Climate and Health Vulnerability Assessment CAMBODIA CLIMATE INVESTMENT FUNDS © 2024 International Bank for Reconstruction and Development/The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory, or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. 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CAMBODIA Climate and Health Vulnerability Assessment June 2024 CLIMATE INVESTMENT FUNDS TABLE OF CONTENTS Acknowledgments................................................................................................................................................vi List of abbreviations.............................................................................................................................................vii Executive summary................................................................................................................................................ 1 INTRODUCTION..............................................................................................................................5 Country context..................................................................................................................................................... 6 I. CLIMATOLOGY............................................................................................................................. 11 Cambodia’s geography........................................................................................................................................11 Climate Contexts: Observed and Projected Climatology............................................................................12 Climate-Related Hazards ...................................................................................................................................15 Key messages.......................................................................................................................................................21 II. CLIMATE-RELATED HEALTH RISKS........................................................................................23 III. ADAPTIVE CAPACITY OF THE HEALTH SYSTEM................................................................33 Health system overview..................................................................................................................................... 33 Leadership and governance............................................................................................................................. 34 Health service delivery......................................................................................................................................36 Health workforce................................................................................................................................................. 37 Health information systems............................................................................................................................... 38 Essential medical products and technologies..............................................................................................39 Health financing...................................................................................................................................................40 IV. RECOMMENDATIONS.............................................................................................................43 Health information systems............................................................................................................................... 44 Health financing................................................................................................................................................... 44 Health service delivery...................................................................................................................................... 44 Health workforce................................................................................................................................................. 44 Leadership and governance............................................................................................................................. 44 ANNEX............................................................................................................................................47 REFERENCES................................................................................................................................ 49 iv | Climate and Health Vulnerability Assessment: Djibouti INDEX OF TABLES Table 1. Provinces Most Impacted by Extreme Heat: Annual Number of Hot days (Tmax > 35°C) and Tropical nights (Tmin > 20°C and > 26°C) in the 2030s and 2050s, Under SSP3-7.0..........................14 Table 2. Food Production, Per Capita Food Consumption, and Hunger Attributable to Climate Change (CC)...................................................................................................................................................25 Table 3. Gaps in Adaptive Capacity.........................................................................................................................42 INDEX OF FIGURES Figure 1. WHO’s Operational Framework for Building Climate-Resilient Health Systems........................... 8 Figure 2. Administrative Boundaries of Cambodia’s Provinces......................................................................... 9 Figure 3. Elevation of Cambodia and Major Cities................................................................................................12 Figure 4. Projected Average Monthly Temperature Anomalies in Cambodia for the 2030s and 2050s, Under the SSP3-7.0 Scenario..............................................................................................................13 Figure 5. Projected Annual Number of Hot Days (Tmax > 35°C) in Cambodia for 2030s and 2050s, Under the SSP3-7.0 Scenario..............................................................................................................13 Figure 6. Number of People Affected by Key Natural Hazards, 1980–2020.................................................15 Figure 7. Types of Flood Risks in Cambodia...........................................................................................................16 Figure 8. Rainfall-Triggered Landslides in Cambodia.......................................................................................... 17 Figure 9. SPEI’s Projected Anomalies Under the SSP3-7.0 Scenario...............................................................18 Figure 10. FWI for Wildfires in Cambodia.................................................................................................................19 Figure 11. Cyclone Risk in Cambodia (Source: ThinkHazard, GFDRR)............................................................20 Figure 12. Stunting Prevalence by Region.............................................................................................................24 Figure 13. Summary of the Nature of Association Between Monthly Minimum Temperatures and Monthly Cases of Diarrhea................................................................................................................................28 Figure 14. WHO’s Climate-Resilient Health System Building Blocks............................................................... 34 Figure 15. WHO’s Operational Framework for Climate-Resilient Health Systems....................................... 43 Table of Contents | v ACKNOWLEDGMENTS This Climate and Health Vulnerability Assessment (CHVA) for Cambodia was produced by the Health, Climate, Environment and Disasters (HCED) Program in the Health, Nutrition, and Population (HNP) Global Practice of the World Bank, led by Tamer Rabie and Stephen Dorey. The assessment was authored by Jessica Huang, Mikhael Iglesias, Kim Heang Ung, Judith Namanya, and Paul Jacob Robyn, with contributions from Ana Lucrecia Rivera-Rivera, Muloongo Simuzingili and Loreta Rufo. This work also benefited from the administrative support of Fatima-Ezzahra Mansouri, the editorial work of Kah Ying Choo, and the production of Sarah Jene Hollis. The authors are thankful to the Climate Investment Funds (CIF) and the Climate Support Facility (CSF) for funding this work. 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: Djibouti LIST OF ABBREVIATIONS AAP Ambient Air Pollution AIDS Acquired Immunodeficiency Syndrome AQI Air Quality Index AR5 Fifth Assessment Report AR6 Sixth Assessment Report CCAP Climate Change Action Plan CCCSP Cambodia Climate Change Strategic Plan CCDR Country Climate Development Report CCFF Climate Change Financing Framework CCKP Climate Change Knowledge Portal CCRI Child Climate Risk Index CCSP Climate Change Strategic Plan CCTWG Climate Change Technical Working Group CEGIM Climate Economic Growth Impact Model CHVA Climate and Health Vulnerability Assessment CIF Climate Investment Funds CMIP6 Coupled Model Intercomparison Project Phase 6 CNM National Center for Parasitology Entomology and Malaria Control COPD Chronic Obstructive Pulmonary Disease CPA Complementary Package of Activities CPEIR Climate Public Expenditure and Institutional Review DALYs Disability-Adjusted Life Years DCC Department of Climate Change DHS Demographic and Health Survey ENSO El Niño Southern Oscillation FWI Fire Weather Index GCF Green Climate Fund GDP Gross Domestic Product GFDRR Global Facility for Disaster Reduction and Recovery GHG Greenhouse Gases GHSC-PSM Global Health Supply Chain Program-Procurement and Supply Management HAP Household Air Pollution HCED Health, Climate, Environment and Disasters HDI Human Development Index HEF Health Equity Funds HIV Human Immunodeficiency Virus List of Abbreviations | vii HNP Health, Nutrition, and Population HSS Health System Strengthening HWDP Health Workforce Development Plan ICT Information and Communication Technologies INDC National Determined Contributions IPCC Intergovernmental Panel on Climate Change JMP Joint Monitoring Programme MAFF Ministry of Agriculture, Forestry and Fisheries MEF Ministry of Economy and Finance MOE Ministry of Environment MoH Ministry of Health NASA National Aeronautics and Space Agency NCD Noncommunicable disease NCDM National Committee for Disaster Management NCSD National Council for Sustainable Development NDC National Determined Contributions NGO Non-Governmental Organization OOP Out-of-Pocket Expenditure PM2.5 Particulate Matter (2.5µ) PMD Preventive Medicine Department PTSD Post-Traumatic Stress Disorder SPEI Standard Precipitation Evapotranspiration Index SSCSP Sectoral Climate Change Strategic Plan SSP Shared Socioeconomic Pathway UNDP United National Development Programme UNFCCC United National Framework Convention on Climate Change UNICEF United Nations Children’s Fund USAID United States Agency for International Development V&A Vulnerability and Adaptation Assessment VBD Vector-Borne Disease WASH Water, Sanitation, and Hygiene WBD Waterborne Disease WHO World Health Organization viii | Climate and Health Vulnerability Assessment: Djibouti EXECUTIVE SUMMARY Cambodia is highly exposed and vulnerable to climate change, which has significant direct and indirect impacts on human health. Climate-related hazards — such as heavy rainfall, flooding, landslides, sea-level rises, extreme heat, droughts, wildfires, and storms — affect agricultural productivity significantly, with tremendous implica- tions on food security and nutrition. They also lead to increased waterborne disease (WBD) outbreaks and the transmission of vector-borne diseases (VBDs) in Cambodia. Moreover, flooding, strong winds, and extreme heat cause damage to the health in- frastructure, medical equipment, and supplies in the country. The increasing burden of climate-sensitive diseases, coupled with the impacts on the health infrastructure, is putting pressure on the already fragile health system in the country, thereby affecting adaptive capacity and increasing health inequalities in Cambodia. Considering Cambodia’s high vulnerability and exposure to climate change, a Climate and Health Vulnerability Assessment (CHVA) was conducted. The objective of this CHVA is to assist decision-makers with planning effective adaptation measures to deal with climate-related health risks. Where available, these measures are provided at the subnational level to assist regional health planners. The recom- mendations of this CHVA are primarily aimed at the health sector and related sectors that influence health risks from climate change, such as disaster risk management. The CHVA begins with an analysis of observed climatic changes and projected trends derived from the World Bank’s Climate Change Knowledge Portal (CCKP). It highlights the changes in temperature and precipitation, as well as climate-related hazards, along with the relationship to human health risks in Cambodia: • Mean annual temperatures have increased by approximately 0.5°C over the past half century and they are projected to increase by 1.0°–1.2°C by the 2050s. April has had the highest mean temperature (29.4°C), while January has had the lowest mean temperature (24.3°C). Nonetheless, projections show that mean monthly temperatures will increase from 27.4°C in the historical reference period (1995–2014) to 28.6°C in the mid-term period. • Mean annual precipitation in Cambodia has declined by 2.46 millimeters (mm) since the 1960s (from 1961–1990 to 1990–2020). Rainfall patterns are projected to show slight variations; however, there is likely to be greater variability during the year, with a drier dry season for the 2030s and 2050s. • Projected increases in the frequency and intensity of erratic rainfall events during the 2030s and 2050s are likely to exacerbate flood and landslide risks. The average largest one-day precipitation is projected to reach nearly 100 mm during October in Kep (97.4 mm) and Kampot (95.3 mm) by 2020–2039. 