community organiza- been identified as part of a comprehensive tions, and private initiatives. Moreover, the approach for some climate-related health agency has deepened efforts to evaluate, risks to reduce the overall burden. NDMA adapt, and improve EWS and disseminate was launched in 2020 with the mandate to the information, which could be expanded use science, innovation, and data to predict, to the health sector (NDMA 2020). anticipate, plan for, and report on the full disaster management cycle, including a focus The creation of these institutional structures on climate change mitigation and adaptation. stems from the work conducted under the The establishment of the NDMA is a result of Office of National Security (ONS): it has been the NDMA Act that also created the National mandated to coordinate the management Disaster Management Fund and the National of national disaster mitigation, including the Platform for Disaster Risk Reduction, reflecting preparation of a Disaster Management Policy NDMA’s consideration of climate change as (2006) and a National Disaster Management a critical variable for the country’s strategic Plan (2006), along with the establishment of a planning on DRM. NDMA also highlights specific Disaster Management Department. An the need for cooperation among different updated National Disaster Risk Management governmental institutions, regional disaster Policy and Emergency Preparedness and management committees in each admin- Response Plan are currently under development istrative region, the Chiefdom Disaster to reflect the new institutional arrangement. GAPS IN ADAPTIVE CAPACITY 95. Health service delivery in Sierra Leone faces fundamental challenges, in terms of accessibility, affordability, availability, quality, and inefficiency. Given the barriers to quality health service delivery facing Sierra Leone already, additional shocks and stresses related to climate change have the potential to exacerbate existing issues. Health system strengthening is needed to enhance its adaptive capacity and identify further gaps in planning and service delivery. Climate-resilient healthcare facility and health infrastructure assessments lack adaptive 96. retrofitting approaches, long-term construction planning, and opportunities to reduce carbon footprints. This includes adequate coordination across sectors to ensure that climate risks are incorporated into infrastructure planning. Protection from flooding events (coastal and inland) or landslides requires that overall strategies for future climate projection guide existing infrastructure. There is also an urgent need to establish/strengthen/implement national guidelines, standards, zoning, and building codes to support the building of resilience and the strengthening of health technologies and infrastructure for climate change-related events. 97. Essential infrastructure, including for health, should be planned after assessing the relevant quantitative and qualitative information regarding an area’s geographical distribution, vulner- 50 | Climate and Health Vulnerability Assessment: Sierra Leone ability, and hazard occurrence to reduce the risk of damage from climate-related phenomena. Currently, there are initiatives on DRM that are focused on increased awareness, governance, and collaboration among sectors, the improvement of finance mechanisms, and preparation and post-disaster recovery. However, the extent to which infrastructure assessments for the health sector are being conducted, building designs are incorporating projected climate change impacts, and retrofitting measures are being carried out is still unclear (World Bank 2020). 98. There is a lack of access to healthcare facilities in rural areas, which is exacerbated during extreme weather events related to climate change. Sierra Leone’s experience with Ebola management tested the country’s health system, leading to improvements in essential healthcare services and infrastructure for addressing the epidemic. However, those efforts have not been long-lasting and they have not incorporated climate change into strategic planning for healthcare facilities, including building long-term resilience, supporting ongoing maintenance, and possible relocation. 99. Climate change and associated impacts are not mainstreamed into the operations of health programs, nationally or subnationally. Climate change impacts a wide range of health inter- ventions that are important for service delivery, including CDs, maternal and child health, and nutrition; yet, there is no designated unit within MOHS that focuses on climate change and health risks. Although climate change adaptation actions that could improve population health have been identified, notably in climate change planning, they have not been incorporated into health sector planning and operations. 100. Climate change is, and will, likely continue to impact other determinants of health in Sierra Leone, such as water quality and quantity, air quality, nutrition and food security, waste management, and housing. Programs exist (for example, Environmental and One Health) that would contribute to enhanced adaptive capacity to manage climate change and health risks. However, none of the described interventions considers the effects of climate change on the implementation of these plans now and into the future. 101. Baseline information is lacking in the key environmental determinants of health, including air pollution and WASH coverage in healthcare facilities. For example, there is a need to build climate-resilient water and sanitation systems and infrastructure in Sierra Leone. This includes efforts to promote education and social awareness in confronting and controlling water pollution, along with waterborne and water-related diseases, and subsequently in improving human health, as well as further policy level actions, particularly at district levels, to create water regulatory authorities. 102. Experience from past disasters and an assessment of the DRM system have highlighted the lack of adequate institutional and policy frameworks for the efficient execution of DRM mandates (World Bank 2020). This leads to overall inadequate disaster preparedness and response systems, including limited early warning and monitoring capabilities, infrastructure, equipment, and human resources. Further, the link between DRM and climate change adaptation for health, including coordination with MoHS around specific interventions, could be strengthened. Adaptive Capacity of the Health System | 51 FINANCING More recently, the government created the FHCI to reduce OOP expenditure for pregnant 103. Although the healthcare sector has been and lactating mothers and children under 5 severely compromised due to flooding years old. The initiative provides funding of (coastal and inland), landslides, as well approximately USD97 million in 2015 — an as the Ebola epidemic and now COVID-19 amount that is expected to increase to USD136 pandemic, Sierra Leone has increased its million by 2025. Most of this budget has been expenditure (as a percentage of GDP) in this directed to increasing salaries for health sector over the last decade. Public health workers and drugs procurement. spending rose from 10.94 percent in 2010 to 16.06 percent as of 2018. According to the 105. Limited experience with strategic purchasing National Health Accounts (NHA), public health precludes climate and health results from expenditure was approximately USD590 million being appropriately achieved in Sierra Leone. in 2013, where 47 percent came from donors, The prioritization of basic health services and 33 percent from households, 12 percent from preventative programs are the most effective NGOs, and 7 percent from the government. approach that governments can adopt to In 2013, 52 percent of the total budget went strategically purchase health services. The to hospitals and 