Climate and Health Vulnerability Assessment THE REPUBLIC OF YEMEN © 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. The World Bank encourages the dissemination of its knowledge; thus this work may be reproduced, in whole or in part, for noncommercial purposes, as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Cover image: Hajjah, Yemen. February 14 of 2021. Climate and Health Vulnerability Assessment THE REPUBLIC OF YEMEN Contents List of Abbreviations vi Acknowledgments viii Introduction 1 SECTION I. Climate 4 Observed and Projected Climatology 5 Climate Hazards 9 SECTION II. Climate-Related Health Risks 14 Nutrition and Food Insecurity Risks 15 Waterborne Diseases (WBDs) 18 Vector-Borne Diseases (VBDs) 20 Heat-Related Morbidity and Mortality 25 Direct Exposure to Floods 28 Flood Risks for Health Infrastructure 29 SECTION III. Adaptive Capacity and Readiness 31 Leadership and Governance 32 Health Information Systems 33 Health Service Delivery 35 Health Financing 37 SECTION IV. Proposed Actions 40 Leadership and Governance 40 Health Information Systems 41 Health Service Delivery 41 Health Financing 42 Proposed Actions for Further Research 43 Annexes 44 Annex A. Methodology 44 Annex B. Population Exposed to Extreme Temperatures 47 Annex C. Districts with More than 30 Percent of Health Facilities at Risk of Flooding 49 References 51 iv | Climate and Health Vulnerability Assessment: The Republic of Yemen Tables Table 1. Population Exposed to the Daily Maximum Wet-Bulb Globe Temperature (WBGT) Index Above 35°C During a 1-in-20-Year Heat Wave, Aggregated by Governorate............................................ 47 Table 2. Districts with More than 30 Percent of Health Facilities at Projected Risk of At Least 15 cm Floodwater Depth During a 1-in-100-Year Flood Event (2050, SSP7-3.0)................................................. 49 Figures Figure 1. Administrative Boundaries of The Republic of Yemen’s Governorates. ...................................................2 Figure 2. Mean Annual Precipitation Levels for the Observed Period of 1991–2020 and the Projected Periods of 2020–2039 and 2040–2059.............................................................................................7 Figure 3. Mean Annual Temperatures for the Observed Period of 1990–2020 and the Projected Periods of 2020–2039 and 2040–2059. ...............................................................................................................................8 Figure 4. Projected Anomalies for the Number of Hot Days with Tmax > 35 °C for 2020–2039 and 2040–2059...................................................................................................................................................10 Figure 5. Projected Maximum Daily Temperature Anomalies for 2020–2039 and 2040–2059. .........................11 Figure 6. Multi-Model Averages of Historic (1970–1999) and Projected (2040–2069) Persons at Risk of Malaria Infection in Yemen Under SSP2-4.5 and SSP5-8.5 Climate-Change Scenarios.................................22 Figure 7. Modeled Historic (1970–1999) and Projected (2040–2069) Persons at Risk of Dengue Infection in Yemen Under SSP2-4.5 and SSP5-8.5 Climate-Change Scenarios..............................................24 Figure 8. Population Exposed to the WBGT Index Above 35°C During a 1-in-20-Year Heat Wave, Aggregated by District. ......................................................................................................................................27 Figure 9. Population Exposed to At Least 15 cm of Floodwater Depth During a 1-in-100-Year Event in 2050, Aggregated by District. ......................................................................................................................................29 Figure 10. Health Facilities at Projected Risk of At Least 15 cm of Floodwater Depth (100-Year Return Period, 2050)..........................................................................................................................30 Figure 11. Leadership and Governance Capacity Scores........................................................................................32 Figure 12. Health Information Systems Capacity Scores........................................................................................33 Figure 13. Health Service Delivery Capacity Scores................................................................................................35 Figure 14. Health Financing Capacity Scores..........................................................................................................37 Figure 15. Yemen Health System Capacity Scores..................................................................................................39 Contents | v List of Abbreviations CCKP Climate Change Knowledge Portal CHVA Climate Health Vulnerability Assessment CMIP Coupled Model Intercomparison Project DALY Disability-Adjusted Life Years DGM Statistical Dengue Model DHS Demographic and Health Survey eDEWS Electronic Disease Warning System FAO Food and Agriculture Organization GDP Gross Domestic Product GFF Global Financing Facility GHG Greenhouse Gas HIP Health Infrastructure Plan HNAP Health National Adaptation Plan IDP Internally Displaced Person IPCC Intergovernmental Panel on Climate Change ITCZ Intertropical Convergence Zone LCMI Lancet Countdown Malaria Indicator LMM Liverpool Malaria Model MENA Middle East and North Africa Mm Millimeters MoPHP Ministry of Public Health and Population NAPA National Adaptation Programme of Action NCCRC National Climate Change Research Centers NCDs Non-Communicable Diseases NDC Nationally Determined Contribution OSF Open Science