1 • Cambodia already has a high number of high heat index days per year (> 35oC) based on a global comparison; they are projected to increase by the 2050s. Tropical nights (> 20oC) are also expected to be near the maximum possible from March to October, with slight increases projected for the remaining months by the 2050s. Cambodia faces significant health challenges from communicable and non-communicable diseases, and climate change will worsen the severity of these health challenges. Moreover, climate health risks are not evenly distributed in the population, with some groups at greater risk of exposure than others. Cambodia’s CHVA assesses six climate-related health risk categories: • Nutrition, food access, and food safety risks: Stunting and undernutrition are major climate-sen- sitive concerns in Cambodia. Regional variability in nutritional deficiencies is high. In Cambodia, nutrition services for people living in poverty and other vulnerable populations are critical, especially among rural populations. • Vector-borne diseases (VBDs): Malaria, dengue, Zika, chikungunya, and Japanese encephalitis are among the climate-sensitive VBDs circulating in Cambodia. While there has been significant progress in reducing malaria, with cases declining by over 90 percent from 2010 to 2020, projected changes in temperature and precipitation in the 2030s and 2050s will adversely impact this progress. • Waterborne diseases (WBDs): While Cambodia has made significant progress in decreasing the under-five mortality rates from diarrheal diseases since the year 2000, preventable deaths still occur. Given the challenges of the country’s water, sanitation, and hygiene (WASH) infrastruc- ture and the projected increases in floods and landslides, the incidence of diarrheal diseases in Cambodia will likely increase. • Heat-related morbidity and mortality: Increases in average seasonal temperatures, as well as the frequency and intensity of heat wave events, are projected to increase heat-related morbidity and mortality. Oddar Meanchey, Preah Vihear, and Siem Reap are anticipated to experience the largest number of very hot days (> 35°C), thereby exposing over two million people to extreme heat. • Air pollution risks: Ambient air pollution (AAP) and indoor (household) air pollution pose a risk to the health of people in Cambodia, although levels of exposure are relatively mild compared with other highly urbanized countries in the region. • Mental health and well-being risks: Cambodia is experiencing a rise in mental health challenges following the stressors of the COVID-19 pandemic. Climate change-related events can worsen mental health through direct and indirect impacts over the short and long terms. 2 | Climate and Health Vulnerability Assessment: Djibouti The extent to which the health system in Cambodia is prepared for climate change and possesses the capacity to manage hazard exposure and susceptibility will determine its resilience in the coming decades. In this assessment, Cambodia’s adaptive capacity to prevent and manage climate-re- lated health risks is examined according to the World Health Organization’s (WHO) six health system building blocks: • Leadership and governance: The government of Cambodia recognizes climate change and its impacts on the country’s health sector. It has made substantial efforts in furthering health into the country’s policies and strategies to address climate change. However, at a subnational level, the development and implementation of policies and plans to address climate-related health risks appear mixed due to the inadequate integration of strategic plans around local-level climate and health planning. • Health service delivery: There have been considerable investments in the health system to increase both access to quality health services and their utilization in order to improve the quality of care. While health facilities at the subnational level have improved and health staff deployment has increased at the health center level, efforts to assess the climate resilience and adaptive capacity of health service delivery have been limited. • Health workforce: Cambodia’s Health Strategic Plan 3 outlines the importance of having appropri- ately skilled health staff who are adequately motivated, proficiently trained, and equitably deployed. However, there has been limited coordination between healthcare professionals concerning the response to the health risks and disaster risks arising from climate change. • Health information systems: Although surveillance, reporting, and early warning systems exist in Cambodia, there is limited coordination between them. Furthermore, not all sources of data are shared with the appropriate stakeholders to enable a coordinated response to climate-related health risks. • Essential medical products and technologies: Laboratory capabilities in Cambodia face several challenges including testing services, the transport of specimens, quality management, and regulations. Further, limited supply chains result in a lack of basic needs, as well as contribute to stockouts of laboratory reagents, consumables, and equipment. • Health financing: Several health financing policies have been implemented in the country to improve access to health services. They include community-based health insurance, the development of a donor-supported health equity fund (HEF), a voucher scheme, and government-funded HEFs. However, vulnerable populations (the elderly, poor, and children under five) are not adequately covered by risk-pooling mechanisms such as the HEF. 3 The extent to which the health system in Cambodia is prepared for changes in hazards, exposure, and susceptibility and has the capacity to manage them will determine its resilience in the coming decades. The recommendation options are based on an assessment of both the magnitude of the current and projected climate-related health risks, the existing gaps in the adaptive capacity to manage and / or prevent these risks, and the feasibility of developing them in the short and medium terms. • Expand the community-level mobile application developed by the National Center for Parasitology, Entomology and Malaria Control (CNM) to include other climate-sensitive diseases.  • Incorporate a health sector climate adaptation line into the national budget. Increased financing capacity should focus on improving risk-pooling mechanisms that are targeted at climate-vulner- able populations. • Conduct an infrastructure assessment to identify key facilities and areas that need further investments to ensure resilience in the face of climate-related hazards.  • Develop and ensure the enforcement of building codes that include adaptation and mitigation standards for the health infrastructure. • Develop tailored capacity-building modules for healthcare workers and health center administra- tors, accounting for subnational differences in climate-related hazards and health risks.  • Integrate non-governmental organizations, research institutes, and private sector providers of health services into multi-stakeholder coordination mechanisms, such as the Climate Change Technical Working Group (CCTWG).  4 | Climate and Health Vulnerability Assessment: Djibouti INTRODUCTION COUNTRY CONTEXT 1. Cambodia has experienced significant economic and social development: its average annual growth rate was 7.7 percent between 1998 and 2019, making it one of the fastest-growing economies in the world. Cambodia had a Gross Domestic Product (GDP) of USD26.96 million in 20211 and a Human Development Index (HDI) value of 0.594 in 2019.2 The country achieved the lower-middle-income status in 2015, fueled largely by tourism and the garment industry.3 During this period, the poverty rate in 3. The population of Cambodia, which dropped Cambodia was declining by 1.6 percent per by nearly a quarter during the Khmer Rouge year, thanks to rising wages, even though rural genocide from 1975 to 1979, has been poverty remained worse (22.8 percent) than increasing to reach 16.6 million in 2021. While in urban areas (12.6 percent) and the capital the overall population has been growing, the city of Phnom Penh (4.2 percent).4 The Gini annual population growth rate has slowed to coefficient measure of inequality had fallen 1.4 percent in 2021 after hovering at nearly 3 from over 40 percent in 1997 to around 30 percent or higher until the mid-1990s.9,10 The percent in 2012.5 Cambodia announced its age dependency ratio in Cambodia has also aspirations to achieve the upper-middle-in- shifted dramatically since the mid-1990s. It come status by 2030. dropped from a high of 98 percent in 1994 to 55 percent in 2021, meaning that there are 2. However, the COVID-19 pandemic led to significantly fewer people younger than 15 an economic downturn, accompanied by years old or older than 64 years old vis-à-vis increases in poverty and inequality. In 2020, the working-age population of between 15 the Cambodian economy contracted by 3.1 and 64 years old.11 percent, which constituted the country’s worst economic performance since 1994.6 Cambodia’s population remains relatively The poverty rate was projected in 2020 to young: approximately 60 percent was under increase by up to 2.8 percent,7 with the unem- 25 in 2019.12 The female proportion of the ployment rate also rising to 0.6 percent in population, which increased to 53.1 percent 2021 after staying at 0.1 percent from 2017 in the wake of the Khmer Rouge rule, has been to 2019.8 The impact of the pandemic on declining to reach 51.2 percent in 2021.13 The the Gini coefficient measure of inequality in rural population, which increased dramatically Cambodia is unknown. from 71 percent in 1974 to 96 percent in 1975 during the Khmer Rouge rule, has also been 5 decreasing, though it remains significantly These INDCs outline Cambodia’s commitment above the majority — at 75 percent — in 2021.14 to addressing climate change within its own borders in addition to planned mitigation 4. Affected by floods and droughts on a seasonal and adaptation strategies in order to reduce basis, Cambodia is one of the more disas- the country’s vulnerability to the adverse ter-prone countries in Southeast Asia. impacts of climate change. Regarding climate Cambodia’s vulnerability to climate change change’s impact on health, Cambodia has is affected by its status as a post-civil war outlined heatwaves and higher tempera- and an underdeveloped country, which is tures as a main concern for human health. predominantly agrarian; nearly 80 percent of Adaptation and mitigation measures related to the population lives in rural areas. The country’s human health and healthcare system impacts weak adaptive capacity, poor infrastructure, focus on (a) improving surveillance and early and limited institutions further exacerbate its warning systems; (b) enhancing the resilience vulnerability to climate variability and change. of the health system to ensure health service delivery; (c) strengthening capacity building for The government recognizes that floods and the diagnosis, detection, control, prevention, droughts — the main climate-related hazards and treatment of vector-borne and water-borne affecting the country — are one of the main diseases, injuries, and food poisoning-related drivers of poverty. During the 20-year period illnesses; (d) conducting a water, sanitation, from 1987 to 2007, a succession of droughts and hygiene (WASH) vulnerability assessment and floods led to significant losses of lives and developing interventions accordingly and considerable economic losses. Approxi- at the community and facility levels, as well mately 80 percent of the country’s population as (e) enhancing institutional capacity to lives along the Mekong River, which is better incorporate climate-related risks and known to fluctuate significantly. Moreover, adaptation measure into the health sector’s rising sea levels pose a significant threat to strategic planning.18 marine coastal areas that already suffer from storm surges, high tides, beach erosion, and seawater intrusion.15 AIMS OF ASSESSMENT AND CONCEPTUAL FRAMEWORK 5. Cambodia is committed to tackling climate 6. The objective of this Climate and Health change within its own borders by putting Vulnerability Assessment (CHVA) is to assist strategies in place to mitigate net greenhouse decision-makers with planning effective gas (GHG) emissions and developing plans adaptation measures to deal with climate-re- to reduce the country’s vulnerability to lated health risks. Where available, these climate change. Cambodia signed the Paris measures are provided at the subnational Agreement of the United National Framework level to assist regional health planners. The Convention on Climate Change (UNFCCC) on recommendations of this CHVA are primarily April 22, 2016,16 which aims to limit the global aimed at the health sector and related sectors mean temperature increase to well below 2°C influencing health risks arising from climate compared with pre-industrial levels. Cambodia change, such as disaster risk management. submitted its intended nationally determined contributions (INDCs) on June 2, 2017,17 and submitted an update on December 31, 2020. 6 | Climate and Health Vulnerability Assessment: Djibouti 7. Adaptation priorities need to run alongside 9. The World Health Organization’s (WHO) fundamental and urgent action to mitigate operational framework for building climate-re- climate change. It is important to stress how silient health systems is adopted to analyze complex the climate challenge is and how the adaptive capacity to adequately deal hard it is to predict exactly how severe climate with current and future identified risks. exposures facing populations will become. Following this framework (Figure 1), the There are many factors that could slightly assessment is structured around the six health slow or significantly speed up rates of change, system strengthening (HSS) building blocks. including positive feedback effects, and, most These six categories serve as a structure for worrying of all, cascading climatological tipping assessing the country’s capacities and gaps — points. For this reason, mitigating existing now and into the future. The framework was GHG emissions, as well as developing and then used to consider the 10 components of implementing measures to protect human Cambodia’s health system climate resilience development from the changing climate, is for the development of the Recommenda- of paramount importance. tions section. 