30 percent to PHUs. From shift from passive budgeting to strategic 2014 to 2015, the country increased its health purchasing can ensure improvements in health expenditure to respond to the Ebola epidemic, outcomes while strengthening governance underlining the relevance of health financing and accountability mechanisms. Further, it is within the country’s budget. During this time, incumbent upon governments to embrace 63 percent of the total budget was directed an equity lens to ensure pro-poor health to address the epidemic. The last report on care service delivery. Selection of providers health financing was produced in 2016, and using public funds should consider capacity, it is also included as a relevant topic within quality, and price. To this end, considerations the country’s National Health Sector Strategic for different provider payment mechanisms Plan 2017–2021. need to be given full attention to incentivize provider behaviors geared toward achieving 104. Despite increases, low public financing on strategic objectives. Finally, dimensions health in Sierra Leone has led to significant related to regulation, provider autonomy, and OOP payments, thereby increasing poverty, competition are fundamental for successful especially in light of ongoing climate-related strategic purchasing arrangements. risks. By 2018, there was a per capita public expenditure of 85.775 (World Bank 2018). 106. There is no evident allocation of funding Moreover, OOP expenditure represented dedicated to addressing climate change’s 44.77 percent. Most of the funding comes impact on health and health systems within from donors and multilateral cooperation the health sector. To date, the government with organizations such as UKAID, the African has prioritized climate-related interventions Development Bank, and Centers for Disease (EPA 2021that take into account environmental Control and Prevention (CDC) (WHO 2017). determinants of health such as adaptation 52 | Climate and Health Vulnerability Assessment: Sierra Leone measures for the agricultural sector and food NAP; however, it is unclear how or if the health security, forest management and protection, sector will be prioritized, which could hinder water and sanitation management (EPA 2021). climate-related health resource allocations. However, there is no integration of climate Thus far, the government has prioritized change risks into their National Health Sector climate-related interventions that consider Strategic Plan 2017–2021, nor are there precise environmental determinants of health such as strategic planning for climate-related health adaptation measures for the agricultural sector finance and resource allocations for climate- and food security, forest management and related health risks and vulnerabilities. The protection, water and sanitation management). country is currently developing an updated GAPS IN ADAPTIVE CAPACITY 107. Sierra Leone’s health budget is dependent on OOP expenditure and aid or donors’ resource allocations. The country needs to prioritize health and increase expenditure (as a percentage of GDP), while building a financial model that is aimed at reducing dependence on aid and donors. Building resilient health systems for climate change requires budget allocations as an integrated component in the overall planning of a national health plan. 108. Guidelines for integrating a climate-resilient approach for health care and public health systems are not available to inform rationalized resource allocations. Raising awareness is needed both within and outside the health sector to communicate the current and projected climate and health risks and the necessary adaptation resources to prevent related mortality and morbidity. Although there are health priorities within the country’s climate change policy, there is no integration of climate change events into the health system’s budget planning. As a result, no current funds are allocated to climate-related health interventions within MoHS. Further, from a climate change perspective, there are no precise estimations of funding aimed at climate-related adaptation investments, including for the health sector. 109. Risk pooling in Sierra Leone does not account for climate and health-related risks. In general terms, illnesses and health care costs are not evenly distributed, with some population groups facing higher health risks, which may be exacerbated by climate change. Climate change can augment underlying health burdens, while increasing the potential and size of certain catastrophic financial health risks, especially among the most vulnerable. Risk pooling can address this challenge. Strategies to mobilize health funds will, to a large extent, determine the mechanisms and ability to pool resources to address such risks. General revenues are most suited for pooling risks if health services are accessible to the entire population or for subsidizing premiums of high-risk groups. In Sierra Leone, government-pooled funds for health through general Adaptive Capacity of the Health System | 53 revenues are limited; moreover, they are characterized by a high level of fragmentation. Non-govern- ment pools of funding for health include private health insurance and social security funds. Further, as previously noted, OOP expenditures that constitute the largest share of total health expenditures are not pooled at any level. These arrangements do not take into account the pooling of funds for climate-related risks, thereby falling short of providing any form of financial protection for the poor and vulnerable populations affected by climate- and health-related risks. 110. Health co-benefits of climate change mitigation have not been adequately promoted as cost-effective options. Arguments for implementing climate change mitigation policies often focus on perceived short-term financial gains. However, cost assessments rarely account for the benefits of these policies and the appropriate actions needed to improve human health. Therefore, additional studies are needed to quantify further economic costs and the health co-benefits of climate change mitigation policies in Sierra Leone. TABLE 9. Summary of the health system’s adaptive capacity gaps for Sierra Leone HEALTH SYSTEM’S SUMMARY OF GAPS IN BUILDING BLOCK ADAPTIVE CAPACITY Leadership and • Prioritization of climate change, along with health risks and adaptation options, in governance national policies and plans (both health and climate change- focused) remains varied and lacking in specific detail • Limited engagement of health sector with coordination mechanisms to facilitate cross-sector action on climate change • Implementation of policies and plans, particularly at subnational levels, slow and fragmented Health workforce • Health sector facing an imbalance in number, skill mix, and deployment of health workforce, including large urban-rural disparities • Absence of a systematic approach for the capacity development of the health workforce in climate change, including the development and integration of training materials • Knowledge, technical capacity, and resources of the health workforce to prevent and manage current and future climate change-related health risks still unknown Health information • Health information and disease surveillance systems currently not integrated, with and disease no inclusion of climate/weather data or other environmental factors surveillance systems • No comprehensive climate-informed health EWS • Comprehensive national assessment of climate change impacts, vulnerability, and adaptations for health needing to be conducted Essential medical • Healthcare facilities under-resourced and hard to reach in rural areas, especially products and during extreme weather events technologies • Laboratory capacities and other health technologies in Sierra Leone needing further assessment to better understand the