Framework RSCZ Red Sea Convergence Zone SSP Shared Socioeconomic Pathway [Scenario] TNC Third National Communication to the UNFCCC UN United Nations UNDRR United Nations Office for Disaster Risk Reduction UNFCCC United Nations Framework Convention on Climate Change UNICEF United Nations International Children’s Emergency Fund UNOCHA United Nations Office for the Coordination of Humanitarian Affairs vi | Climate and Health Vulnerability Assessment: The Republic of Yemen UNOPS United Nations Office for Project Services USAID United States Agency for International Development VBD Vector-Borne Disease WaSH Water, Sanitation, and Hygiene WBD Waterborne Disease WBGT Wet Bulb Globe Temperature WHO World Health Organization WRM Water Resource Management YCIARN Yemen Climate Impacts and Adaptation Research Network List of Abbreviations | vii Acknowledgments This Climate and Health Vulnerability Assessment (CHVA) for Yemen was produced by the Climate and Health Global Program in the Health, Nutrition and Population (HNP) Global Practice of the World Bank, which is led by Tamer Rabie. It is authored by Charles Minicucci, Mikhael Iglesias, Kent Garber, and Pri- yanka Kanth, with contributions from Alethea Wen Lan Cook and Tarini Gupta. The authors sincerely appreciate the valuable guidance of Zara Shubber, who leads the Climate and Health Systems and Eco- nomics workstream. This work also benefited from the administrative support of Julie Bazolana, and the editorial work of Kah Ying Choo and Emilie Cavendish, as well as the production of Sociopúblico. The authors are grateful to the Japan Policy and Human Resources Development Fund (PHRD) Trust Fund for supporting this report. The authors are also extremely grateful to the HNP management team for the strong support of the Cli- mate and Health Program and this product and would like to extend their thanks to Juan Pablo Uribe and Monique Vledder. viii | Climate and Health Vulnerability Assessment: The Republic of Yemen Introduction A fter nearly a decade of conflict, the Republic of Yemen is facing one of the world’s worst humanitarian and development crises. The severe damage done to the coun- try’s economy has been further compounded by the COVID-19 pandemic. With a pop- ulation of 34.35 million, the country’s negative gross domestic product (GDP) growth trend has started to slow and reverse since 2021 — with a projected increase of 2 percent in 2024, its 2022 GDP of USD22.7 billion is still half of what it was in 2014 (World Bank Group, 2024a, 2024b). The Yemeni economy was formerly dominated by oil production, however it has been sup- ported by significant foreign aid and remittances from migrant workers in neighboring Gulf States for years (World Bank Group, 2023). Efforts on behalf of the government to diversify the economy have been ineffective due to the war (Noaman, 2018). In this context of low economic growth and high levels of poverty, the country’s fragility is only set to increase with climate change. The Republic of Yemen is exposed to climate-relat- ed hazards that can exacerbate conflict and fragility, limit growth, and hinder human capital development. Due to the country’s variable geography, climate-associated risks across the country are characterized by substantial differences. The Republic of Yemen’s coastal cities, especially those along the Arabian Sea, are vulnerable to cyclones that can directly damage infrastructure and overwhelm water and sanitation systems already under strain from years of conflict. Highland areas are susceptible to intense rainfall as well as associated flooding, erosion, and landslides, with lower-lying areas susceptible to flash flooding due to heavi- er rainfall upstream. Drier, low-lying areas are also vulnerable to considerable erosion from even moderate rainfall surges, thus causing damage to critical croplands and infrastructure. The eastern areas in the interior and coastal plains are also impacted by extreme heat waves, which directly threaten population health and exacerbate recurrent droughts (World Bank Group 2023, USAID, 2017). Introduction | 1 The Republic of Yemen’s substantial climate hazards and associated health risks impact its vulnerable populations differentially. The factors affecting people’s vulnerability to climate are often similar to those that affect health more broadly. Identifying key vulnerable groups is therefore critical for targeting adaptation measures in order to increase their adaptive ca- pacity in the face of climate hazards and their impact on health. There are estimated to be over four million internally displaced persons (IDPs) in The Republic of Yemen, 75 percent of whom are women. IDPs are currently concentrated in Marib, Al Hudaydah, Hajjah, and Taizz. Due to the informal and inconsistent nature of the sheltering arrangements, these people are more vulnerable to extreme heat, floods, water scarcity, and outbreaks of climate-sensitive diseases. Water scarcity disproportionately impacts the health and wellbeing of women and children due to their roles as primary water collectors. Because FIGURE 1. Administrative Boundaries of The Republic of Yemen’s Governorates. Sa’dah Al Jawf Hadramaut Al Mahrah Amran Hajjah Amanah al-’Asmah Ma’rib Al Mahwit Sana’a Al Hudaydah Shabwah Dhamar Raymah Al Bayda’ Ibb Ad Dali’ Abyan Ta’izz Lahij ‘Adan Socotra 0 55 110 220 Miles Source: adapted from United Nations Office for the Coordination of Humanitarian Affairs (OCHA) (2021), https://data.humdata.org/dataset/cod-ab-yem. 2 | Climate and Health Vulnerability Assessment: The Republic of Yemen they travel long distances to get water, women and children are more exposed to myriad risks, including