8. Investing in adaptation strategies to proactively address the effects of climate change on health outcomes is critical. This assessment is concerned with climate risks to health and health systems, the adaptive capacities that are in place to deal with these risks, and recommendations to meet identified gaps. The primary focus of this assessment is, therefore, on climate adaptation and resilience measures. However, as the Sixth Assessment Report (AR6)19 of the Intergov- ernmental Panel on Climate Change (IPCC) makes clear, “Global surface temperature will continue to increase until at least the mid-century under all emissions scenarios considered.” Mitigation is no longer a sufficient strategy, regardless of the pace at which governments and communities around the world act. Adaptation is now as critical a part of climate action as mitigation. This report, therefore, focuses on adaptation measures, but where possible, it also includes recom- mendations for reducing GHGs or facilitating the decoupling of emissions from progress toward human development goals. Introduction | 7 FIGURE 1. WHO’s Operational Framework for Building Climate-Resilient Health Systems. ATE RESILIENCE CLIM hip & Heal ders Workf th Lea vernance orce Go V uln pac ation t Fin alth & A Ca apt men He ate era ity & Leadership As g d ess Clim cin bil & Governance Health s ity, an Workforce Financing Preparedness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential C li o r m e h Re ima & I n f e a lt m s Medical ma d C l a lt h se te Products & h H ra Pro te a rc Technologies He - g Ma nt na ili e Env ge m ent o m a t e Res le f C li ir o n in a b D et m ental & S u st a gies ri m e o lo n ts Tech n re of H ct u e a lt h s tr u & Infra Source: WHO, 2015 10. This assessment follows a stepwise linear of Health (MOH); the Ministry of Environment approach. The first step characterizes the (MOE); as well as the Ministry of Agriculture, climatology in Cambodia by highlighting Forestry and Fisheries (MAFF). the observed and future climate exposures relevant to health. The second step examines 11. The assessment incorporates subnational the country’s climate-related health risks, considerations for health-related climate including identifying vulnerable populations action. For the purpose of this assessment, the most at risk. The final step assesses the 25 administrative departments of Cambodia, adaptive capacity of the health system by known as provinces, were considered: identifying gaps in managing current and future Banteay Meanchey, Battambang, Kampong climate-related health risks. Together, these Cham, Kampong Chhnang, Kampong Speu, steps inform a series of recommendations for Kampong Thom, Kampot, Kandal, Koh Kong, reducing climate-related health vulnerability Kratie, Mondulkiri, Phnom Penh, Preah Vihear, in Cambodia. The assessment was based on Prey Veng, Pursat, Ratanakiri, Siem Reap, a review of the published literature, national Preah Sihanouk, Stung Treng, Svay Rieng, statistics, and consultations with key counter- Takeo, Oddar Meanchey, Kep, Pailin, and parts in government — including the Ministry Tboung Khmum. 8 | Climate and Health Vulnerability Assessment: Djibouti FIGURE 2. Administrative Boundaries of Cambodia’s Provinces. Source: World Bank Cartography Unit Introduction | 9 SECTION I. CLIMATOLOGY 12. This section describes observed climatic changes and projected trends, high- lighting the priority climate-related hazards in relation to human health risks in Cambodia. Observed changes in temperature and precipitation are taken from the World Bank Group’s Climate Change Knowledge Portal (CCKP) for the 1901–2021 period. Climate data in the CCKP is derived from the Coupled Model Intercom- parison Project, Phase 6 (CMIP6); this is the foundational data used to present global climate change projections in the Sixth Assessment Report (AR6) of the Intergovernmental Panel on Climate Change (IPCC). CMIP6 uses shared socio- economic pathways (SSPs) — representations of possible societal development and policy scenarios — to determine the climate response. Essentially, the SSPs offer different plausible future societal development storylines and associated contrasting emission pathways, which outline how future emissions and land use changes would translate into responses in the climate system. This assessment explores observed climate conditions for the latest climatology (1991–2020), as well as projected climate conditions and changes under SSP3-7.020 for the near (2030s; 2020–2039) and medium terms (2050s; 2040–2059). CAMBODIA’S GEOGRAPHY 13. A country in Southeast Asia, Cambodia is bordered by Laos, Thailand, Vietnam, and the Gulf of Thailand. The Mekong River — a prominent geographical feature of the country — flows from Laos in the north to the Mekong Delta of Vietnam in the south and feeds the Tonle Sap Lake. The Tonle Sap, covering almost 10 percent of the nation’s surface area, is a vital natural resource for the country during the peak of the southwest monsoon season. The topography of Cambodia includes the low-lying central plains of the Mekong, which are surrounded by mountainous and highland regions.21 11 FIGURE 3. Elevation of Cambodia and Major Cities. Source: Natural Earth, ASTER GDEM Version 3 CLIMATE CONTEXTS: OBSERVED AND TEMPERATURE PROJECTED CLIMATOLOGY 15. Over the past half-century, across the national average, mean temperatures have increased by approximately 0.5°C. April has 14. Cambodia has a tropical humid climate, had the highest mean temperature (29.4°C), though there are some subtropical dry regions while January has had the lowest mean in the southwest.22 The wet, monsoon-driven temperature (24.3°C). As the country has a rainy season occurs from May to October, with homogenous topography, climate variations southwesterly winds ushering in clouds and at the subnational level are low: temperatures moisture that account for significant rainfall range from 26.1°C in Mondul Kiri and Ratanak (85 percent of the country’s annual rainfall) Kiri to 28.3°C in Banteay Meanchey. from the southwest monsoon. The dry season (November–April) is characterized by cooler 16. Under the SSP3-7.0 scenario, tempera- temperatures, particularly between November tures are projected to increase through the and January. The interannual variation in mid-century throughout the country. Mean climate is driven by the El Niño southern monthly temperatures will increase from 27.4°C oscillation (ENSO), which influences the nature in the historical reference period (1995–2014) of the monsoons in the region and generally to 28.6°C in the mid-term period. The level brings warmer and drier-than-average winter of increase in temperature will vary across conditions across Southeast Asia, while the the region. In the 2050s, median tempera- La Niña episodes bring cooler-than-average tures are projected to increase by 1.0°C in conditions.23 the southwest coastal region and by 1.2°C in the northern region. Median temperatures will, therefore, range from 29.7°C in Pusat to 32.6°C in Otdar Meanchey. 12 | Climate and Health Vulnerability Assessment: Djibouti FIGURE 4. Projected Average Monthly Temperature Anomalies in Cambodia for the 2030s and 2050s, Under the SSP3-7.0 Scenario. Source: World Bank’s CCKP 17. Extreme heat is projected to increase July. In the 2050s, the Pailin Province in the through the mid-century, with north and northwest is expected to experience the most northwestern regions at the highest risk. severe heat exposure impact, mainly in May. The annual number of hot days (Tmax > 35°C) will increase to 74.12 days by the 2030s and Daytime temperature increases will be to 91.29 days by the 2050s. Departments coupled with high nighttime temperatures, such as Otdar Meanchey and Preah Vihear whereby the minimum nighttime tempera- will experience the greatest number of hot tures exceed 20°C (known as tropical days (141.2 and 122.64, respectively). In the nights). Cambodia is already prone to tropical 2030s, the greatest heat impact would occur nights. By the 2030s, most of the country will from June through November, while the least experience at least 300 tropic nights a year; heat impact would occur in April and May. In by the 2050s, this figure will almost reach the the 2050s, however, a large increase in the whole year. heat index is projected from March through FIGURE 5. Projected Annual Number of Hot Days (Tmax > 35°C) in Cambodia for 2030s and 2050s, Under the SSP3-7.0 Scenario. Source: World Bank’s CCKP Climatology | 13 TABLE 1. Provinces Most Impacted by Extreme Heat: Annual Number of Hot days (Tmax > 35°C) and Tropical nights (Tmin > 20°C and > 26°C) in the 2030s and 2050s, Under SSP3-7.0. 2030s 2050s NO. DAYS NO. DAYS Hot Days ( >35 °C ) Oddar Meanchey 118.38 (70.49, 135.02) 141.2 (97.66, 172.13) Preah Vihear 101.33 (56.91, 122.1) 122.64 (77.51, 158.73) Siem Reap 93.37 (50.84,114.38) 114.76 (69.03, 152.62) Tropical Nights ( >20 °C ) Preah Sihanouk 364 (362, 362.25) 364.6 (362.3, 365.25) Kep 362.1 (357.05, 364.9) 363.5 (359.5, 365) Kampot 353.46 (353.46, 363.56) 362.14 (357.26, 364.2) Tropical Nights ( >26 °C ) Preah Sihanouk 185.75 (134.7, 212.05) 243.2 (203.05, 289.2) Pailin 127.25 (76.54, 174.15) 188.78 (133.92, 232.38) Koh Kong 107.06 (67.41, 154.67) 173.1 (128.9, 230.57) Source: World Bank’s CCKP PRECIPITATION receive approximately 2,000–2,600 mm of 18. Mean annual precipitation in Cambodia rainfall annually, with even higher quantities in has experienced a slight decline of 2.46 the mountainous areas in the Northeast.25 But mm since the 1960s (from 1961–1990 to Koh Kong has the greatest amount of rainfall 1990–2020). Although the trend is weak, at an annual average of 3,214 mm, while Siem the precipitation variability is linked to the Reap has the lowest amount (1,413 mm). An ENSO phenomenon: the years of strong El overall precipitation decrease during May has Niño are correlated with moderate and severe been experienced throughout the country, droughts.24 with declines reaching 58 mm in Koh Kong. In general, Cambodia experiences significant Nonetheless, precipitation increases are variability in its average annual rainfall at the projected for October, with average increases subnational level. Precipitation levels range of 23.2 mm across the country and maximum from 1,400 mm in the central lowlands to increases (43.46 mm) in Koh Kong by the 4,000 mm near the Cardamom mountains 2020–2039 period. The projected precipi- in the west and nearby coastal areas in the tation increase during October is expected southwest. The country’s eastern plains 14 | Climate and Health Vulnerability Assessment: Djibouti to rise to an average of 32.9 mm across the CLIMATE-RELATED HAZARDS country by 2040–2059. 20. Climate-related hazards linked to changes 19. Rainfall patterns are projected to show slight in baseline temperatures and precipitation variations under the SSP3-7.0 scenario; affect population health in Cambodia. however, there is likely to be greater Cambodia was ranked 55 out of 191 countries variability during the year, with a drier dry in the 2019 Inform Risk Index.26 The country season for the 2030s and 2050s. Increases faces high disaster risk levels and struggles in rainfall are projected for most of the wet with major climate-related hazards such as season (June–October), with decreases during flooding, landslides, extreme heat, sea-level the dry season (March and April). The regional rises, extreme weather events, wildfires, and dynamic will provide spatial heterogeneity in droughts (Figure 10). The overall impacts of future precipitation patterns. In the 2050s, such events will not merely be attributable increases in seasonal rainfall (June and to changing environmental conditions but August) are expected in the northern and also compounded by anthropogenic causes northeastern regions of the country. Annual including rapid deforestation, urbanization, average precipitation decreases are projected and inadequate housing. for the Pusat Province (to the west) and the Kampot Province (to the south coast). FIGURE 6. Number of People Affected by Key Natural Hazards, 1980–2020. Source: World Bank’s CCKP Climatology | 15 FLOODS FIGURE 7. Types of Flood Risks in Cambodia. 21. Cambodia is exposed to flood-related hazards. Floods occur frequently during the River Flood Risk monsoon seasons — the rainiest months from June to September. They are often triggered by heavy or sustained rainfall, increasing river volumes, and insufficient or blocked drainage infrastructure. Between 2000 and 2024, there were 20 major floods (as reported to the Inter- national Disaster Database Em-Dat), affecting more than 11 million people and resulting in USD1.2 billion in damages.27 In August 2022 alone, 16 out of 25 provinces in Cambodia were reported to have experienced flooding for the season28. Urban Flood Risk The impact of floods differs by setting. In the urban areas, Cambodia’s urban flood risk is categorized as “high” by the World Bank’s Global Facility for Disaster Reduction and Recovery (GFDRR): this means that potentially damaging and life-threatening urban floods are expected to occur at least once in the next 10 years.29 Floods in densely populated urban areas (such as Phnom Penh) are of particular concern, as they lead to costly infrastruc- ture damage, as well as the loss of life and livelihoods. In the case of the rural setting, Cambodia’s farming and fishing communities Costal Flood Risk rely on the annual flooding of the Mekong River Delta from August to November.30 Therefore, shifts in the flooding pattern due to climatic changes could impact livelihoods. Notably, flooding patterns increase risks for drowning and snake bite. 22. Cambodia’s precipitation may become more variable, exacerbating flood and landslide hazards. The average largest one-day precipitation is projected to reach nearly 100 mm during October in Kep (97.4 mm) and Kampot (95.3 mm) by 2020–2039 under the SSP3-7.0 scenario, which is an indicator Source: ThinkHazard 16 | Climate and Health Vulnerability Assessment: Djibouti of both a flood risk and a landslide risk. The In 2023, a major flood in the Pursat region five-day cumulative rainfall indicator is also damaged 2,785 houses, eight roads, and useful for identifying water-saturated areas, six sewers while triggering six landslides. thereby increasing the risks of flooding and landslides through the sustained loss of slope stability. The average largest five-day SEA-LEVEL RISES cumulative rainfall is projected to exceed 243 mm during September in Pailin by 2020–2039 24. While Cambodia has no extensive coastline, and 267 mm by 2040–2059. rising sea levels pose a risk to coastal communities. CCKP data shows sea-level anomalies exceeding 200 mm between LANDSLIDES 1993 and 2015, with maximum rises of 23. Landslides have resulted in the loss of lives 250 mm observed near the coast of Koh and damaged homes and other infrastruc- Kong.32 The Cambodian government’s 2013 ture (for example, transport, energy, and Climate Change Strategic Plan (CCSP)33 health) in Cambodia, and climate change anticipates projected sea-level rises exceeding will increase landslide risks. According to half a meter by 2090, which could inundate GFDRR, the highest landslide risks are in 25,000 hectares (ha) of land and force the provinces of Koh Kong and Pursat: this thousands to relocate. Sea-level rises could means those regions have “rainfall patterns, significantly threaten marine coastal areas terrain slope, geology, soil, land cover, and already experiencing storm surges, high (potentially) earthquakes that make localized tides, beach erosion, and seawater intrusion. landslides a frequent hazard phenomenon.”31 This may affect low-lying areas, including settlements, beach resorts, seaports, coastal fisheries, and mangrove forests. FIGURE 8. Rainfall-Triggered Landslides in Cambodia. Source: Natural Earth, ASTER GDEM Version 3, and GFDRR 2020 Climatology | 17 DROUGHTS EXTREME HEAT WEATHER EVENTS 25. Drought projections indicate future variable 26. Cambodia already experiences extreme precipitation values, further damaging temperatures, with an estimated national Cambodia’s food systems. The Standard average of 64 days per year when the Precipitation Evapotranspiration Index (SPEI) maximum temperature exceeds 35°C. Days shows slightly positive values in the future, with a heat index exceeding 35°C are projected suggesting a positive water balance (wetter to increase in all future climate scenarios. environments), particularly in the northwestern Thirumalai et al. (2017) suggested that climate region; these values are impacted by the change contributed to extreme temperatures high humidity of Cambodia and the projected by 29 percent across Southeast Asia in April increases in the variability of the rainfall. 