ability to manage current and projected climate-sensitive diseases, as well as guide dissemination of resources 54 | Climate and Health Vulnerability Assessment: Sierra Leone HEALTH SYSTEM’S SUMMARY OF GAPS IN BUILDING BLOCK ADAPTIVE CAPACITY Health service • Coordinated approach lacking at multiple levels with multiple stakeholders to delivery address climate-sensitive epidemics and disease outbreaks • Climate-resilient healthcare facility and health infrastructure assessments lacking, including addressing inadequate coordination across sectors to ensure incorpora- tion of climate risks into infrastructure planning • Climate change and associated impacts needing to be mainstreamed into the operations of health programs at all levels • Baseline information lacking on the key environmental determinants of health • Strengthened disaster contingency plans needed, especially at the community level Financing • Guidelines for integrating a climate-resilient approach in health care and public health systems unavailable for informing rationalized resource allocations • Risk pooling in Sierra Leone needing to account for climate- and health- related risks • Budgets within the health sector needing to incorporate climate change risks • Health co-benefits of climate change mitigation inadequately promoted as cost-ef- fective options Adaptive Capacity of the Health System | 55 SECTION V. RECOMMENDATIONS TO ENHANCE HEALTH SYSTEM RESILIENCE TO CLIMATE CHANGE This section outlines a set of recommendations to enhance Sierra Leone’s health system resilience and adaptation to climate change, including potential health in- terventions and strategies that can be put in place. The recommended options are based on an assessment of both the magnitude of the current and projected climate- related health risks and the existing gaps in adaptive capacity to manage and/or prevent these risks. This section is organized, using the 10 components the NAP, as well as the next round of NDCs. of climate-resilient health systems (Figure 14), This should include detailed descriptions of and it draws from consultations and reviews of priority climate change-related risks, health all relevant governmental policies, as well as the sector adaptation options, and opportunities World Bank’s Health, Nutrition and Populations to link with non-health sectors. Currently, when (HNP) Climate and Health Guidance Note. See health is mentioned, the information is limited Annex D for a summary of recommendations for and too broad to effectively inform concrete building a climate-resilient health system across action. identified climate change-related health risks. • Facilitate a memorandum of understanding (MOU) between MOHS and other key stake- holders at the national level, including other COMPONENT 1: LEADERSHIP AND sectors such as agriculture, planning and de- GOVERNANCE velopment, and transportation. This could link the health sector to the NSCC multistakeholder Options to strengthen leadership and governance committee and strengthen their engagement include the following aspects: with each other. NATIONAL (CENTRAL-LEVEL GOVERNMENT AGENCY IN CHARGE OF CLIMATE CHANGE NATIONAL (HEALTH SECTOR) ACTION) • Develop a Climate Change and Health National • Integrate health into national-level climate Strategy and Action Plan that should incor- adaptation planning, with the priority being porate all available evidence and senior en- 57 FIGURE 14. WHO’s Operational Framework for Building Climate-Resilient Health Systems LIMATE RESILIENCE C hip & Heal eaders nce Workf th L verna orce Go V uln pac ation t Fin alth & A Ca pt en He ate era ity & Leadership As g da ssm Clim cin bil & Governance Health se ity, an Workforce Financing Preparedness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential C li o r m e h Re ima & I n f a lt s Medical ma d C l a lt h se te Products & h He ra m Pro te a rc He Technologies - g Ma 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 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. dorsement to facilitate implementation. This climate change in the health sector, including should also be closely aligned with the NAP to the designation of a national climate and health facilitate integration and enable multisectoral focal point. approaches to be implemented. • Develop and deliver climate- and health-re- • Systematically integrate adaptation activi- lated workshops and national policy briefs ties to respond to identified climate-related aimed at senior health sector policymakers, as health risks when updating the National Health well as collaborate with other key sectors, to Sector Strategic Plan (2017–2021). This could develop climate and health policies and plans build from the past experience with the Ebola and advocate for them at the national level. outbreak, mobilizing resources and stakehold- ers to strengthen health system functions. SUBNATIONAL • Establish/form a unit on climate change and • Develop subnational adaptation plans for health in MoHS that includes a team of special- climate change and health. This could enable ists to plan, coordinate, and monitor action on the prioritization of adaptation needs and 58 | Climate and Health Vulnerability Assessment: Sierra Leone ensure the allocation of sufficient financial and nursing schools, as well as for all other resources for implementation by local councils health professionals, to ensure that the at district levels. health workforce of tomorrow possesses the • Develop city-level policies and plans for cli- knowledge and skills to deliver health care in mate-related health risks. This could build a changing climate. from the momentum of the appointment of • Develop educational and awareness-raising Africa’s first Chief Heat Officer in Freetown, as materials and implement training for health- well as activities highlighted in the Transform care workers to better understand the health Freetown Strategy in relation to urban greening, impacts of climate change, including the uti- flood resilience, improved WASH systems, and lization of train-the-trainer (ToT) models. This nutrition interventions. These activities could may include capacity-building activities, such be replicated in other urban centers such as as targeted training for health personnel to Bo, as well as the Northern Province that is manage changes in VBDs (especially dengue projected to experience increases in extreme and chikungunya), heat-related illnesses, and temperatures. food insecurity/undernutrition, particularly at subnational levels, as well as conduct analyses of climate-sensitive diseases, and vulnerability COMPONENT 2: HEALTH WORKFORCE and adaptation assessments. Options to strengthen the health workforce include the following areas: • Conduct a specific climate and health workforce COMPONENT 3: VULNERABILITY, needs and knowledge assessment to integrate CAPACITY, AND ADAPTATION climate change-related impacts into workforce ASSESSMENT planning. This would include considerations Options to strengthen vulnerability, capacity, and of the size of the health workforce, the skill adaptation assessments include these areas: mixes, and the geographical distributions of personnel needed to meet expected health • Conduct additional climate change and health needs (for example, addressing urban-rural vulnerability and adaptation assessments to disparities). capture new information and engage stake- • Train health sector policy makers and planners holders, including conducting more advanced to use climate information to inform the design analyses and prioritizing adaptation inter- of health sector programs and enhance day- ventions. Assessments should be repeated to-day service delivery as well as during and at least every five years. This could include after extreme weather events, such as flooding the exploration of impacts and adaptation at (coastal and inland). This may