gender-based violence (Sowers and Weinthal, 2021). Against the backdrop of a protracted conflict, The Republic of Yemen faces complex and multifaceted development challenges that demand the country’s resources and attention. These challenges will worsen if the country remains vulnerable to extreme weather events and climate-related hazards. However, there is potential for the country to build long-term resilience to climate change and prevent current challenges from worsening. The objective of this Climate and Health Vulnerability Assessment (CHVA) is to assist decision-makers with planning adaptation measures to deal with the country’s climate-related health risks. This assessment includes subnational considerations for health-related climate action (see Annex A for the methodology), factoring in the country’s 21 governorates and one capital territory (see Figure 1). It also incorporates data from a climate and health economic valuation con- ducted by the World Bank to estimate potential economic costs of health impacts arising from projected changes in temperature and precipitation (see Annex B for the methodology). Introduction | 3 SECTION I. Climate T he Republic of Yemen, located in the southwest corner of the Arabian Peninsula, is a topographically diverse country with some of the most sparse water and agricultur- al resources in the world (Price, 2022). The country’s 21 governorates (or muhafazat) comprise the culturally and ecologically distinct island of Socotra, as well as four primary geo- graphic regions on the mainland. They include 1) the western and central highlands, which en- compass the official capital territory (amanah) of Sana’a; 2) two extensive coastal plains along the Red Sea and the Gulf of Aden; 3) an eastern plateau; and 4) a northern desert (extremely sparsely inhabited) (World Bank Group, 2023; World Bank Group 2022). The Republic of Yemen also has more than 1,900 kilometers (km) of coastline and claims sovereignty over more than 100 Red Sea islands in addition to Socotra (World Bank Group 2023). Only approximately half of the nation’s 527,970 square kilometers of land area is home to most of its population of 33.7 million people, as the remaining half is desert country. Much of the population and agricultural activity are concentrated in the coastal areas and west-central highlands (Gadain and Libanda, 2023). This section describes observed climatic changes and projected climate trends in The Republic of Yemen and discusses key climate-related hazards facing the country in relation to human health risks. Observed climatic changes are presented for 1901–2020. Modeled data on projected climate trends are presented for the periods 2020–2039 (2030s) and 2040–2059 (2050s), under the shared socioeconomic pathway (SSP) 3-7.0. The SSP 3-7.0 refers to a high-green- house gas (GHG) emission scenario under which countries are increasingly competitive and emissions continue to climb, doubling from current levels by 2100 (see Annex A for the com- plete methodology). 4 | Climate and Health Vulnerability Assessment: The Republic of Yemen Observed and Projected Climatology Heavy rainfall and high temperatures in The Republic of Yemen drive patterns of drought and floods — both of which are projected to increase in frequency and intensity due to cli- mate change. Temperatures, which vary across region and time, can be extreme. The country has an average national warm season maximum of 36.50°C in June (observed during 1991– 2020) with December averages dipping to 13°C in the central highlands. Rainfall is similarly variable, with wet seasons in spring (March–May) and summer (July–September) driven by the Red Sea and the Intertropical Convergence Zones (RSCZ and ITCZ), respectively; each de- livers about one-third of the country’s total annual precipitation. The national average annual rainfall during the 1991–2020 period was 190 millimeters (mm), ranging from 519 mm in Ibb to 80 mm in Al Mahrah (World Bank Group, 2023). Levels of rainfall differ depending on altitude; with altitudes exceeding 3,000 meters (m) above sea level and precipitation rates of up to 1 m per year, the country’s western highlands are the highest and wettest region in the Arabian Peninsula. In contrast, the central highlands (~2,000m above sea level) are more temperate, while the eastern plateau (~1,000m above sea level) and low-lying coastal areas are substantially hotter and drier. CLIMATOLOGY Current Projected The mean annual temperature in Under SSP3-7.0, The Republic of The Republic of Yemen increased Yemen’s annual temperatures are by 0.42°C per decade between 1971 projected to increase over the histor- TEMPERATURE and 2020. It was accompanied by ical mean of 25.40°C (reference pe- substantial increases in the annual riod: 1995–2014). The 50th-percen- number of hot and humid days and tile projections are 26.16°C (+0.76°C nights. The northern desert saw change) for 2020–2039 and 27.02°C the highest temperature increases, (+1.64°C change) for 2040–2059. especially during the summer and - the fall. Coastal governorates are projected to experience the greatest tempera- ture increases during the winter 5 and spring months, while highland governorates will see their highest increases during the spring. National mean annual precipitation Under SSP3-7.0, all the governorates in The Republic of Yemen decreased are projected to see increases in an- modestly (6.25 mm per decade) be- nual precipitation by the mid-century, tween 1971 and 2020. Significantly though with uncertainty and subna- higher-than-national decreases in tional variability. Most of the highest PRECIPITATION precipitation were seen during the increases will be concentrated in same period in coastal areas to the the wet summer months, with some west and southwest, particularly potential negative decadal anoma- during the summer and fall. The lies during the dry season months Al Hudaydah governorate saw the (including April and December– greatest decrease of 34.46 mm per February). The northern highlands decade, with Al Mahwit, Raymah, will see the highest seasonal Taizz, Aden, and Lahj seeing de- increases (exceeding the reference creases of 29.09 mm, 28.02 mm, period of 1995 to 2014 by more 23.39 mm, 23.03 mm, and 22.91 than 10 percent). The central and mm, respectively. southern highlands will experience the highest increases in the five-day cumulative rainfall (exceeding the same reference period by more than 10 mm). 