2016, while ENSO contributed 49 percent.35 Additionally, the increased frequency and Nonetheless, Cambodia is impacted by intensity of heat waves have been observed droughts. The Svay Rieng Province is one recently. In 2015–2016, Cambodia experienced of the most drought-prone provinces in the the worst drought in 50 years, amplified by country: it has experienced economic losses an intense El Niño event in the region, during due to crop failure, health problems, and envi- which ambient temperatures soared to an ronmental damage. A 2019 drought in Tonle all-time high of 42.6°C.36 Higher temperatures Sap Lake damaged over 70,000 ha of rice and humidity values will result in increased fields and impacted the food supply. Overall, heat stress, which will regularly surpass safe between 2000 and 2024, there have been levels for humans and biodiversity. four major droughts that affected approxi- mately 4 million Cambodians.34 FIGURE 9. SPEI’s Projected Anomalies Under the SSP3-7.0 Scenario. Source: World Bank’s CCKP 18 | Climate and Health Vulnerability Assessment: Djibouti WILDFIRES CYCLONES AND TROPICAL STORMS 27. Many regions of Cambodia are considered at 28. Cyclones are an ongoing climate hazard high risk for wildfires; projected decreases in Cambodia; projected wind speeds and in rainfall levels and projected increases in rainfall increases may exacerbate risks for rainfall variability could exacerbate them. the population and infrastructure. Histor- Based on the Fire Weather Index (FWI), most ically, cyclones and tropical storms have regions in Cambodia beyond the southwest caused injuries and deaths, losses to farms are categorized as “ in very high danger,” and livestock, and damage to homes and while others are categorized as “ in extreme public infrastructure. According to the Global danger.” According to the National Aeronautics Facility for Disaster Reduction and Recovery and Space Agency’s (NASA) satellite data, 45 (GFDRR), cyclone risk is categorized as “high” high-confidence fire alerts were reported in across the country, except for the provinces of the forested area around the Tonle Sap Lake Preah Sihanouk, Kampong Speu, and Kampong between April 1 and July 1 of 2021, which Chhnang which are categorized as medium experienced decreased water levels. Forests risk (See Figure 11). A “high” risk indicates a in Cambodia have declined significantly 20 percent chance of potentially damaging in recent decades due to the widespread wind speeds over the next 10 years. Between practice of slash-and-burn-swidden agriculture 2000 and 2023, there has been a total of in Southeast Asia: small-scale subsistence eight storms reported to the International farmers light fires in forested areas, thus Disaster Database (Em-Dat), resulting in almost increasing the risk of wildfires. On February 1 million people affected and USD100 million 18, 2020, a NASA satellite captured an image of in damages.37 hundreds of fires burning across large swaths of land in both Myanmar and Cambodia. FIGURE 10. FWI for Wildfires in Cambodia. Fire Weather Index (FWI) Scale Very low danger: <5.2 Low danger: 5.2-11.2 Moderate danger: 11.2 -21.3 High danger: 21.3-38.0 Very high danger: 38.0-50 Extreme danger: >50 Source: NASA - Global Fire Weather Database (GFWED) Climatology | 19 More specifically, Ketsana Typhoon in 2009, 29. Storm events started to increase in magnitude and Haiyan Typhoon in 2013 impacted and frequency during the late 2000s broadly lives and livelihoods in Cambodia. Notably, through Southeast Asia, which has seen Ketsana Typhoon resulted in USD 132 million cyclone activity move eastward and away in economic damages, and around 1.4 percent from the Mekong Basin. Cambodia’s coastal of Cambodia’s population being affected.38 zones are known to be exposed to cyclones In April 2022, the National Committee for and tsunami-induced storm surges, albeit at Disaster Management (NCDM) reported lower levels than other Southeast Asian nations. home losses and damage following an In Cambodia, rising temperatures, particularly unprecedented rainfall event during the dry in the case of sea surfaces with temperature season that triggered a 0.5-meter (m) rise in thresholds of 28.2°C, are associated with the the Mekong River water level. In June 2022, rising frequency of superstorms, increased additional storms triggered floods, causing cyclone intensity, and thus, damage.39 heavy damage to farms and homes in the Sre Russey Commune of the Thala Parivat District. FIGURE 11. Cyclone Risk in Cambodia (Source: ThinkHazard, GFDRR). Source: Think Hazard - GFDRR 20 | Climate and Health Vulnerability Assessment: Djibouti KEY MESSAGES: Projected Climate → Temperature: Median temperatures may increase by 0.98–1.23°C by the 2050s (SSP3-7.0), with high daytime temperatures accompanied by tropical nights. → Precipitation: Rainfall patterns are expected to increase in variability, with a projected decrease (median) of 40 mm in the 2050s (SSP3-7.0), and characterized by high levels of uncertainty. Climate Hazards → Floods: River flood risk is categorized as “high” in most of the country outside of the southwestern coastal region (with potentially damaging and life-threatening events anticipated at least once over the next 10 years). Urban flood risk — categorized as “high” in 75 percent of the provinces — is also impacted by project planning and construction methods. Both are expected to increase in the future with projections of more frequent heavy-rainfall days. → Landslides: Rainfall-triggered landslide risk, which is categorized as “very high” in the south- western coastal region, is expected to increase in the future, with projections of more variable rainfall that can impact slope and bedrock stability. → Droughts: Projected Standard Precipitation Evapotranspiration Index (SPEI) anomalies for 2050s are highest in the northwest, indicating that the region may become wetter (including evapotrans- piration) and be at less risk of droughts. → Wildfires: Wildfire hazard — as measured by the Fire Weather Index (FWI) — is “high” across most of the country outside of the southwest coastal region. This is expected to increase in the future, with rising temperatures and more variable rainfall projected by climate models. → Increasing Temperatures: Cambodia already has a high number of high heat index days (> 35oC) days per year based on a global comparison. This number is projected to increase by the 2050s, with the number of tropical nights (whereby minimum nighttime temperatures stay > 20oC) projected to be near the maximum possible from March to October, while slight increases are projected for the remaining months by the 2050s. This combination may make it more difficult for the human body to cope with increasing temperatures. → Extreme Weather Events: The average cyclone wind speed and rainfall are expected to increase in the future. Cyclone risk is categorized as “high” (with the likelihood of potentially damaging wind speeds happening in the next 10 years exceeding 20 percent) across the country. Exceptions to this trend are Preah Sihanouk, Kampong Speu, and Kampong Chhnang. Climatology | 21 SECTION II. CLIMATE-RELATED HEALTH RISKS 30. Cambodia has made significant advances in reducing its burden of infectious diseases since the 1990s, but it now faces an increasing burden of noncommu- nicable diseases (NCDs) that may be exacerbated by climate change. From 2000 to 2020, life expectancy has increased from 61 to 73 years in the female popula- tion and from 57 to 68 years in the male population.40,41 Nonetheless, Cambodia has been undergoing an epidemiological transition and faces the dual burdens of disease from NCDs and infectious diseases42 — both of which could be worsened by climate change. The four major NCDs in Cambodia — cardiovascular disease, diabetes, chronic respiratory disease, and cancer — are responsible for nearly one in four premature deaths (23 percent).43 31. Risks to health outcomes from climate are (d) heat-related morbidity and mortality (e) not evenly distributed in the population; air quality health risks; as well as (f) mental some groups are at greater risk of exposure health and well-being risks. Each category to climate-related health risks than others. is assessed in terms of current and future The factors affecting a population’s exposure risks, with considerations of both national and to climate-related health risks are often similar subnational peculiarities where possible. It is to the factors affecting health disparities more important to note that these risk categories broadly. Climate change may exacerbate represent only the most pressing health risks existing health inequalities, especially among to the population in Cambodia. Other important people living in poverty, rural areas, and climate-related health risks include but are informal urban settlements. Demographics not limited to direct injuries and mortality that may be more affected include women associated with natural hazard events. and young children, the elderly, and those living with pre-existing conditions and disabil- ities. Investment in adaptation and mitigation NUTRITION, FOOD ACCESS, measures must carefully consider groups who AND FOOD SAFETY RISKS would directly benefit from, or be disadvan- taged by, adopted measures. 33. Weather and climate are the foundational drivers of healthy and sustainable diets. A key 32. This CHVA for Cambodia assesses six determinant of food availability is agricultural climate-related health risk categories. These productivity, which is affected by weather include (a) nutrition, food access, and food and climate. Moreover, the mechanisms by safety risks; (b) vector-borne disease (VBD) which climate change affects nutrition via risks; (c) waterborne disease (WBD) risks; the food system are profound. They include 23 the acute and chronic effects on agricultural 34. Stunting and undernutrition are major production, storage, processing, distribution, climate-sensitive concerns in Cambodia. and consumption. Nutritionally secure and There are significant regional variabilities stable diets not only depend on agricultural in levels of nutritional deficiencies, as seen production but also the complex interactions in the figure below. World Vision reported of market demand, economic situations, significant differences in stunting rates in legislation, food waste, nutrient losses, food 2019 — 34 percent of children in rural areas safety, and food access. Climate variability (as high as 44 percent in Preah Vihear and is already contributing to increases in global Stung Treng) compared with 24 percent in hunger and malnutrition. urban areas (as low as 18 percent in Phnom Penh). At the same time, the 2021–2022 While a comprehensive analysis of climate Cambodia Demographic and Health Survey change’s impact on the food system is (DHS) showed lower overall stunting rates at beyond the scope of this assessment, this 22 percent — a 10-point drop from 2014.45 On CHVA examines climate and nutrition linkages the other hand, wasting rates have remained through a food access lens in Cambodia, relatively stagnant.46 particularly in relation to the weather and climate impacts on agricultural productivity. In Cambodia, nutrition services to people living In Cambodia, 77 percent of the population in poverty and other vulnerable populations are inhabits rural areas that constitute approxi- a concern. Nutrition risks can be compounded mately 98 percent of the country; about 80 by specific health conditions: for example, percent of the rural population depends on there is a need to provide proper nutrition for subsistence farming.44 patients with NCDs (for example, diabetes) and FIGURE 12. Stunting Prevalence by Region. Source: Reported by the National Institute of Statistics in 2015 and Published by the World Food Programme Summary Report in 2017 24 | Climate and Health Vulnerability Assessment: Djibouti sufficient maternal and child nutrition. Recently, more frequent flooding around the Tonle Sap a 2021 World Food Programme report found area and the floodplains around the Mekong that the COVID-19 pandemic negatively could affect crop yields. Agricultural losses affected the statistics above in children under are already amounting to approximately five — a population highly vulnerable to the USD100–170 million annually.48 Overall food nutrition risks of climate change.47 production is expected to decrease, resulting in lower per capita food consumption (approx- 35. Gaps in food access and poor nutritional imately 150 kilocalories [kcal] less due to outcomes in Cambodia can be exacerbated climate change) and approximately 500,000 by shifting climate baselines and shocks (for additional people at risk of hunger by the example, climate-related hazards such as 2050s (see table below). droughts). Projected warmer temperatures, precipitation changes and water deficits, along Besides rice, fish is also essential to the with the increasing frequency and intensity of Cambodian diet, constituting around 80 climate-related hazards, are likely to interrupt percent of animal protein being consumed. food production and increase nutritional Additionally, the fishing industry is critical to deficiencies, with important geographical the country’s gross domestic product (GDP) variations. and the household’s annual income.49 The effect of climate change is likely to threaten Notably, with most of the population the fisheries sector — in terms of produc- dependent on subsistence farming, especially tivity, distribution, species composition, and rain-fed crops such as rice — a staple food in habitats, thereby requiring changes in how the country, climate shocks can exacerbate fisheries and aquaculture operations are risks for food security and nutrition. For managed. Projected increases in ocean acid- example, between 2004 and 2005, the ification and sea temperatures are likely to country experienced prolonged droughts