also include subnational levels, including the evaluation designing protocols to reduce risks to health of adaptation interventions. workers in flood-prone areas (for example, • Utilize modeling techniques, including climate, evacuation plans and alerts), particularly in disease, and economic scenarios to guide future Freetown and coastal communities, which are vulnerability adaptation assessments. This could the most vulnerable to flood risks. integrate outputs from tools currently under • Create a national curriculum that integrates development by the World Bank, including climate-related health threats into medical the Climate and Health Economic Valuation Recommendations to Enhance Health System Resilience to Climate Change | 59 Tool (CHEVT), as well as others. These tools inland), to better integrate and disseminate would make use of information collected in health information (for example, vector-borne this and other CHVAs. and water-related disease outbreaks following • Conduct a review of the climate resilience of flooding events) and link with emergency oper- current healthcare infrastructure, including the ations center systems (see Table 7 in Section impacts of extreme weather events such as IV for key stakeholders involved in EWS). flooding (coastal and inland). This should start • Review the extent to which human, animal, with the 81 healthcare facilities identified as and plant disease surveillance systems are being at risk of flooding. integrated and incorporate climate factors • Review the extent to which current health in- to ensure that a One Health approach is formation systems incorporate meteorological utilized and strengthened. This should build variables for climate-sensitive diseases. from the National One Health Strategic Plan (2019–2023) and Communication Strategy that incorporates lessons from the Ebola outbreak COMPONENT 4: INTEGRATED RISK to strengthen multisector government coordi- MONITORING AND EARLY WARNING nation, collaboration, and communication for preparedness and response to emergencies Options to strengthen integrated risk monitoring and public health threats. and EWS include these aspects: • Collect information to establish and central- • Support expanded, enhanced, and electronic ize agreed baselines for monitoring vulnera- coverage of health surveillance for climate-sen- ble populations/regions and existing or new sitive diseases, for example, in terms of geo- health-related human resource, technical, and graphic, population, and seasonal aspects. health services delivery capacity. This should build from lessons learned during • Support the identification and/or development the Ebola outbreak that would include linking of indicators to measure climate change and with environmental/meteorological monitoring health impacts and response capacity for in- structures to develop climate-informed EWS tegration into national and subnational moni- and response mechanisms. For example, flood toring systems. This would also support future monitoring systems should be linked to public climate change and health vulnerability and health communication channels that dissemi- adaptation assessments. nate educational materials and risk messaging to reduce water-related diseases before and after an event. COMPONENT 5: HEALTH AND • Support hospitals in updating their admissions CLIMATE RESEARCH and emergency case records to track heat-re- lated morbidity and mortality, as well as other Options to strengthen climate and health research climate-sensitive diseases, starting with the include the following areas: Eastern and Northern Provinces, which are • Develop research partnerships (for example, projected to experience significant tempera- national and international academic institu- ture increases. tions) to conduct studies and projects on key • Develop EWS for extreme weather events, climate change and health topics, such as such as heatwaves and flooding (coastal and the following: 60 | Climate and Health Vulnerability Assessment: Sierra Leone 1. Modeling studies to quantify the current diseases, particularly emerging and reemerg- and projected burdens of climate-sensitive ing CDs, such as VBDs (for example, dengue diseases, and chikungunya), as well as NCD burdens. 2. Economic analyses to better understand • Develop and implement national building the healthcare costs related to climate codes/permits for healthcare facilities, change, including to retrofit, refurbish, and maintain 3. Quantification of the health co-benefits of existing health infrastructure. Importantly, this climate change mitigation actions, should include the incorporation of climate 4. Operational research to test and evaluate risk projections into these codes/permits, for the implementation of evidence-based in- example, to include siting and construction, terventions, such as targeted resource de- functioning and operation, energy and water ployment for extreme weather events; and supplies, storm drains and sewers, and sani- 5. Development and testing of contextual- tation services of health care facilities, as well ized climate change and health risk com- as a focus on improving the transportation munication materials and dissemination network to ensure access to facilities during approaches. extreme weather events. • Additionally, research priorities for specific • Support the integration of new and innova- climate-related health risks may include studies tive technologies to monitor environmental on climate-resilient crops, analyses of malaria change (for example, satellite imagery) to breeding sites related to irrigation systems, inform measures that will improve the per- and analyses of water demand under different formance of the health system, for example, to climate scenarios. directly support local health capacity planning to respond to anticipated increases in wa- ter-related diseases and food insecurity due to COMPONENT 6: CLIMATE-RESILIENT climate change. Other examples would relate AND SUSTAINABLE TECHNOLOGIES to droughts and nutrition, precipitation, heat AND INFRASTRUCTURE and humidity, and VBDs, as well as mapping Options to strengthen the climate resilience of air quality impacts on health outcomes. Mental health technologies and infrastructure include health services should also be considered. these areas: • Introduce sustainable cooling measures (for • Conduct an assessment of the climate vul- example, increasing natural ventilation, and nerability of current health infrastructure in integrating solar and biomass energy sources) Sierra Leone, including closely-linked systems for health care facilities and laboratories to (for example, transportation, coastal/fisheries, enhance energy efficiency, space cooling, and energy, along with water and sanitation, systems medical cold chains, and ensure sustainable and infrastructure). This could include agreeing refrigerant technologies are used. These on a minimum threshold for health care infra- measures should follow a hierarchy of inter- structure to be considered climate resilient and ventions starting from passive measures, such environmentally sustainable in Sierra Leone. as building design and vegetative shading, to • Assess current laboratory capacities to more active technologies, such as powered diagnose current and future climate-related air conditioning as a secondary option. Recommendations to Enhance Health System Resilience to Climate Change | 61 • Development of structures to integrate health COMPONENT 7: MANAGEMENT OF and climate considerations into urban design to reduce the threat of urban heat islands, es- ENVIRONMENTAL DETERMINANTS pecially in Freetown, with a focus on informal OF HEALTH settlements. This could involve strengthening Options to strengthen the management of envi- health impact assessments and specific initia- ronmental determinants of health include the tives, such as the continued