6 | Climate and Health Vulnerability Assessment: The Republic of Yemen FIGURE 2. Mean Annual Precipitation Levels for the Observed Period of 1991–2020 and the Projected Periods of 2020–2039 and 2040–2059. OBSERVED PERIOD Annual National Precipitation, Observed a 1991-2020 and Projected Milimiters 80 (min) 81-160 161-240 241-320 321-400 401-480 1991-2020 481-519 (max) 153 mm PROJECTIONS b 2020-2039 Projected Anomaly (mm) 2020-39 0-6 projection 6 - 12 168 mm +10% 12 - 15|17 15|17 - 37|39 c 2040-2059 37|39 - 56 56- 87|97 87|97 - 152 2040-59 projection 179 mm +17% Source: World Bank’s Climate Change Knowledge Portal (CCKP) Climate | 7 FIGURE 3. Mean Annual Temperatures for the Observed Period of 1990–2020 and the Projected Periods of 2020–2039 and 2040–2059. OBSERVED PERIOD Annual National Temperature, Observed a 1991-2020 and Projected Degrees C 18 (min) - 20 20 - 22.5 22.5 - 25 25 - 27.5 27.5 - 29 (max) 1991-2020 25.4° C PROJECTIONS b 2020-2039 Projected Anomaly (Degrees C) < 0.67 (min 0.58) 2020-39 0.67 - 0.72 projection 0.72 - 0.81 26.1° C +3% 0.81 - 1.44 1.44 - 1.71 c 2040-2059 1.71 - 1.81 (max) 2040-59 projection 27.0° C +6.5% Source: World Bank’s CCKP 8 | Climate and Health Vulnerability Assessment: The Republic of Yemen Climate Hazards At baseline, approximately 100,000 in the population of The Republic of Yemen are exposed to natural and climate-driven disasters per year (Al-Akel, 2020). The climate hazards covered in this assessment include extreme temperatures, floods, droughts, and sea-level rises, with floods accounting for most of the risks. According to the United Nations Office for Disaster Risk Reduction (UNDRR), approximately 87 percent of The Republic of Yemen’s economic losses to natural disasters between 1971 and 2013 were due to flooding (Price, 2022). In 2020, extreme rains contributed to a humanitarian crisis that saw 300,000 people lose their homes and agricultural livelihoods in the country. It also had the worst flood-related death toll in 2021 worldwide, from both waters and resultant landslides (Lahn and Shapland, 2022). Climate change is expected to increase the severity and frequency of both droughts and floods, primarily through the increased intensity and variability of rainfall. Increased tem- peratures will also accelerate evapotranspiration rates, reducing already extremely low levels of groundwater recharge rates (< 1 percent) from the country’s surface water (Gadain and Libanda, 2023) In fact, in the Middle East and North Africa (MENA), The Republic of Yemen is the country worst affected by floods and is forecast to experience the most significant chang- es in both annual heat and floods due to climate change. (Lahn and Shapland, 2022) Sea-level rises are also expected to severely impact The Republic of Yemen’s highly vulner- able coastal regions, primarily through worse storm surges during seasonal cyclones wand resulting erosion, infrastructure damage and saltwater intrusion into coastal aquifers, which threaten half of the country’s coastal population, as well as the land areas and the GDP of its coast (Price, 2022). EXTREME TEMPERATURES Under SSP3-7.0, The Republic of Yemen is projected to experience increases in extreme heat risks by mid-century, with some spatiotemporal differences. Nationally, the number of days surpassing 35°C is projected to increase by 28.40 for the 2040–2059 period compared with the historical reference period (1995–2014), rising to a total of 109.04 days annually. Increases will be higher along the coasts and during the wetter months, when atmospheric moisture content is high. The Al Hudaydah governorate on the western coast will see EXTREME the largest increases, with 46.29 days above 35°C. TEMPERATURES Under SSP3-7.0, The Republic of Yemen will also see an increase of 36.45 tropical nights (that is, with minimum temperatures above 20°C) over the historical reference period (1995–2014), rising to a total of 177.87 nights 9 annually. The northern highlands will see the highest increases, particularly during the summer, with the Raymah governorate projected to see the largest increases, with a further 64.90 tropical nights by the mid-century. FIGURE 4. Projected Anomalies for the Number of Hot Days with Tmax > 35 °C for 2020–2039 and 2040–2059. a PROJECTED ANOMALIES 2020–2039 Days 0 0-5 5 - 10 10 - 15 15 - 20 20 - 25 (max) b PROJECTED ANOMALIES 2040–2059 Days 0 0-5 5 - 10 10 - 15 15 - 20 20 - 25 25 - 30 30 - 35 35 - 40 40 - 45 45 - 50 (max) Source: World Bank’s CCKP 10 | Climate and Health Vulnerability Assessment: The Republic of Yemen FIGURE 5. Projected Maximum Daily Temperature Anomalies for 2020–2039 and 2040–2059. a 2020–2039 Degrees C < 0.6 (min = 0.58) 0.6 - 0.62 0.62 - 0.65 a 0.65 - 0.69 0.65 - 0.74 0.74 - 0.8 (max = 0.78) < 1.25 (min = 1.17) 1.25 - 1.37 1.37 - 1.50 b 1.50 - 1.64 1.64 - 1.79 (max = 1.70) b 2040–2059 Source: World Bank’s CCKP Climate | 11 FLOODS Under SSP3-7.0, The