negatively impact marine life migration and, that resulted in 30 percent of the agricultural consequently, marine food production off land being affected and a 14 percent decrease the coast of Cambodia, similar to anticipated in rice yields. Moreover, it is expected that impacts across the broader Asia-Pacific region. TABLE 2. Food Production, Per Capita Food Consumption, and Hunger Attributable to Climate Change (CC). WITHOUT CC WITH CC 2010 2030 2050 2030 2050 Aggregate food production 1.000 1.176 1.302 1.102 1.155 (2010 index = 1.00) Per capita food consumption 2,348 2,515 2,614 2,463 2,508 (kcal per capita per day) Hunger 2.4 1.9 1.5 2.2 2 (millions of people at risk) Source: IFRPI, 2022.50 Climate-Related Health Risks | 25 36. The impacts of climate change on algal The National Center for Parasitology, blooms and eutrophication pose ongoing Entomology and Malaria Control (CNM) health risks to the population of Cambodia by developed a mobile application that enables increasing the risks of food contamination. healthcare workers to report malaria cases at As temperatures increase, algal blooms can the grassroots level.55 It has also been training flourish in coastal waters and inland freshwater community health center malaria workers to sources, which in turn contaminate shellfish do diagnostic tests and provide anti-malarial and fish. These algal blooms formed by dinofla- medication (particularly targeting adult men, gellates can result in paralytic and neurotoxic who constituted 81 percent of all malaria cases shellfish poisoning, as well as ciguatera fish in 2020).56 As a result, heavily affected areas poisoning due to Gambierdiscus toxicus. The have experienced progress (including the resulting health impacts can include nausea, Greater Mekong subregion, which reported vomiting, and other neurologic symptoms. Addi- a 31 percent drop in annual cases in 2021).57 tionally, eutrophication — a process whereby Cambodia also moved forward with its pledge a body of water becomes more enriched by to eliminate the dangerous Plasmodium minerals and nutrients, including nitrogen and falciparum malaria parasite from 2025 to phosphorus — can damage fragile underwater 2023.58 ecosystems and negatively impact surrounding communities. 38. Weather and climate patterns are critical drivers of the spatiotemporal suitability During a February 2023 World Bank mission to of vector distribution and transmission Cambodia, the Food and Drug Departmental dynamics. On large scales, changes in precip- representatives from the Ministry of Health itation and temperature can either cause the (MOH) raised the concern of food safety.51 expansion or contraction of vector ranges, They anticipated increases in contamina- both in terms of geography and months of tion associated with projected temperature the year during which there is an optimal increases.52 temperature for vector reproduction. For example, a study shows that between 1998 VECTOR-BORNE DISEASES (VBDS) and 2012, the transmission of dengue occurred 37. Malaria, dengue, Zika, chikungunya, and between May and October — the wet season. Japanese encephalitis are among the That same study showed a significant relation- climate-sensitive VBDs circulating in ship between the average temperature and Cambodia. While there has been significant dengue across Banteay Meanchey, Kampong progress in reducing malaria, with cases Thom, and Siem Reap. Essentially, a 1°C declining by over 90 percent from 2010–2020, increase in the average mean temperature challenges remain for the “last mile” of resulted in an increase of dengue cases by malaria elimination.53 They include artemisinin 38.6 percent, 39.1 percent, and 19.9 percent, resistance and logistical difficulties in reaching respectively. Further research is required remote regions.54 to estimate the changes in vector suitability and reproduction at a more granular level in Cambodia. 26 | Climate and Health Vulnerability Assessment: Djibouti WATERBORNE DISEASES (WBDS) 40. Temperature increases affect the risk of 39. Climate-related hazards, such as floods diarrheal diseases. A global study found and landslides, can reduce access to safe that an additional 1°C increase in projected water, sanitation, and hygiene (WASH) mean average temperatures would result in services, which can, in turn, increase the a 7 percent increase in all-cause diarrhea.60 incidences of waterborne and water-related Another study conducted in Cambodia found diseases. Current drivers of WBDs (including that floods were significantly associated the sources, quality, and quantity of drinking with increased diarrhea in two provinces water, sanitation and waste management (Kampot and Pursat).61 However, a possible facilities, and hygiene practices) can be protective effect from improved infrastruc- negatively affected by climate-related factors, ture, such as toilets and piped water, was particularly floods and landslides. Increased found.62 Similarly, there have been observed precipitation, floods, and landslide events can increases in diarrheal diseases since 2001 increase disease transmission in areas with in two of the worst flood-affected provinces limited access to safely managed drinking (Prey Veang and Kampong Cham). After the water and sanitation services. 2009 typhoon, the 2011 floods, and the 2013 floods, diarrheal disease cases were recorded A United Nations Children’s Fund (UNICEF) in affected provinces across the country. In report — using the 2021 Joint Monitoring particular, during the 2011 floods, diarrheal Programme (JMP) data — estimates that nearly diseases increased to epidemic levels in a third (31.2 percent) of the country’s population three provinces (Banteay Meanchey, Oddar was not using at least basic sanitation services Meanchey, and Kampong Thom): as many and that over a quarter (28.8 percent) of the as 22 percent of the children had diarrhea country’s population was not using at least following exposure, with those living in poor improved water sources in 2020.59 While households with untreated drinking water Cambodia has made significant progress in and unimproved sanitation facilities being decreasing the under-five mortality rates for at the highest risk. diarrheal disease since 2000, preventable deaths still occur. Additionally, multi-drug-re- sistant typhoid prevalence has increased dramatically since 1992. Although there has been progress in improving WASH coverage over the last decade, many areas still face notable obstacles, especially those susceptible to annual floods and droughts. This includes provinces within the Tonle Sap basins and upland regions regularly impacted by climatic disasters, such as floods and droughts. They are considered areas that present complexities for ensuring WASH, particularly in a challenging context. Climate-Related Health Risks | 27 FIGURE 13. Summary of the Nature of Association Between Monthly Minimum Temperatures and Monthly Cases of Diarrhea. Source: McIver et al. 2016 HEAT-RELATED MORBIDITY AND MORTALITY Longer-term mental health risks are also an important effect to consider. 41. The health risks of heat are wide-ranging: they include effects on mortality, heat-re- In addition to the impacts on individuals, the lated injuries, mental health, and well-being. whole-of-population exposure that occurs with Several factors influence mortality and an extreme heat event can lead to significant morbidity in relation to extreme heat events: increases in hospitalizations, thus imposing a the magnitude of their impacts are related to strain on health systems.64 their timing, duration, and intensity, an indi- vidual’s level of acclimatization (or adaptive 42. Increases in average seasonal temperatures, response to a hot environment), the built along with increases in the frequency and environment (for example, the urban heat intensity of heat wave events, are projected island effect), the adaptive capacity of the to increase health risks. Revisiting Table 1 affected populations, and the resilience of in the section on climatology shows Oddar infrastructure and institutions, among others.63 Meanchey, Preah Vihear, and Siem Reap as the provinces projected to experience the Health effects include the direct effect of highest number of very hot days (> 35°C), while heat stress, heat rash, cramps, exhaustion, Sihanouk, Pailin, and Koh Kong are expected and dehydration, as well as the acute exac- to experience the highest number of tropical erbation of pre-existing conditions including nights (> 26°C). Using provincial population respiratory and cardiovascular diseases. projections from MOH for the latest year 28 | Climate and Health Vulnerability Assessment: Djibouti available (2023), this may potentially expose to employ over a third (35 percent) of the over 2 million people to extreme heat, with Cambodian population.67 The combination of implications for the health of those populations, low average income levels, high dependence particularly vulnerable groups such as children on industries such as agriculture, and high under five years old, people over 65 years burdens of NCDs (including diabetes and old, pregnant women, and individuals living hypertension) contributes to elevated heat with heat-sensitive chronic health conditions. health impacts. A UNICEF report found that 2.2 million children AIR POLLUTION RISKS or over a third (37.1 percent) of Cambodia’s total 44. Ambient air pollution (AAP) and household child population are exposed to high heatwave air pollution (HAP) pose a risk to the health frequency.65 Even if the world were to keep of people in Cambodia, although the levels warming at 1.7°C or lower, it would still mean of exposure are relatively mild compared that 100 percent of Cambodian children will be with other highly urbanized countries in the exposed to more than 4.5 heatwaves a year, region. Exposure to urban air pollution and with 55.7 percent experiencing extremely high smoke from indoor cooking, wildfires, and temperatures (whereby more than 83 days a dust storms can affect health and contribute year exceed 35°C). If warming rises to 2.4°C, to the development of severe chronic health the proportion experiencing extreme high conditions. This occurs when individuals inhale temperatures will exceed 87.2 percent. fine particulate matter 2.5 micrometers or While there has been limited data on the smaller (PM2.5) and other toxins that can enter baseline level of heat-related mortality in the deeper sections of the lungs and blood Cambodia, a World Health Organization (WHO) stream. People who are particularly vulnerable report estimated four heat-related deaths per to particulate air pollutants include those 100,000 people each year from 1961–1990. with asthma, chronic obstructive pulmonary The report goes on to predict a significant diseases (COPDs), children, and those with increase to over 25 heat-related deaths per close exposure to the sources of air pollution 100,000 people each year by the 2050s, using such as women when cooking with biomass a high-emissions scenario, with the figure and firefighters addressing wildfires. rising to 56 by the 2080s. Without adaptation, The age-standardized mortality rate attributed heat-related deaths in the broader Southeast to ambient and household air pollution in Asia region are projected to increase by 295 Cambodia was 149.8 deaths per 100,000 in percent and 691 percent by the 2030s and 2016.68 As with many other countries in the the 2050s, respectively.66 region, 100 percent of the population has 43. Additionally, agricultural workers’ exposure been exposed to PM2.5 air pollution levels to heat is a growing concern because exceeding the WHO guideline values since physical work capacity can decline when this indicator has been tracked (1990–2017), high temperatures and humidity exist for with the average being four times the guidance several months each year. Occupational heat values.69 risks are of particular concern to workers in On the whole, urban populations are often sectors such as agriculture, which is estimated exposed to higher levels of AAP exposure Climate-Related Health Risks | 29 than their rural counterparts.70 Based on its shown that poor air quality is significantly average Air Quality Index (AQI) value of 67 associated with the risk of autoimmune in 2021, urban air pollution in Phnom Penh diseases, such as connective tissue disorder, was considered “moderate.” In contrast, rural inflammatory bowel disease, and rheumatoid households are exposed to higher levels of arthritis.74,75 HAP due to limited access to clean fuels and technologies for cooking than their urban counterparts;71 an estimated 25 percent of the MENTAL HEALTH AND WELL-BEING RISKS rural population has access to such technolo- 46. Cambodia is experiencing a rise in mental gies compared with 70 percent of the urban health challenges following the stressors of population.72 the COVID-19 pandemic. Climate change-re- lated events can also worsen mental health 45. Climate change exacerbates air pollution through their direct and indirect impacts risks to human health. Studies have found over the short and long terms. Epidemio- that climate change is expected to increase logical studies show high rates of anxiety, global exposure to environmental health risk depression, and post-traumatic stress disorder factors, including air pollution.73 In urban areas, (PTSD) in Cambodia.76 The suicide mortality increased temperatures can result in “heat rate was estimated to be 4.9 per 100,000 island” effects, which are characterized by people in 2019.77 More recently, the COVID-19 an increased risk of smog formation due to pandemic has worsened the mental health of the stagnation of air containing increased Cambodians, especially among youth: UNICEF levels of ozone and particulate matter, thus found that 16 percent of adolescents felt more impacting health acutely as well as chronically anxious or depressed, while 58 percent of by damaging the cardiovascular and respiratory secondary school students reported expe- systems. riencing at least one mental health issue. Ambient air quality is also impacted by smoke Acute climate hazards (such as floods or from wildfires, which typically occur during the cyclones) can precipitate a psychopathological drier months, and the projected increases in pattern similar to experiencing traumatic stress temperatures and the risk of wildfires could in the short term. The National Climate Change lead to a deterioration in air quality, especially Action Plan for Public Health 2019–2023 when combined with high wind speeds and refers to a study in the Kampong Cham prolonged droughts. Droughts can also Province, which found that the most frequently increase the frequency, intensity, geographic experienced traumatic events — a lack of proximity, and duration of the wildfire season food and water, access to medical care, and in Cambodia, thus worsening wildfire-induced access to shelter — can all be exacerbated by air pollution. climate change. There is particular concern for younger generations, as exposure to extreme Additionally, increasing temperatures and or prolonged weather-related impacts may atmospheric carbon dioxide can extend the result in delayed mental impacts, such as the allergy season due to its impact on plant symptoms of post-traumatic stress disorder phonologies. While this is not well-documented (PTSD) and other psychological impacts in in Cambodia, recent research elsewhere has the future. 