support of urban following areas: tree planting in cities, cool-roof interventions • Develop improved national regulations and (for example, painting roofs white), and the policies on key environmental health services development of public transport systems, as and determinants (for example, drinking water, identified in the Transform Freetown Strategy. air quality, food system, housing, transport, energy, and waste management). Actions that have also been identified as contrib- • Map areas using unsafe drinking water and utors to enhanced sustainability and reduced unimproved sanitation facilities; assess service GHGs in the health sector include the following: delivery gaps; and invest in improved drinking • Assess the carbon footprint of Sierra Leone’s water, sanitation, and sewage infrastructure health sector. to improve water quality and reduce climate- • Prioritize sustainability in the selection of health driven exposures. system procurement strategies procedures • Establish an improved centralized healthcare and and products that would include focusing on medical waste management system in Freetown the incorporation of low-carbon, energy-effi- and other urban centers that can withstand the cient technologies, such as photovoltaic cells, impacts of extreme weather events. solar-powered machinery, vaccine chains, and • Support community-led efforts to improve san- water pumps. itation practices and controls to prevent water • Promote modern energy cooking solutions and foodborne diseases, as well as commu- (MECS), such as low-emission cookstoves, nicate potential climate change-related risks. to reduce solid fuel use and household air • Establish a climate and environmental health pollution. database to support the development of • Develop regulations that support sustainable national regulations on the management of healthcare waste management (for example, environmental health services (for example, shifting away from medical waste incineration water supply, sanitation, and food safety). and promoting the recycling of non-hazardous • Increase support and integration with non- waste at facility levels where possible). health sector-focused interventions. This could include, for example, the promotion of sus- tainable/climate-smart agricultural practices by smallholder farmers (for example, alternate wet and dry irrigation for rice), appropriate modeling tools to assist strategic planning of water resources under climate change, and/or technical guidelines that incorporate climate change to increase supportive supervision, along with the monitoring and testing of potable water and sanitation services. 62 | Climate and Health Vulnerability Assessment: Sierra Leone COMPONENT 8: CLIMATE-INFORMED • Establish a national risk register that includes climate change-related risks, and if necessary, HEALTH PROGRAMS implement a process of national risk assessment Options to strengthen climate-informed health to enable the prioritization of climate-relat- programs include these areas: ed health risks alongside other national-level • Use mainstream and social media to spread threats. awareness and issue warnings related to pre- • Enhance contingency planning for deployment ventive measures for improving population and response (at national, provincial, district, health literacy concerning climate-sensitive and community levels) for acute climate shocks, health risks. such as flooding and consequent disease • Engage district-level community groups outbreaks, as well as longer-term climate (focusing on youth and women’s groups) and stressors, such as droughts and SLR. This leadership structures (for example, chiefdoms should include integrating climate-related disaster management committees) to support health considerations into district-level and dialogues and the development of prospec- community-level disaster management plans tive climate and health programs and policy to support stakeholders in organizing activities options, as well as their integration into the related to the preparedness of emergency planning and support of health promotion responses. programs directed toward climate-related • Establish seasonal and sub-seasonal climate health threats. This could include incorporating outlooks (MoHS, in collaboration with the climate change risks into existing supplemen- Meteorological Agency) to inform disease tary and/or emergency feeding programs to control/prevention programs ahead of potential reduce undernutrition. extreme weather events, as well as facilitate • Strengthen PHC through actions to ensure multisectoral engagement with first responders, these systems have improved adaptive capacity, disaster management authorities, and com- including knowledge and resources to manage munity-based groups to conduct outreach current and future climate change-related risks. and awareness regarding climate-sensitive Activities may include revising public health diseases. program SOPs to incorporate responses to • Ensure climate-related health risks are in- climate risks and the delivery of interventions, tegrated into stockpiling and distribution as well as mainstreaming climate change risks plans to support disaster response supplies into relevant policies and operational plans for (for example, water purifiers and safe water VBDs, water-related diseases, and nutrition storage containers). programs. • Conduct scenario-based simulation exercises with subnational health workers to enhance planning and response to health emergen- COMPONENT 9: EMERGENCY cies that are outside the range of historical experience. PREPAREDNESS AND MANAGEMENT Options to strengthen emergency preparedness and the management of climate change-related disaster risks include these aspects: Recommendations to Enhance Health System Resilience to Climate Change | 63 COMPONENT 10: CLIMATE AND vincial and district health investment plans for building climate resilience at subnational levels HEALTH FINANCING and for supporting continued investments in Ultimately, the aim of establishing the recommen- poverty reduction, health equity promotion, and dations below is to reach a “climate-smart” UHC increased access to essential services. This approach through the lens of health financing. should also incorporate mitigation activities, Options to strengthen climate and health financing such as the solarization of health facilities. include the following actions: • Explore the financial benefits of the health • Establish a budget line item at the national co-benefits of climate action. The economic level to finance critical preparedness activities benefits of mobilization of financial resources and adaptation interventions. in Sierra Leone seeks to support the health • Initiate pooling health funds to cover climate- sector in assessing the co-benefits of climate related health risks. This could include the action in other health-determining sectors consideration of a pre-payment mechanism and to identify climate actions that bring the for providing this financial protection for greatest benefits to health. climate-related health impacts through the • Seek international and external donor funding pooling of resources. Additionally, this could opportunities and mechanisms. This can include include expanding the FHCI to reduce OOP the Green Climate Fund, Global Environment expenditure as a subsidy. Facility, and the Adaptation Fund for dissemina- • Ensure that strategic purchasing (for example, tion toward health-based adaptation measures, increasing the equitable distribution of the control of climate-sensitive diseases, resources) includes climate considerations. research projects, and mitigation projects, This should be tailored to include climate con- including the NDCs. Additionally, there should siderations across national and subnational be efforts to improve engagement from the levels. The impact of climate on the utilization health sector with ongoing and/or planned of resources needs to be factored into pro- climate change adaptation projects. 