Republic of Yemen is projected to experience more intense precipitation extremes for the 2040–2059 period compared with the historical reference period (1995–2014). Most of the largest changes are anticipated in the summer on the Red Sea coastal plains and in some parts of the highlands. Notably, the Aden governorate on the Arabian Sea coast will see the highest increase over this period, which is projected at 9.7 percent. EXTREME PRECIPITATION Due to The Republic of Yemen’s low groundwater recharge rates and rainwater AND FLOODS runoffs, even minor shifts in intensity or predictability can substantially chal- lenge water resource management and intensify flood risks. Worse and more frequent flooding is already occurring nationwide, with conditions expected to worsen. The Republic of Yemen is projected to see a total increase of 35.95 percent in its precipitation by the mid-century, with its average five-day cumulative precipitation concomitantly rising by 4.43 mm. These changes do not necessarily match the same months and areas projected to experience the largest increases in total precipitation. The largest increase in the 5-day precipitation maximum in this period — at 24.00 mm — is projected for the Al Mahwit governorate. DROUGHTS AND GROUNDWATER DEPLETION Droughts are frequent in The Republic of Yemen and can be extreme, occurring nearly every year and often lasting for months in some areas. The Republic of Yemen currently ranks 12th out of 164 countries on the World Resource Institute’s Water Stress Index. Ma’rib is the worst-affected governorate, though Al Jawf, Amran, Shabwah, Hadramawt, Amana Al Asimah, Al Mahrah, and Sa’dah also have the a maximum index value of 5 across all three sectors DROUGHTS (agricultural, residential, and industrial) (WRI, 2023). The Republic of Yemen has no perennial surface waterways and suffers from an annual national water deficit of approximately 900 million liters, which is compensated by unsustainable groundwater extraction. Freshwater availability 12 is estimated at 125 cubic meters (m3) per person per year — one of the lowest rates on earth; water tables across the country have been falling by 1–7 m annually for several years. While water scarcity in The Republic of Yemen today is largely driven by unregulated water resource management rather than climate, climate change (despite projected precipitation increases) threatens to exacerbate this situa- tio due to less predictable seasonal rainfall as well as increased temperatures and evapotranspiration rates. Rain-fed agricultural areas, particularly those in coastal areas (especially in the Gulf of Aden) have worse water deficits than the country in general, based on nationwide averages (Al-Akel, 2020; Gadain and Libanda, 2023; Price, 2022). SEA-LEVEL RISES1 Sea-level rises and coastal inundations will increasingly threaten The Republic of Yemen’s coastal zones. Under SSP3-7.0, the major port of Aden is projected to see sea levels rise by 0.22 m and 0.67 m by 2050 and 2100 respectively, compared with the historical reference period (1995–2014). According to The Republic of Yemen’s Second National Communication to the United Nations Framework Convention on Climate Change (UNFCCC), a rise in sea levels SEA-LEVEL of 0.6 m would cause an estimated USD2 billion in damages in Aden alone, RISES AND threaten local groundwater sources with salination, and affect half of the SEA-SURFACE governorate’s population (Noaman, 2018). Socotra and Hadramawt’s port city TEMPERATURES of Mukalla are also likely to see significant damage from sea-level rises by the end of the century. 1 Data extracted from the Climate Change Knowledge Portal (CCKP): https://climateknowledgeportal.worldbank.org/ Climate | 13 SECTION II. Climate-Related Health Risks T he Republic of Yemen is undergoing an epidemiological transition. Non-communicable diseases (NCDs) have replaced communicable diseases as the primary cause of death and disability since 1990; however, infections still make up an important portion of the country’s total disease burden. According to the Institute of Health Metrics and Evaluation, communicable, maternal, neonatal, and nutritional diseases made up approximately 35 per- cent of total disability-adjusted life years (DALYs) in 2019. This figure is the second highest in the MENA region, nearly equivalent to Afghanistan. In comparison, NCDs and injuries repre- sented approximately 45.4 percent and 19.5 percent, respectively. Notably, the top three sin- gle causes of death and disability in 2019 were 1) ischemic heart disease, 2) neonatal disorders, and 3) conflict and terror. Another area of concern is The Republic of Yemen’s lack of progress on maternal and child health compared to its work in combating other diseases since 1990. Malnutrition has been a top risk factor for total DALYs since 2009. Life expectancy at birth fell from 68 years in 2013 to 64 years in 2021 — far below the MENA regional average of 73 years (Global Burden of Disease Collaborative Network, 2024; World Bank 2021). 