30 | Climate and Health Vulnerability Assessment: Djibouti 47. Community support helps protect subsistence farmers from increased anxiety and stress levels related to climate change’s impact on rural communities, such as effects on water access. In this sense, climate change impacts on mental health and well-being are mediated by social and contextual factors, including poverty conditions, water insecurity, sudden loss of property, personal or family diseases, and illness. Households that experience cumulative shocks are less able to develop coping mechanisms that are built on structural and social support, thus worsening their well-being and the possibil- ities of improving their livelihoods.78, 79 48. It is challenging to project mental health outcomes related to climate change in Cambodia, but associations between mental health and climate change have been found in other contexts. In Cambodia, there is a need for improved surveillance and diagnostics, as well as specialist training and services to meet the mental health and well-being needs of the population. Projections for the impact of climate change on mental health would need to consider the vulnerability of livelihoods, communities’ resiliency, and individual coping mechanisms. Research in other countries80 have projected levels of heat-related excess mortality for mental disorders (0.7 percent) and an increase in suicide rates (3.1 percent) for a 1oC increase in the monthly average temperature.81 Climate-Related Health Risks | 31 SECTION III. ADAPTIVE CAPACITY OF THE HEALTH SYSTEM HEALTH SYSTEM OVERVIEW 49. Cambodia has made significant improvements in health coverage; however, gaps between policy and implementation remain, especially at the subnational level. The public health system in Cambodia is decentralized, with commune-level health facilities being transitioned under the subnational government rather than the central Ministry of Health (MOH). Additionally, there is significant use of private services and services by non-governmental organizations (NGOs) in addition to the public system. 50. Policies and strategy planning documents systems, including healthcare facilities and highlight the pivotal role of collaboration healthcare staff. This is especially important among stakeholders and actors across sectors in settings that need additional health system for increasing access to health services and strengthening (HSS), where there might be the quality of delivery. Although there has limited resources and capacity. been an expansion of health services around the country and the adoption of bottom-up 52. The extent to which the health system in programs, there is room for significantly Cambodia is prepared for climate change improvements in the quality of health services. and whether it has the capacity to manage Efforts in building cross-sectoral partnerships hazard exposure and susceptibility will have been cited as essential in the main determine its resilience in the coming policies and guidelines of the health sector. decades. In this assessment, Cambodia’s However, coordination gaps remain when it adaptive capacity82 to prevent and manage comes to implementation, particularly at the climate-related health risks is examined intersection of climate and health. according to the World Health Organization’s (WHO) six health system building blocks, as 51. The emergence of the COVID-19 pandemic shown in the figure below (see also the annex has brought with it a focus on health and for the Adaptive Capacity Rapid Assessment health systems, specifically the capacity and a summarized Adaptive Capacity and to manage emerging public health risks. Climate Change-Related Health Risks Gap Climate change, as with COVID-19, has the Analysis, which inform this section). potential to disrupt and overwhelm health 33 It should be noted that several factors outside social conditions. Promotion of equity is the scope of the health sector can drive also important as a cross-cutting theme for reductions in adaptive capacity to manage the enhancing adaptive capacity and resilience to health risks of climate change in Cambodia’s the health risks of climate change. Adaptive institutions and people. They include the capacity is likely to be greater when access country’s economic challenges, changing to resources within a community, nation, or demographic patterns, and slowly improving the world is equitably distributed. FIGURE 14. WHO’s Climate-Resilient Health System Building Blocks. Leadership & Governance Health Workforce Financing Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential Medical Products & Technologies Source: WHO, 2015 LEADERSHIP AND GOVERNANCE the National Strategic Plan on Disaster Risk Management for Health (2020–2024). The 53. The government of Cambodia’s response to National Council for Sustainable Development climate change includes a range of priorities (NCSD) ensures that the CCCSP is incorporated that cover the health sector. However, the into the development planning of Cambodia development of subnational-level policies is and monitors its progress while liaising with varied, as well as the level of implementa- the United Nations Framework Convention tion. Key policy frameworks that relate to on Climate Change (UNFCCC). climate and health include the Cambodia Climate Change Strategic Plan (CCCSP, Cambodia has shown leadership in climate 2014–2023), the Health Strategic Plan (2016– policies through its Climate Public Expenditure 2020), the National Adaptation Plan (2017, and Institutional Review (CPEIR), Climate update in progress), the National Climate Change Financing Framework (CCFF), the Change Action Plan for Public Health, and 34 | Climate and Health Vulnerability Assessment: Djibouti Ministry of Economy and Finance (MEF)’s of climate change. This policy document Climate Economic Growth Impact Model focuses on three key objectives: (a) improve (CEGIM), and engagement across line the health care infrastructure and the capacity ministries for climate adaptation. For example, of health personnel to cope with vector-borne the Ministry of Health’s (MOH) Department and water-borne diseases in the context of of Preventative Medicine (DPM), which is climate change; (b) enhance emergency charged with leading climate change for the preparedness and response to cope with health sector, is given responsibility by the extreme weather and climate change-related Ministry of Environment’s (MOE) Department of disasters; and (c) improve the knowledge and Climate Change (DCC) for the Sectoral Climate research capacity on health impacts and Change Strategic Plan (SSCSP) and the Climate vulnerability to climate change. Likewise, in Change Action Plan (CCAP) on health. The terms of the strategic approach, three key MOH also submits budget needs for sectoral climate-related diseases — namely, vector- climate adaptation, while MEF requests line borne diseases (VBDs), waterborne diseases ministries including MOH to integrate climate (WBDs), and extreme weather-related impacts change into annual budgets and investments. — are prioritized. 54. Cambodia has made substantial efforts Nonetheless, no progress reports on the to incorporate health to a greater extent activities are outlined in the Action Plan. into its policies and strategies to address Information on the adoption and implemen- climate change. Health has been identified tation of these activities at the subnational in the policy landscape as a key sector for level is limited. Similarly, the development of furthering adaptation to climate change. In policies / programs for ensuring resilience at addition to having DPM serve as the focal the health system and the facility levels is also point for climate-related issues at MOH and minimal. MOE’s DCC asking MOH to take ownership of its own sector’s adaptation planning, coor- 56. At the subnational level, the development dination mechanisms have been put in place. and implementation of policies and plans They include the cross-sectoral Technical to address climate-related health risks Working Group for Climate Change and a One appear mixed. Cambodia’s Third National Health initiative jointly led by three ministries: Communication includes a subnational-level MOH, MOE, and the Ministry of Agriculture, climate vulnerability assessment. Strategic Forestry and Fisheries (MAFF).83 However, plans around climate and health could be although policymakers have demonstrated better integrated into local-level planning an awareness of the health impacts of climate initiatives. Regions that are highly vulnerable change, technical capacities among staff at to climate-related hazards, such as the south- the Phnom Penh headquarters, as well as western coast, require tailored programs among staff at subnational sites, are limited.84 and strategic planning in order to address the compounded effect of different climate 55. The National Climate Change Action Plan hazards and climate-related health risks (for for Public Health provides an overarching example, floods and WBDs). framework for advancing adaptation measures of the health sector in the face Adaptive Capacity of the Health System | 35 57. The World Bank’s Country Climate 59. In terms of access to health services, Development Report (CCDR) for Cambodia, outpatient consultations (both old and new which has been published, provides policy cases) totaled 64,127,629 cases between 2018 guidelines for increasing efforts in mitigation and 2022, averaging 12,825,526 cases per and adaptation strategies, including climate year. The majority of these cases (52,555,992) change impacts on health. The CCDR for were new cases, averaging 10,511,198 cases Cambodia takes an all-of-government per year. The ratio of new cases for outpatient perspective on climate change — high- consultations at public health facilities varies lighting just and green transitions as well substantially from one province to another as providing macroeconomic and selected — ranging from 0.12 cases to 0.84 cases per sectoral recommendations to support the person per year in 2022, while the average country in responding to climate change while countrywide ratio was 0.56 cases. protecting economic development. The CHVA has served as an input to the elaboration of 60. Despite improvements in health facilities at the CCDR for Cambodia.85 the subnational level and increased health staff deployment at the health center level, there have only been limited efforts to assess HEALTH SERVICE DELIVERY the climate resilience and adaptive capacity of health service delivery. Mapping the vulner- 58. There have been considerable investments ability of healthcare facilities is necessary to in the health system with the intention of ensure that communities and local authorities increasing both access to quality health are well-informed in formulating and imple- services and their utilization in order to menting appropriate actions. One important improve the quality of care. These investments initiative has been the mapping of the flood include but are not limited to the construc- risks posed to health facilities by a team at tion, rehabilitation, renovation, and expansion the World Bank Cambodia office. However, of health facilities; supply of medicines and with limited data availability, it has not yet health commodities; supply of medical been possible to map flood risks for other equipment; information and communication relevant health infrastructures, such as labo- technologies (ICT) networks; means of trans- ratories and diagnostic facilities or supply portation; production of health professionals; warehouses and storage units. competency and skill development; and other essential supporting services such as medical Additionally, there has been limited coordi- laboratories and blood bank services. For nation in planning by key stakeholders at example, from 2018 to 2022, the total number subnational levels (including MOH’s provincial of health centers increased from 1,205 in 2018 departments of health, health facilities, and to 1,288 in 2022, while the number of referral community organizations and representatives) hospitals, including 12 national hospitals, rose to address climate-related health risks and from 123 to 132, during the same period. The disaster risks. There are gaps in implementing number of occupancy beds at public hospitals vulnerability reduction measures and ensuring and health centers also grew by 2,937 beds preparedness to respond to climate-sensitive nationwide between 2018 and 2022. disease outbreaks and natural disasters. 36 | Climate and Health Vulnerability Assessment: Djibouti HEALTH WORKFORCE recruiting, attracting, and retraining the health workforce in rural and remote health facilities, 61. An increase in the size of the health workforce and ensuring that deployment is based on the has been central to improvements in gaps in the plans submitted at the national and coverage and access to health services. In subnational levels. This is crucial for ensuring order to prioritize the rebuilding of the health that the populations likely to be disproportion- workforce, MOH invested in Health Workforce ately affected by climate-related health risks Development Plans (HWDPs). They provide are able to access health services. guidance on staff levels and distribution, as well as pre-service and in-service training. 63. Efforts by WHO to build a strong local As a result of concerted and coordinated response to COVID-19 have proven successful efforts since the 1990s, the total number in increasing capacity for managing outbreaks of public health personnel increased from and emergency health responses at the local 20,954 in 2015 to 32,240 in 2022, indicating level. This experience has also covered the an average increase of around 1,612 (6.66 development of an incident management percent) health personnel per year between system that supports communities in 2015 and 2022. This has been accompanied responding to climate-related hazards such as by a rapidly growing private sector: clinics and floods.86 However, there is limited information pharmacies increased from 12,785 places and on the scope, progress, and implementation providers in 2018 to 16,181 in 2022. However, of these efforts across the country. most of the increases were in Phnom Penh and the larger provinces. 