64 | Climate and Health Vulnerability Assessment: Sierra Leone ANNEXES ANNEX A. METHODS FOR THE mosquitoes in Sierra Leone with population data from the Global Human Settlement Layers (2015) to ESTIMATION OF MOSQUITO calculate the number of Sierra Leoneans residing SUITABILITY UNDER RCP 8.5 IN in suitable areas, by region. Population data was SIERRA LEONE held constant in all models in the absence of spatial population projection data. The output MODEL CONSTRUCTION spatial resolution of products is 1000 meters this analysis is performed at the landscape, not Spatio-temporal distributions of Anopheles the microscale, level. Microscale variations in gambiae s.l. mosquitoes were determined, using climatological and land use and land cover can a raster-based suitability model constructed and do affect the species’ actual distributions. with the Google Earth Engine. It was adapted from the methodology presented by Frake et al. [107]. This methodology uses abiotic variables SUITABILITY DATA AND PARAMETERS specific to the thermal tolerances of vector species Temperature and biotic variables that give consideration to species habitat preferences. “Suitable areas” are Temperature is critical to mosquito development defined as patches of landscape that facilitate the and life history. Temperatures that are either too development of malaria mosquitoes through the low or too high can increase mortality in aquatic production and persistence of oviposition sites or adult stages. Bayoh and Lindsay [109] demon- and where temperatures do not exceed or fall strated that the upper and lower thresholds for below thermal tolerances. Parameter thresholds Anopheles gambiae s.s. aquatic development of all input variables were selected, based on are 18°C and 34°C, respectively. The minimum a literature review of the Anopheles gambiae and maximum temperature thresholds for this s.l. habitat: Temperature, Landcover, Precipita- analysis were set to 18°C and 34°C, respectively. tion, Flow Accumulation, and Water Resources Data was acquired from the NASA NEX-GDDP (Table A1). at a spatial resolution of 0.25 degree. The thresholds were then used to create binary Land Use and Land Cover maps for each predictor (that is, “suitable” [1] There is a significant relationship between or “unsuitable” [0]) that were combined using land use and land cover and the distribution of Boolean logic to produce suitability maps for mosquito species, with many species demon- Sierra Leone’s historic malaria transmission strating strong preferences for specific land cover period (May–November) across three epochs — types. Land Use and Land Cover (LULC) data was the historical reference period of 1986–2005), acquired from the Copernicus Global Land Service along with 2030–2049 and 2040–2059 [108]. Proba-V-c3 product. To determine whether classi- Population vulnerability was demonstrated by fications were suitable for Anopheles gambiae s.l. spatially overlaying the suitability maps of malaria mosquitoes, class descriptions were compared to 65 the habitat preferences of the species according habitat preferences were considered. Anopheles to the literature review. The mosquito habitats of coluzzi show a preference for forested areas, Anopheles gambiae are characterized by open, greater sunlight exposure, higher water vapor sunlit pools: they may be associated with human pressure, along with lower temperatures and activity including agriculture, which may facilitate evapotranspiration. S-forms prefer dry savannah water pooling. and deciduous forests. To account for these species’ preferences, Proba class values — 20, In this analysis, M-form and S-form Anopheles 30, 40, 50, 60, 90, 111, 112, 113, 114, 115, 116, 121, 122, gambiae s.s. (now known as Anopheles coluzzi and 123, 124, 125, and 126 — were set to “suitable” Anopheles gambiae s.s., respectively) mosquitoes’ (Table A2). TABLE A1. Model parameterization and data sources for habitat characterization INDICATOR DATA SOURCE PRODUCT SPATIAL RESOLUTION THRESHOLD Temperature NASA NEX-GDDP 0.25 degrees Anopheles gambiae s.s. Min: 18°C Max: 34°C Land Cover Copernicus Global Proba-V-C3 100 m See Table A2* Land Service Water Resources JRC GSW1_0 30 m >0 percent water occurrence Flow WWF HydroSHEDS 500 m Accumulation Population JRC GHSL/P2016/POP_ GPW_GLOBE_V1 TABLE A2. Copernicus Global Land Cover Layers: CG:S-LC100 Collection 2 global landcover map classifications CLASS CLASS DESCRIPTION SUITABLE VALUE ANOPHELES GAMBIAE S.L. LAND COVER 0 Unknown; no or not enough satellite data available No 20 Shrubs; woody perennial plants with persistent and woody stems and without Yes any defined main stem being less than 5 m tall; shrub foliage either evergreen or deciduous 30 Herbaceous vegetation; plants without persistent stem or shoots above Yes ground and lacking definite firm structure; tree and shrub cover less than 10% 66 | Climate and Health Vulnerability Assessment: Sierra Leone CLASS CLASS DESCRIPTION SUITABLE VALUE ANOPHELES GAMBIAE S.L. LAND COVER 40 Cultivated and managed vegetation/agriculture; lands covered with temporary Yes crops followed by harvest and a bare soil period (for example, single and multiple cropping systems; note that perennial woody crops will be classified as the appropriate forest or shrub land cover type 50 Urban/built-up; land covered by buildings and other man-made structures Yes 60 Bare/sparse vegetation; lands with exposed soil, sand, or rocks, and never Yes with more than 10% vegetated cover during any time of the year 70 Snow and ice; lands under snow or ice cover throughout the year No 80 Permanent water bodies; lakes, reservoirs, and rivers; either freshwater or No saltwater bodies 90 Herbaceous wetland; lands with a permanent mixture of water and herba- Yes ceous or woody vegetation; vegetation present in either salt, brackish, or freshwater 100 Moss and lichen No 111 Closed forest, evergreen needle leaf; tree canopy >70 %, almost all needle Yes leaf trees remaining green all year round; canopy never without green foliage 112 Closed forest, evergreen broadleaf; tree canopy >70 %, almost all broadleaf Yes trees remaining green all year round; canopy never without green foliage 113 Closed forest, deciduous needle leaf; tree canopy >70 %, consisting of Yes seasonal needle leaf tree communities with an annual cycle of leaf-on and leaf-off periods 114 Closed forest, deciduous broadleaf; tree canopy >70 %, consists of seasonal Yes broadleaf tree communities with an annual cycle of leaf-on and leaf-off periods 115 Closed forest, mixed Yes 116 Closed forest, not matching any of the other definitions Yes 121 Open forest, evergreen needle leaf; top layer — trees 15–70 % and second Yes layer — mix of shrubs and grassland, consisting of almost all needle leaf trees that remain green all year round; canopy never without green foliage 122 Open forest, evergreen broadleaf; top layer — trees 15–70% and second layer Yes — mix of shrubs and grassland, consisting of almost all broadleaf trees that remain green all year round; canopy never without green foliage 123 Open forest, deciduous needle leaf; top layer — trees 15–70% and second Yes layer — mix of shrubs and grassland, consisting of seasonal needle-leaf tree communities with an annual cycle of leaf-on and leaf-off periods 124 Open forest, deciduous broadleaf; top layer — trees, 15–70% and second Yes layer — mix of shrubs and grassland, consisting of seasonal broadleaf tree communities with an annual cycle of leaf-on and leaf-off periods 125 Open forest, mixed Yes 126 Open forest, not matching any of the other definitions Yes 200 Oceans, seas; either freshwater or saltwater bodies No Annexes | 67 Precipitation Finally, a water resources layer, derived from the Water is fundamental to mosquito larvae JRC Global Surface Water Bodies Mapping Layer v1.0 product, was developed by buffering water development. To estimate areas likely to become bodies by 250 m to approximate water-rich soils inundated, annual average precipitation was that would support larval development. calculated from the Climate Hazards Group InfraRed Precipitation and Station Data (CHIRPS v2.0). Likewise, flow accumulation was derived from the HydroSHEDS Flow Accumulation product ANNEX B. WATER POINTS to determine the natural drainage from a given IN SIERRA LEONE pixel to an adjacent, downslope pixel to determine See Figure B1 for a map of the water points in the areas of inundation for larval oviposition sites. Sierra Leone. FIGURE B1. Waterpoints in Sierra Leone Source: Government of Sierra Leone Integrated Geographic Information System (GIS) Portal (https://gis.dsti.gov.sl/). 