14 | Climate and Health Vulnerability Assessment: The Republic of Yemen The Republic of Yemen’s CHVA assesses six primary climate-related health risk categories: (1) food and nutrition insecurity, (2) waterborne diseases (WBDs), (3) vector-borne diseases (VBDs), (4) heat-related morbidity and mortality, (5) direct exposure to floods, and (6) flood risks to health infrastructure. These health risks represent those where data was available and that are being outlined as the main health challenges in key policy documents and grey literature.2 Each category is assessed in terms of its current and future risks (depending on data availabil- ity), with considerations for national and subnational variations where possible. It is import- ant to note that these risk categories represent only a fraction of the many pressing health risks to the country’s population, as highlighted in the policy documents. Other climate-re- lated health risks have not been included in this assessment, including direct injuries and mortality associated with natural hazard events, air quality, and zoonotic diseases. Likewise, all the exposure pathways can have compounding or cascading effects, further increasing the burden of disease attributable to climate change, although this is beyond the scope of this assessment. Nutrition and Food Insecurity Risks Weather and climate are key to healthy and sustainable diets. The mechanisms by which cli- mate change affects nutrition via the food system are profound, leading to acute and chronic effects on agricultural production, storage, processing, distribution, and consumption. Food insecurity in The Republic of Yemen is pervasive, made worse by the war, which has which has significantly disrupted agricultural productivity. Damage to agricultural produc- tivity has sharply increased due to extreme rainfall and flooding, according to Yemeni govern- ment research: increasingly limited arable land, scarce water resources, poor water resource management and transitions from traditional to unsustainable agricultural practices have all resulted in rising food prices and reliance on staple imports. Severe poverty, especially in ru- ral areas, magnifies all these challenges (Noaman, 2018; The Republic of Yemen, 2009; USAID, 2017; Yemen Family Care Association (YFCA), 2023). Although a comprehensive analysis of climate change’s impact on the food system is beyond the scope of this assessment, the CHVA does address climate and nutrition linkages through a food security lens as it relates to weather and climate impacts on The Republic of Yemen’s agricultural productivity. 2 Key policy documents and grey literature included: the Nationally Determined Contribution under the UNFCCC (2015); the National Adaptation Programme of Action (NAPA) (2009); the Third National Communication to the UNFCCC (2018); the Yemen Family Care Association’s (2023) policy report, Climate Change Impacts on Yemen and Adaptation Strategies; the National Health Strategy 2010–2025 (2010); the United States Agency for International Development’s (USAID) (2017) Climate Change Risk Profile; UNFCCC’s (2022) Technical Assessment of Climate Finance in the Arab States; the World Bank’s (2023) Climate Risk Country Profile; the World Health Organization’s (WHO) (2023) Health and Environment Scorecard; a WHO technical report entitled Climate Change Adaptation in the Health Sector Using Integrated Water Resources Management Tools (2017); the United Nations’ (UN) (2022) Yemen Sustainable Development Framework 2022–2024; the National Biodiversity Strategy and Action Plan II (2017); and the First Biennial Update to the Conference of Parties of UNFCCC (2017). Climate-Related Health Risks | 15 Current Projected Food insecurity and malnutrition are persistent Climate change is projected to put an additional health risks in The Republic of Yemen. It is the 1.2 million people in The Republic of Yemen at 11th- most food-insecure country in the world, risk of hunger by 2050 (IFPRI, 2022). ranking 123rd out of 125 countries on the 2023 Global Hunger Index (Global Hunger Index, Hotter and lower-lying areas (especially Raymah, 2023). Abyan, and most of the eastern governorates) are expected to experience lower yields due to As of 2023, 3.87 million people in The Republic drought and temperature increases. Millet, in of Yemen are experiencing crisis-level food inse- particular, will perform worse due to climate curity (Phase 3+) (IPC, 2024). Despite consider- change, while the production of drought-tolerant able humanitarian efforts in the wake of a con- barley and sorghum may need to be scaled up flict, an unprecedented 17 million peo ple in The (Price, 2022). Republic of Yemen — roughly half the population — remained food insecure as of 2022, according Climate change can increase food insecurity to the Food and Agriculture Organization (FAO). in a number of ways. Greater rainfall variability (Gadain and Libanda, 2023). could make droughts longer, more extreme, and less predictable. Flooding unpredictability and In 2022, approximately 40.7 percent of children intensity are projected to damage agricultural in The Republic of Yemen were moderately or land (with downstream impacts on livelihood as severely underweight, 48.6 percent were stunted, well as food availability), compounded by unsus- and 16.9 percent were wasted. More than 90 per- tainable transitions in agricultural land use and cent of all children aged six to 24 months were irrigation techniques. Coastal plains and arid not receiving the minimum acceptable diet (CSO lowlands are more susceptible than other areas and UNICEF, 2023). to such damage (Price, 2022). Despite importing 90 percent of its staples since Crop yield will have decreased across the whole the war started (much of which has been funded MENA region by 2050 due to climate change, by international aid), Yemen relies on domes- with pulses seeing the highest attributable loss- tic production at baseline to fill about 25–30 es at 17.2 percent against a ‘no climate-change’ percent of its total food needs. Between 1995 scenario. Climate change-attributable consumer and 2021, the country saw a one-third reduction price increases by 2050 in the MENA region for in grain yields, with a 40 percent reduction in its oilseeds and roots and tubers are estimated at overall agricultural output since the outbreak of 20.82 and 35.17 percent, respectively (IFPRI, war in 2015 (Husein and Libanda, 2023; Lahn and 2022). Shapland, 2022; Namdar, Karami, and Keshavarz, 2021). 