64. In terms of maternal and child health, midwives have been allocated to every 62. Cambodia’s Health Strategic Plan 3 from health center since the late 1990s, with the 2016–2020 outlines the importance of majority being primary midwives who have having appropriately skilled health staff received one year of training. As a result who are adequately motivated, proficiently of the high maternal mortality ratio (470 per trained, and equitably deployed. Building 100,000 live births), MOH began allocating on the achievements of previous HWDPs, secondary midwives with 3.5 years of training MOH’s HWDP 4 is an ongoing development to every health center throughout the country. plan that is driven by the vision of building a The allocation of secondary midwives at health health workforce for the future who will ensure centers increased from 25 percent in 2000 safe and healthy lives for all Cambodians and to over 80 percent in the last few years. enhance their well-being. 65. There are at least 19 public and private Strategies within the HWDP 4 involve preparing training institutions (seven public institu- for future needs such as climate-related health tions and 12 private institutions) currently risks. They include ensuring that planning in Cambodia.87 Legislation is in progress to aligns with health service and population regulate the quality of both public and private needs, developing skills and competencies medical education. Despite a large number of for the workforce to address pressing current graduating health professionals, the number and future needs, and building institutional recruited to civil service positions is still insuf- capacity for projecting future needs. Addition- ficient to meet expanding needs. Furthermore, ally, HWDP 4 focuses on the importance of Adaptive Capacity of the Health System | 37 the number of medical specialists is inadequate change. Additionally, there is a need to build in meeting current needs according to the the capacity of the health workforce with national guidelines on the complementary regard to climate and health, particularly at package of activities (CPA) for hospitals. the subnational level where less training is offered on such topics. This is needed to To improve staff performance, there have been improve system performance for coping with annual salary increases from the government climate change and disaster risks. and initiatives such as the midwifery incentive scheme. Staff allocation has improved as a result of enhanced management tools, HEALTH INFORMATION SYSTEMS planning, and oversight with appropriate 68. Although surveillance, reporting, and early indicators. However, further increases in health warning systems exist in Cambodia, there is personnel and improvements in equitable limited coordination among the platforms, allocation will be needed to bridge current and not all sources of data are shared with staffing gaps, especially at the district level and the appropriate stakeholders responding to in remote health facilities. Lower-level health climate-related health risks. For example, facilities are more likely to lack the appropriate MOH’s National Center for Parasitology, mix of staff with the necessary skills to meet Entomology and Malaria Control (CNM) has existing and new health demands. developed a mobile application for healthcare workers to collect community-level information The introduction of a comprehensive package on malaria cases across the country. However, of financial and non-financial incentives could access to the data is highly restricted and help with rural deployment and retention. not necessarily shared with key stakeholders Between 2018 and 2022, the deployment to enable them to act on emerging risks. of health personnel at referral hospitals and Furthermore, this mobile application platform health centers was prioritized for the capital has not yet been applied to collect data on and the provincial level. other climate-sensitive diseases and health 66. Within the public sector, nurses and midwives conditions. In the context of Cambodia, where together comprise 70 percent of the health the majority of health programs and services workforce, while general medical practi- are delivered by non-public entities, access tioners, specialists, dentists, and pharmacists to information across stakeholders is critical make up 21 percent. Women represented for evidence-based decision-making. 53 percent of the health workforce in 2022, Paying attention to climate-related variables with the majority being nurses and midwives. (such as temperature or precipitation) is also Females are still underrepresented in certain critical to improving and strengthening surveil- cadres of medical professions such as lance systems by focusing on prevention and specialists, general practitioners, and dentists. preparedness. For example, the surveillance 67. There has been limited coordination between of VBDs, such as dengue or malaria, can be healthcare professionals concerning the improved by focusing on monitoring changes response to the wide range of interrelated in precipitation patterns and vector control. health risks and disaster risks from climate 38 | Climate and Health Vulnerability Assessment: Djibouti At the same time, as early warning systems in at strengthening adaptation to climate-re- Cambodia are limited, communities lack the lated hazards at the community level and information needed to develop preparedness preparedness for them. mechanisms that can reduce their exposure or risk in the face of climate-related hazards. 71. NGOs are key stakeholders in the ecosystem of health information systems. For example, 69. Although the Third National Communica- UNICEF is in the process of developing a tion led by the MOE Department of Climate Child Climate Risk Index (CCRI). The CCRI Change includes a subnational Vulnera- includes two pillars: a) exposure to climate bility and Adaptation (V&A) assessment, and environmental shocks (including water it is not yet a dynamic assessment that is scarcity, floods, cyclones, heat, VBDs, air frequently updated. MAFF worked with the pollution, soil pollution, and water pollution); United Nations Development Programme and b) child vulnerability in social sectors (UNDP) to create a text-based warning (including health and nutrition, poverty and system to notify farmers of climate-related social protection, as well as water, sanitation risks, such as floods and droughts. However, and hygiene [WASH]). The aim is to integrate this platform is not yet linked with the health CCRI with national platforms, including MOE’s sector for it to be used, despite the relevance existing commune-level climate vulnerability of warnings on floods, landslides, droughts, index. CCRI does not currently predict future and potential food shortages to healthcare exposure and vulnerability. personnel for addressing corresponding health risks. Similarly, while the Ministry of Water Resources and Meteorology monitors other ESSENTIAL MEDICAL PRODUCTS climate hazards such as heat, wildfires, and AND TECHNOLOGIES extreme weather events, this information is not always disseminated to affected health 72. There is limited monitoring and evaluation facilities. Moreover, not all healthcare workers of expired and stock essential medicines. are trained on how to use meteorological The lack of data makes it challenging to information. assess and plan for adequate drug stocks and allocate resources to health facilities. 70. Risk communication is also a key area of the Nonetheless, the U.S. Agency for Interna- National Health Centre for Health Promotion, tional Development’s (USAID) Global Health which has been supported by the United Supply Chain Program-Procurement and Supply Nations Children’s Fund (UNICEF) in the Management (GHSC-PSM) has documented the country’s response to COVID-19. The National availability of high-quality health commodities Health Centre for Health Promotion also has for the prevention and treatment of human an Environmental Health area that is furthering immunodeficiency virus (HIV) / acquired immu- the climate change and health agenda. Notably, nodeficiency syndrome (AIDS) and malaria it conducted a vulnerability assessment in to help ensure uninterrupted availability.89 the Ratanakiri Province. 88 Nevertheless, there are no specific risk communication At the same time, there are still under-re- systems or channels in place that focus on sourced hospitals and healthcare facilities climate-sensitive diseases, which are aimed (including preventive, dispensaries, and critical care entities) that tend to be more ill-equipped. Adaptive Capacity of the Health System | 39 They are characterized by limited health tech- healthcare financing also includes voluntary nologies, stockouts of medicines and supplies, health insurance. Although the country’s and a lack of management of health system total health expenditure as a percentage of needs. Gaps in equipment and supplies at gross domestic product (GDP) is among the healthcare facilities (ranging from preventive highest for low- and middle-income countries and critical care providers to dispensaries) in the region, public health expenditure as can exacerbate the impact of climate-related a percentage of GDP is among the lowest.93 health risks. Reliable stockpiles of essential medicines and emergency supplies are 75. The government finances approximately needed to adequately prepare for extreme 20 percent of the health sector. Per weather events, particularly in more remote capita government expenditure has been rural health centers and peripheral health units. increasing over the past two decades from USD3.90 in 2000 to USD27.54 in 2019.94 Yet, 73. Laboratory capabilities in Cambodia government expenditure (as a percentage face several challenges including testing of current health expenditure) was low at services, the transport of specimens, quality approximately 24 percent in 2019. External management, and regulations. Further, poor / donor health expenditure (as a percentage supply chains result in the lack of basic needs of current health expenditure) also declined (for example, water and electricity), as well as from approximately 22 percent in 2014 to contribute to stock-outs of laboratory reagents, 6.5 percent in 2019.95 By comparison, OOP consumables, and equipment. Laboratory expenditure was extremely high in 2019, capacities and other health technologies in representing approximately 64 percent of Cambodia need further assessments to better the current health expenditure96 — higher determine their ability to manage current and than the WHO’s recommended threshold projected climate-sensitive diseases. This of 20 percent. OOP health expenditure by includes the extent to which the laboratory households as a proportion of household capabilities require fundamental strengthening budget was approximately 5 percent — one to ensure access to essential medicines, of the highest in Asia in 2017.97 testing, and equipment. Additionally, while flood risk mapping is in progress for health centers, it has not yet been extended to include POOLING diagnostic laboratories, storage facilities, and 76. Several health financing policies have been other supply chain infrastructure.90 implemented in the country to improve access to health services. They include community-based health insurance (1998); HEALTH FINANCING the development of a health equity fund (HEF) (donor-funded, 2000); and HEFs (govern- REVENUE GENERATION ment-funded, 2008) where public facilities provide free services using transfers from 74. Cambodia has three main sources of health the national budget.98 financing: the government’s general revenue (taxes), donor assistance, and out-of- 77. Risk pooling in Cambodia is insufficient. pocket (OOP) payments;91 there are no Only 17 percent of the population is covered taxes earmarked for health.92 Payments to by social / voluntary health insurance or 40 | Climate and Health Vulnerability Assessment: Djibouti government subsidies. Although Cambodia has health considerations. It includes a bene- seven community-based insurance schemes, fit-cost analysis showing that investing in they only cover 1 percent of the population.99 climate will have benefits that outweigh the As of 2017, there were plans to expand the costs when it comes to new malaria cases.104 coverage of the HEFs to include additional There is evidence that the health sector has vulnerable groups. Although these populations contributed to climate finance, including are more vulnerable to the negative impacts KHR53.3 billion on general health and KHR38 of climate change, there is limited evidence billion on climate-sensitive diseases between to suggest that populations in climate-vulner- 2009 and 2012.105 able areas are targeted by these programs. 