68 | Climate and Health Vulnerability Assessment: Sierra Leone ANNEX C. ADAPTIVE CAPACITY RAPID ASSESSMENT LEADERSHIP AND GOVERNANCE Assessment Questions Yes No Partial N/A 1.1: Does the country have a national climate change and health plan/strategy? 1.2: Is health mentioned as a priority in the Nationally Determined Contributions (NDCs)? 1.3: Is there a designated focal point responsible for health and climate change in the Ministry of Health (MoH)? 1.4: Is there a multisectoral technical working group/committee focused on climate change and health? 1.5: Does MoH actively participate in climate change coordination and/or working groups? 1.6: Is there a MOU between MoH and key climate change-related ministries/ departments (for example, Environment, Meteorological Services, Agriculture, Water)? 1.7: Are decision-makers (both within MoH and outside) aware of climate change and health risks and potential adaptation options? 1.8: Does relevant information related to climate change and health risks and adaptation reach key stakeholders across sectors? 1.9: Is climate change included in health plans at subnational levels? HEALTH WORKFORCE Assessment Questions Yes No Partial N/A 2.1: Are there dedicated full-time staff devoted to climate change and health? 2.2: Are the number of healthcare workers above 4.5 per 1000? 2.3: Are health workers adequately distributed between urban and rural areas? 2.4: Is the health workforce aware of the health risks of climate change? 2.5: Are there capacity-building programs focused on climate change and health within MoH? 2.6: Have the MoH staff received training on climate change and health over the last two years? 2.7: Does the health workforce have the technical capacity to interpret and utilize climate change information (for example, scenarios, projections, forecasts) to inform planning/decision-making? 2.8: Is climate change and health included in the educational curriculum (for example, schools of public health, medicine, nursing)? 2.9: Are there context- or country-specific climate change and health training/ educational materials for the health workforce? Annexes | 69 HEALTH INFORMATION AND DISEASE SURVEILLANCE SYSTEM Assessment Questions Yes No Partial N/A 3.1: Has the country completed a climate change and health vulnerability and adaptation or risk assessment? 3.2. Do surveillance systems exist for climate-sensitive diseases (for example, heat- related illnesses, VBDs, and WBDs)? 3.3: Does the country have a centralized monitoring system for climate-related diseases? 3.4: Do health surveillance systems integrate meteorological and/or environmental information? 3.5: Are there efforts from MoHS to utilize national climate/meteorological information? 3.6: Does the country have a climate-informed early warning system (EWS) for any health risks? 3.7: Are there EWS in place for climate change-related extreme events/hazards? (for example, flooding, drought, and storms)? 3.8: Does MoH coordinate with disaster/hazard-focused EWS? ESSENTIAL MEDICAL PRODUCTS, TECHNOLOGIES, AND INFRASTRUCTURE Assessment Questions Yes No Partial N/A 4.1 Has the country’s healthcare facilities been assessed for climate resilience? 4.2 Are health facilities accessible for rural communities? 4.3: Do healthcare facilities implement measures to remove mosquito breeding sites? 4.4: Have healthcare facilities employed adaptive measures to protect against climate change related hazards (for example, flood walls and drainage systems)? 4.5: Does the national laboratory have the capacity to conduct diagnostic tests for climate-sensitive diseases? 4.6: Are building codes for healthcare facilities designed to protect against climate change-related hazards put in place and enforced? 4.7: Have healthcare facilities implemented “greening” activities (for example, tree planting and cooling designs)? 4.8: Are there efforts to incorporate long-term planning (for example, urban design) to reduce climate change and health impacts? 4.9: Are health facilities adequately equipped for climate change-related hazards and prepared to respond to them (for example, stockpile of medical/emergency supplies)? 70 | Climate and Health Vulnerability Assessment: Sierra Leone HEALTH SERVICE DELIVERY Assessment Questions Yes No Partial N/A 5.1: Has the country enacted legislation mandated universal healthcare coverage (UHC)? 5.2: Are there climate change-specific health programs underway in the country? 5.3 Does health service delivery have contingency measures for extreme weather events (for example, floods, storms, and heatwaves)? 5.4: Does current public health planning consider climate change information (for example, scenarios, projections, and forecasts)? 5.5: Has MoH implemented any climate health awareness campaigns to increase public awareness? 5.6: Is there access to safe WaSH for over 80 percent of the country? 5.7: Do over 80 percent of healthcare facilities have access to safe WaSH and healthcare waste removal/storage? 5.8: Have multihazard risk assessments been conducted in the country? 5.9: If conducted, do multihazard risk assessments include potential health risks? FINANCING Assessment Questions Yes No Partial N/A 6.1: Is MoH currently receiving international funds to support climate change and health work? 6.2: Is there dedicated funding within MoH for climate change and health activities? 6.3: Is the health expenditure percentage of GDP above the WHO recommendation? 6.4: Is the national health budget dependent on donors or foreign aid? 6.5: Are there climate considerations in the national health budget? Annexes | 71 ANNEX D. HEALTH ADAPTATION RECOMMENDATIONS/MENU OF OPTIONS COMPONENT Food security Vector-borne Water-related Extreme Weather Heat-Related Air quality Mental health and nutrition diseases diseases and Climate Hazards Morbidity and and wellbeing Associated Mortality Mortality and Morbidity Component 1: Incorporation of Implementation Promotion of Development and Development and Inclusion of Development of Leadership and climate change of Malaria Control subnational-level implementation of a implementation of a the benefits of a national mental Governance risks into food Strategic Plan water regulatory health-specific DRM plan national heat health mitigation actions health strategy and security and authorities and to be integrated with policy and city-level to health through action plan nutrition strategic engagement with national policies and plans, leveraging reducing air plans, including communities on supported by necessary the appointment pollution into NDCs; sustainable policy options mandates of the Chief Heat establishment of agriculture efforts Officer in Freetown national standards to raise awareness for indoor air of the health pollutants impacts of extreme heat Component 2: Incorporation Training at Awareness raising Conducting of simulation Conducting of Health-specific Training for Health workforce of educational subnational levels targeted at health exercises with health heat-health training awareness