16 The proliferation of water-intensive non-food Additionally, a further 40-percent reduction in crops such as qat coupled with unregulated crop yields is anticipated in the next 20–30 years and unsustainable irrigation practices, has due to groundwater depletion, independent of cli- made the food system in The Republic of mate change (Lahn and Shapland, 2022; Namdar, Yemen more vulnerable to water-related Karami, and Keshavarz, 2021; Price, 2022). shocks (Price, 2022; Sowers and Wienthal, 2021). Importantly, as agriculture becomes more chal- lenging in The Republic of Yemen, the ongoing transition to the more lucrative (but inedible and water-intensive) qat is projected to accelerate under climate change. This will have positive feedback impacts compounding water scarcity and food insecurity (Price, 2022). Climate change also poses significant threats to the fishing sector. The maximum catch potential is projected to decrease by around -16.6 percent under RCP 2.6 to an estimated-23.1 percent under RCP 8.5 between 2041 and 2050 (World Bank Group, 2024). Stunting cases are projected to see an additional 89,000 cases in 2050, attributable to climate change. This translates to more than US$90 million additional climate change-attributable costs associated with stunting in 2050 under a SSP3-7.0 scenario (World Bank Group 2024; World Bank Group, 2024). Climate-Related Health Risks | 17 Waterborne Diseases (WBDs) Water quality, in part affected by climate-related hazards such as floods or other precip- itation anomalies, is a root cause of waterborne disease (WBD) in The Republic of Yemen (Al-Akel, 2020). The Republic of Yemen has a history of challenges with diarrheal illnesses, including a severe cholera outbreak between 2016 and 2020 that saw 2.4 million cases and more than 4,000 deaths (Garrison, Soebiyanto, Hutchinson, Anyamba, and Steen, 2020; REACH, 2024). Children under five, in particular, are at increased risk for diarrheal diseases, especially when compounded by coinciding nutritional deficiencies (Sowers and Weinthal, 2021). WBD threats nationwide are primarily driven by water scarcity and accompanying issues with quality and access as well as infrastructural capacity and reliability (Al-Akel, 2020). This was the case even before the outbreak of the latest iteration of the conflict, when the country’s water scarcity reached critical levels in 2014 (Al-Saidi, 2020). At the time, less than half the population had access to piped water, with even major urban water networks only able to deliver water intermittently. In Taizz City, for example, households only received municipal water once per month at the time. The situation has since further worsened as a result of the war. People without access to clean water rose from 28 percent in 2015 to 69 percent in 2017. According to the United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA), by 2018, 95 percent of the country was relying on private or unregulated wells or basins, with more than 15 million people (about half the population) experiencing trouble in accessing water (Sowers and Weinthal, 2021). According to the United Nations Children’s Fund (UNICEF), the situation improved slightly as of 2023, with approximately 61 percent of households surveyed reporting reliable access to water (CSO and UNICEF, 2023). Over the last five years, The Republic of Yemen has seen outbreaks of hepatitis A, typhoid, and leishmaniasis, in addition to a major cholera epidemic. Health officials interviewed in 2020 reported cholera, typhoid, and paratyphoid as the country’s primary communicable disease threats (alongside malaria and dengue), with flooding as the primary driver of concern and malnutrition as the primary comorbidity of concern (Al-Akel, 2020). 18 | Climate and Health Vulnerability Assessment: The Republic of Yemen WATERBORNE DISEASES (WBDS) Current Projected Survey data from 2023 found that 37.3 percent Rising temperatures and rainfall variability of children in The Republic of Yemeni had threaten to exacerbate water stress and experienced a diarrheal episode in the last downstream health challenges associated with two weeks. Disparities exist with regard to the water, sanitation, and hygiene (WaSH). This is, rate: 39.1 percent for rural children versus 44.6 in turn, linked to flood disruptions of the water percent for children from poor households. The infrastructure as well as the increased duration, highest prevalence was seen in the Al Jawf, intensity, and unpredictability of droughts. Raymah, and Al Mahwit governorates — all of However, modeled precipitation increases could which had rates of 56 percent or higher (CSO and partially alleviate water stress in some areas. UNICEF, 2023). In other cities in the MENA region, such as Beirut The prevalence levels of serious WBDs in The Lebanon, it is projected that food-borne and Republic of Yemen based on 2019 data are as waterborne diseases could be minimal under the follows: (1) diarrheal disease — 131,000 cases lowest-emission trajectory scenario. However, per 100,000 population; (2) hepatitis A — 3,286 they may increase to 35 percent under the new cases; (3) leishmaniasis —1,803 cases per business-as-usual scenario and to 42 percent 100,000; and (4) intestinal worms — 17,615 per under the highest-emission trajectory scenario 100,000 (Global Burden of Disease Collaborative (El-Fadel, Ghanimeh, Maroun, and Alameddine, Network, 2024). 