81. To address climate change risks, Cambodia requires climate adaptation spending of STRATEGIC PURCHASING 3.3 percent of the GDP until 2050;106 this 78. The financing of healthcare provision in the will involve dedicated domestic sources. public sector comes from different sources However, given that Cambodia mainly depends — both government transfers and payments on external funds (86 percent of climate from consumers. These include user fees, expenditure is from external sources),107 fee-for-service payments from small communi- identifying alternative sources of revenue ty-based health insurance, performance-based will be critical to furthering climate adaptation payments, and payments from the HEFs.100 and mitigation activities in the health sector. HEF is a third-party payer mechanism that Such sources include the private sector, reimburses public facilities for health services non-governmental organizations (NGOs) and rendered to the poor.101 development partners, as well as global climate funds (that is, the Green Climate Fund [GCF) 79. National budget lines pay for the infra- and the Climate Investment Funds [CIF)]. In structure and the in-kind distribution of 2022, the World Bank approved a USD113 pharmaceuticals and commodities, while million project to improve access to health the benefits package from the HEF includes care for the most vulnerable, which supported the reimbursement for medical services, the second phase of the Health Equity and transportation, food, and funeral costs. Quality Improvement Project that ran from Currently, there appear to be limited consid- 2016 to 2022. erations of climate-sensitive diseases and other climate-related health risks. While the capacity to align climate finance with national budgets has been limited,108 there is evidence that the Climate Change Alliance FINANCING FOR CLIMATE supported a pilot to integrate climate finance 80. Cambodia has a Climate Change Financing in subnational plans in three districts between Framework102 passed in 2015 to assist 2011 and 2013.109 Furthermore, during a World with the mobilization and management of Bank mission to Cambodia on February 2023, climate finance.103 It identifies sources of DCC from MOE shared that MEF is currently climate finance and proposes the costing of a reviewing a proposal to incorporate climate climate change national response. Cambodia’s change into the national budget.110 Climate Change Financing Framework has Adaptive Capacity of the Health System | 41 TABLE 3: Gaps in Adaptive Capacity. GAPS IN ADAPTIVE CAPACITY • Limited integration of climate vulnerability assessments and tailored interventions into subnational- and local-level planning initiatives • Technical capacities among Ministry of Health (MOH) staff at national LEADERSHIP AND GOVERNANCE and subnational levels are lacking • Lack of policies focusing on furthering resilience at the health system s and health facility levels • Limited information on health infrastructure and health system capacity HEALTH SERVICE DELIVERY • Limited coordination mechanisms for different key stakeholders in health service provision at the subnational level, thus constraining the implementation of risk reduction measures and preparedness strategies • Lack of specialized health workforce to meet current needs as per national guidelines, as well as imbalance in distribution HEALTH WORKFORCE • Health workforce distribution does not account for climate-related health risks • Limited training opportunities at the subnational level to improve system performance in the face of climate change and disaster risks • Fragmentation of surveillance, reporting, and early warning systems limiting coordination between platforms and curtailing data-sharing HEALTH INFORMATION SYSTEMS among key stakeholders • Community-level mobile application for monitoring malaria cases across the country (developed by the National Center for Parasitolo- gy, Entomology and Malaria Control [CNM)) highly restricted and not shared with key stakeholders • Lack of data on essential medicines limiting the monitoring of facili- ESSENTIAL MEDICAL PRODUCTS ties to ensure the procurement and allocation of resources AND TECHNOLOGIES • Testing services, transport of specimens, and quality management and regulations limited in Cambodia, mainly due to poor supply chains, thus undermining the proper procurement of laboratory reagents, consumables, and equipment • Vulnerable populations — including the elderly, the poor, and children under five — not properly covered by risk-pooling mecha- nisms such as the health equity funds (HEFs); these mechanisms not targeting climate-vulnerable areas HEALTH FINANCING • Cambodia heavily reliant on external funds for climate financing, with 86 percent of climate expenditure coming from external sources • No budget line in the national budget for climate-related strategies and interventions 42 | Climate and Health Vulnerability Assessment: Djibouti SECTION IV. RECOMMENDATIONS 82. This section outlines a set of recommendations to enhance health system resil- ience and adaptation to climate change, including potential health interventions and strategies, which can be put in place. The recommended options are based on an assessment of both the magnitude of the current and projected climate-re- lated health risks, the existing gaps in the country’s adaptive capacity to manage and / or prevent these risks, and the feasibility to develop them in the short and medium terms. The discussion is organized using the World all relevant governmental policies as well as Health Organization’s (WHO) climate-resilient the Climate and Health Guidance Note of the health systems, as shown in the figure below. World Bank’s Health, Nutrition, and Population It draws from the consultations and reviews of (HNP). FIGURE 15. WHO’s Operational Framework for Climate-Resilient Health Systems. ATE RESILIENCE CLIM hip & Heal ders Workf th Lea vernance orce Go V uln pac ation t Fin alth & A Ca apt men He ate era ity & Leadership As g d ess Clim cin bil & Governance Health s ity, an Workforce Financing Preparedness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential C li o r m e h Re lima h & I n f a lt s Medical ma d se te Products & C a lt h He ra m Pro te a rc Technologies He - g Ma nt na ili e Env ge m ent o m a t e Res le f C li ir o n in a b D et m ental & S u st a gies ri m e o lo n ts Tech n re of H ct u e a lt h s tr u & Infra Source: WHO, 2015 43 HEALTH INFORMATION SYSTEMS facilities, and strengthening them against climate hazards. Such efforts can build on 83. Expand the community-level mobile current projects, such as the World Bank’s application developed by the National Center mapping of flood risks for health facilities. for Parasitology, Entomology and Malaria Control (CNM) to include other climate-sensi- 87. Develop building codes that include tive diseases, such as dengue and diarrhea. adaptation and mitigation standards for In order to better prevent outbreaks and health infrastructure and ensure their improve responses to them, data access enforcement. These building codes can on case numbers and potential outbreaks mobilize existing efforts by the Cambodia should be extended to key stakeholders. They Green Building Council, the Ministry of should include community-based organiza- Environment (MOE), and the Ministry of Land tions, development partners, and other actors Management, Urban Planning and Construc- within the Ministry of Health (MOH) dealing tion. with health information systems, early warning systems, and communicable diseases (CDs). HEALTH WORKFORCE HEALTH FINANCING 88. Develop tailored capacity-building modules for healthcare workers and health center 84. Incorporate a health sector climate adaptation administrators, which account for subnational line into the national budget. Increased differences in climate-related hazards and financing capacity should focus on improving health risks. A formal system of regular training risk-pooling mechanisms targeting climate-vul- is needed to ensure that human resources are nerable populations. adequately prepared for projected climate-re- lated health risks in the future. 85. Develop an investment roadmap outlining key priorities at the national and subnational levels in terms of health infrastructure and service delivery programs, notably for vector- LEADERSHIP AND GOVERNANCE borne diseases (VBDs), waterborne diseases 89. Integrate non-governmental organizations (WBDs), and extreme weather events. The (NGOs), research institutes, and private sector investment roadmap should outline the roles providers of health services into multi-stake- of public, private, and development sectors. holder coordination mechanisms, such as the Climate Change Technical Working Group (CCTWG). The structure could also provide HEALTH SERVICE DELIVERY members of the technical working group with more time to dedicate to the working 86. Conduct an infrastructure assessment to group and serve as focal points between line identify key facilities and areas that need ministries, as the participation of the Chair further investments to ensure resilience in and other core members is in addition to the face of climate-related hazards. There their full-time job responsibilities. should be a nationwide system for assessing the resilience of the health infrastructure, including laboratories and supply-chain 44 | Climate and Health Vulnerability Assessment: Djibouti 90. Strengthen coordination across the inter- national, national, and subnational levels to improve the management of flood risks, drought risks, and fisheries across the Mekong’s subbasins. Sea-level rises pose risks not only to Cambodia’s coastline but also to the southeastern provinces through Vietnam’s coastal inundation, as cyclones and tropical storm risks extend beyond national borders. It is important for countries to establish effective mechanisms to exchange and share information on coastal and river flood situations, as well as extreme weather events, in order to reduce morbidity, mortality, and infrastructure damage. Recommendations | 45 ANNEX ANNEX A.- ASSUMPTIONS OF FUTURE GLOBAL CLIMATE CHANGE Predicting the future climate of any country Looking to the future, 20-year time periods are requires several assumptions to be made about used as a consequence of the accelerating pace the direction of the future global climate. Climate of global climate change so as to be able to information was acquired from the World Bank analyze climate-related threats over a sufficiently Group’s Climate Change Knowledge Portal proximate timescale. (CCKP). Observed climate data for 1901–2020 was presented at a spatial resolution of 50 km 2030s: This is the 20-year period from 2020 to x 50 km. The model-based climate projection 2039, with 2030 as the chronological mid-point. It data was derived from the Coupled Model represents the immediate coming years requiring Intercomparison Project Phase 6 (CMIP6), with countries and their governments to respond with projections shown through five shared socio- the utmost urgency. economic pathways (SSPs). This assessment explores projected climate change under SSP3-7.0 2050s: This is a 20-year period from 2040 to for the short (2030s; 2020–2039) and medium 2059, with 2050 as the chronological mid-point. (2050s; 2040–2059) terms. The SSP3-7.0 is a It represents a medium-term period, still well high-greenhouse gas (GHG) emissions scenario within the lifetime of current populations whose in which countries are increasingly competitive countries and governments still have sufficient and emissions continue to climb, doubling from time to make profound changes in preparation the current levels by 2100. for expected threats. This assessment uses future time periods that can be compared with the baseline and for which assumptions or models can be used to predict changes in future climate-related disease burdens. The World Bank’s Climate and Health Vulner- ability Assessments (CHVAs) use two 20-year time periods: together, they cover the next four decades to show imminent climatic changes and medium-term climatic changes in a given country. The baseline period covers 30 years (1990–2020): this has conventionally been the length of time over which climatic conditions are measured to reduce noise from annual or other cyclical variations. 47 REFERENCES 1 World Bank, n.d. “GDP (current US $) – Cambodia,” https://data. 21 Alex Chapman, William Davies, and Ciaran Downey, 2021, Climate worldbank.org/indicator/NY.GDP.MKTP.CD?locations=KH. 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Climate Change 8: 723–9, doi: 10.1038/s41558-018-0222-x . 101 Virginia Wiseman, Augustine Asante, Por Ir, Supon Limwattananon, 82 Adaptive capacity is defined by the Intergovernmental Panel on Climate Bart Jacobs, Marco Liverani, Andrew Hayen, and Stephen Jan, 2017, Change (IPCC) in the Fifth Assessment Report (AR5) as “the ability of a “System-Wide Analysis of Health Financing Equity in Cambodia: A Study system to adjust to climate change, moderate potential damages, take Protocol,” BMJ Global Health 2 (1), https://gh.bmj.com/content/2/1/ advantage of opportunities, and cope with the consequences.” The e000153. related term, “resilience,” is the ability to prepare and plan for, absorb, 102 Royal Government of Cambodia. 2015. Climate Change Financing recover from, and more successfully adapt to adverse events. People Framework. https://lpr.adb.org/sites/default/files/resource/921/cambo- and communities with strong adaptive capacity have greater resilience. dia-climate-change-financing-framework.pdf.pdf This assessment makes use of the terms — “adaptation” and “adaptive capacity” — to encompass both “adaptive capacity” and “resilience.” 103 Sara Tchaparian, 2016, “Closing the Climate Finance Gap in Cambodia: Could Training be the Simple Answer,” United Nations Institute for 83 Cambodia MOE DCC Representatives, World Bank Mission Meeting on Training and Research (UNITAR), https://www.unitar.org/about/ February 1, 2023 in Phnom Penh. news-stories/stories/closing-climate-finance-gap-cambodia-could- 84 Cambodia MOE DCC Representatives, World Bank Mission Meeting on training-be-simple-answer. February 1, 2023 in Phnom Penh. 104 Royal Government of Cambodia. 2015. Climate Change Financing 85 Muthukumara Mani, Katherine Stapleton, Tao Wang, Sandra Baquie, Framework. https://lpr.adb.org/sites/default/files/resource/921/cambo- Erica Honeck, Hector Pollitt, Phearanich Hing, Shawn W. Tan, Ha Thu dia-climate-change-financing-framework.pdf.pdf Nguyen, and S. Vaideeswaran, 2023, Country Climate Development 105 Sara Tchaparian, 2016, “Closing the Climate Finance Gap in Cambodia: Report: Cambodia, Washington, DC: World Bank Group, https:// Could Training be the Simple Answer,” UNITAR, https://www.unitar.org/ openknowledge.worldbank.org/entities/publication/83b19e- about/news-stories/stories/closing-climate-finance-gap-cambodia- fc-96d1-4be4-8240-28e0e7f13c9b. could-training-be-simple-answer 86 WHO, 2022, “In Cambodia, WHO’s Preparedness Team Recognised 106 Royal Government of Cambodia. 2015. Climate Change Financing for Helping Build a Stronger Local Response,” October 7, 2022, https:// Framework. https://lpr.adb.org/sites/default/files/resource/921/cambo- www.who.int/westernpacific/news-room/feature-stories/item/in-cambo- dia-climate-change-financing-framework.pdf.pdf dia--who-s-preparedness-team-recognised-for-helping-build-a-stron- ger-local-response. 107 Ibid. 87 Cambodia National Health Congress, March 2023. 108 Sara Tchaparian, 2016, “Closing the Climate Finance Gap in Cambodia: Could Training be the Simple Answer,” United Nations Institute for 88 The National Centre for Health Promotion, n.d., “Environment Health Training and Research (UNITAR), https://www.unitar.org/about/ and Hygiene,” https://nchp.gov.kh/environmental-health. news-stories/stories/closing-climate-finance-gap-cambodia-could- 89 USAID, n.d., “Cambodia,” https://www.ghsupplychain.org/country-pro- training-be-simple-answer file/cambodia. 109 Ma Chan Sethea, n.d. “Climate Finance: The Cambodia Experience,” 90 World Bank Environment Team in Cambodia, World Bank Mission Presentation, https://unfccc.int/files/cooperation_support/financial_ Meeting on February 2, 2023 in Phnom Penh. mechanism/long-term_finance/application/pdf/climate_finance_-_the_ cambodian_experience.pdf. 91 Health Policy Project, 2016, “Health Financial Profile: Cambodia,” May 2016, https://www.healthpolicyproject.com/pubs/7887/Cambodia_HFP. 110 Cambodia MOE DCC Representatives, World Bank Mission Meeting on pdf. 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