and community health materials on climate to enhance the workers with regard workers at subnational for health workers; education materials workers on mental 72 | Climate and Health Vulnerability Assessment: Sierra Leone change impacts on capacity of dengue to climate change levels, focusing on management of for health workers health awareness food security and prevention and impact on WaSH service delivery during occupational heat on risks of indoor and interventions, nutrition into health control, as well as and WBDs emergencies, including exposures and outdoor air especially following worker training the knowledge of compounding/cascading pollution extreme weather climate change- climate-induced disasters events related factors Component 3: Vulnerability District- and Vulnerability Conducting of integrated Conducting Assessment of Further exploration Vulnerability, assessment community-level assessment to multihazard vulnerability assessments for indoor and outdoor of impact of climate capacity, and of nutrition to assessments to assess water and risk assessments at high-risk groups air pollution levels change on mental adaptation climate change; better understand shortages, local/district levels at the city level, and health impacts, health, as well as assessment assessment of local risks rainfall extremes, including informal especially in urban community-based nutritional benefits related to VBDs unpredictable river settlements and areas resilience-building of climate-smart and capacities flows, and baseline incorporation into interventions agricultural for managing WaSH coverage in economic analyses interventions outbreaks healthcare facilities Component 4: Development Building of health Integration of Strengthening of HIS to Heatwave alert Development of air Development of Integrated risk and inclusion of information system climate/weather incorporate emergency systems for quality monitoring mental health monitoring and long-term strategies (HIS) to incorporate information with preparedness and urban and rural systems and surveillance early warning for nutrition climate-informed WBD surveillance the use of technology populations public health risk systems interventions into seasonal outlook systems to forecast for the monitoring communication FEWS (famine early outbreaks and surveillance of warning system) health conditions in emergencies Component Analysis of Conducting of Modeling of water Development and Studies to further Studies on Studies on the 5: Health and long-term effects climate change security/demand inclusion of extreme explore impacts of modeling/ mental health climate research of food insecurity modeling studies projection under weather event attribution extreme heat on quantifying the impact of on health and to estimate dengue different climate studies as evidence of health systems, health co-benefits climate change economy risk projections and scenarios and impacts on human health including urban of mitigation and potential inform adaptation impact on WBDs heat island policies for air community-level decisions mapping pollution interventions Food security Vector-borne Water-related Extreme Weather Heat-Related Air quality Mental health and nutrition diseases diseases and Climate Hazards Morbidity and and wellbeing Associated Mortality Mortality and Morbidity Component 6: Improvement of Improvement Improvement of Revision of specifications Space cooling Improvement of Support of the Climate-resilient drainage systems in of laboratory WaSH systems to include climate risk in healthcare energy supply development of and sustainable crop fields at risk to capabilities in healthcare projections in siting and facilities to prevent and distribution mental health technologies and floods; exploration for testing and facilities to construction, functioning overheating efficiency and centers to support infrastructure of smart- diagnosis of withstand extreme and operation, energy and protect IT use of on-site the distribution of agriculture and endemic, as weather events (for and water supplies, and and equipment; renewable energy services in rural crop diversification well as novel example, drainage sanitation services of energy-efficient or sources (for areas practices and reemerging systems and health care facilities passive measures example, solar diseases; healthcare waste of cooling to reduce photovoltaic) development of management) energy costs in health care a list of essential facilities; promotion medicines needs of low-cost air for VBD outbreaks quality sensor network Component 7: Community-led Community Improvement of Development and Housing standards Improvement of Engagement with Management of efforts to map food awareness household water implementation of and urban planning healthcare waste communities to environmental insecurity and campaigns to security and regulations for disease (built environment) management to assess and improve determinants of inform interventions increase awareness sanitation practices outbreak response and to reduce heat reduce GHGs and mental health health to improve the of climate sensitivity other climate-related risks; household improve local air and well-being, food system in a of VBDs and health emergencies to be water security; and quality including reducing changing climate engage vulnerable incorporated into disaster occupational health stigma and building groups in outbreak management planning management awareness prevention Component 8: Interventions Incorporation of Institution/ Integration of DRM into Incorporation of Engagement Mental health Climate-informed involving the climate change implementation public health training and heat risks into of high-risk program developed health programs establishment information into of SOPs for implementation of public maternal health communities in MoHS of gardens or VBD prevention drinking water and awareness campaigns guidance, guidance to increase food growing and outbreak sanitation provision; focused on the links for diabetes understanding opportunities; response SOPs public awareness- between disasters, management, of impacts of community- raising campaigns climate change, and among others air pollution, as mediated delivery conducted on health well as develop of nutrition services, hygiene, particularly community-level including screening handwashing response Component Food production Inclusion of Development of Conducting of exercises/ Heat included into Incorporation Mental health 9: Emergency and distribution outbreaks of VBDs WaSH-focused testing disaster DRM operations of air quality impacts related to preparedness chain reinforced to in DRM plans at emergency preparedness plans emergencies into extreme weather and management withstand impacts national, provincial, preparedness (tabletop and real world), DRM plans events incorporated of extreme weather district, and and response along with evaluations into DRM planning events community levels plans, including of responses/uses of the stockpiling and plans in the health sector distribution plan for supplies (for example, purifiers and safe water storage) Annexes | 73 Food security Vector-borne Water-related Extreme Weather Heat-Related Air quality Mental health and nutrition diseases diseases and Climate Hazards Morbidity and and wellbeing Associated Mortality Mortality and Morbidity Component 10: Investments in the Formation of Allocation of Resources to support Financing of Facilitation Strengthened Climate and dissemination of proposals for resources to build preparedness for sustainable cities/ of access to resource allocation health financing crop varieties and external donors to climate-resilient extreme weather events cool cities to international for improved mental breeds adapted to support improved WaSH district- level and response address heat risks; 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