2012). Households using unimproved water sources are An estimated 1.1 million excess cases of at an increased risk of WBDs. Nationally, 18.9 diarrhea will be attributable to climate change percent of households use unimproved water in 2050 . This is over 200 additional deaths and sources. This rate is higher for rural and im- more than US$156 million in excess health costs poverished households (26.0 and 54.2 percent, attributable to diarrhea in 2050 under a SSP3- respectively). The Raymah governorate has the 7.0 (World Bank Group 2024; World Bank Group highest rate of unimproved water use at 62.9 2024). percent, while Al Dhale’e, Sa’ada, and Hajjah all have rates of above 40 percent. Additionally, 37.4 percent of households have no access to improved sanitation facilities, with ru- ral and impoverished households reporting rates of 51.6 percent and 75.9 percent, respectively. 19 Al Jawf has the highest rate at 83.6 percent, with Hajjah and Raymah also having rates of above 70 percent (CSO and UNICEF, 2023). Vector-Borne Diseases (VBDs) Weather and climate are critical drivers of spatiotemporal vector-borne disease (VBD) dis- tribution and transmission dynamics. Climate variability causes vector and host ranges to expand or contract, shifting disease distribution, altering seasonality, and/or facilitating the emergence or re-emergence of VBDs. Droughts and precipitation variability and anomalies under climate change — compounded by a challenging development context — are likely to be major drivers behind The Republic of Yemen’s status as a VBD risk hotspot in what WHO classifies as the Eastern Mediterranean Region (Bellizzi, Lane, Elhakim, Nabeth, 2020). The VBDs of primary concern in the country are malaria and dengue, primarily carried by Anopheles (An.) arabiensis and Aedes (Ae.) aegypti mosquitoes, respectively (Al-Eryani et al. 2023). The optimum development and survival temperature for An. arabiensis is 32°C (Lyons, Coetzee, Chown, 2013) while the optimal temperature for Ae. aegypti ranges from 25°C to 30°C (Liu et al. 2023). An. stephensi, another highly efficient malaria vector, was reported in The Republic of Yemen for the first time in 2021 in Aden City. Since then, it has been spotted in three other coastal cities. VBDs (especially malaria and dengue) remain a persistent and growing challenge in The Republic of Yemen that is likely to increase with the effects of rising temperatures on vector ecology. Aden City (with a population of 1.1 million) (World Population Review, 2024), in partic- ular, has experienced significant increases in incidence since 2015 — accounting for 15 percent of all malaria cases in the country between 2018 and 2020. The city is also reporting some of the highest incidence rates of dengue and chikungunya in The Republic of Yemen (Global Burden of Disease Collaborative Network, 2024; El-Aryani et al. 2023). Malaria (particularly when car- ried by An. stephensi) is of particular concern to IDPs (especially in and around Aden) since their environmental conditions and limited access to basic services create an ideal vector habitat (Allan, Weetman, Sauskojus, Budge, Hawail, and Baheshm, 2023). Dengue may also pose a dis- proportionate threat to displaced persons based on a recent outbreak in an IDP settlement in Ma’rib (The New Arab Staff, 2023). Other parts of the country, predominantly in coastal plains, 20 | Climate and Health Vulnerability Assessment: The Republic of Yemen also experienced outbreaks in 2015-2016, 2018, and 2019-2020 (Saghir, Ahmed, Dhaiban, Osman, and Abduljabbar, 2022; El-Hefni, 2020). Of note was a 2022 outbreak in Taizz, exacerbated by flooding and damage to health system infrastructure (Majeed and Christophides, 2021). It is important to note that The Republic of Yemen’s experience with VBDs contrasts with re- gional trends. Neighboring Oman eradicated malaria over a decade ago, while Saudi Arabia’s rare handful of annual cases have all occurred near its border with The Republic of Yemen (Majeed and Christophides, 2021). Population exposure to dengue and malaria risk is projected to increase under climate change by the mid-century. Risk in this context is defined as residing in an area where the length of the transmission season is projected to last for at least one month per year. Global spatial modeling efforts conducted by Colón-González and colleagues in 2021 estimated that more than 40 million and 25 million people in the Republic of Yemen will be at risk of dengue and malaria, respectively, in the 2040–2069 period. This compares with approximately 6.2 million and 4.7 million people at risk for dengue and malaria, respectively, during a historical refer- ence period of 1970 to 1999 (see Figures 6 and 7 below). While some of these increases will likely be attributable to population growth and urbaniza- tion, the obvious geographic expansion of population risk zones indicates that climatic fac- tors, such as temperature and precipitation, will also make transmission seasons last longer. Notably, while Sana’a City remained mostly outside the area of consistent dengue transmis- sion in the historical reference period, part of the metropolitan area is projected to become a risk zone under a moderate climate-change scenario (SSP2-4.5). The at-risk population will exceed 200,000 across the entire city under a more extreme climate change scenario (SSP5-8.5). At-risk populations are the largest across all time periods for both malaria and dengue in the southwest corner of the western highlands (Colón-González et al. 2021). Climate-Related Health Risks | 21 FIGURE 6. Multi-Model Averages of Historic (1970–1999) and Projected (2040–2069) Persons at Risk of Malaria Infection in Yemen Under SSP2-4.5 and SSP5-8.5 Climate-Change Scenarios. HISTORIC (1970–1999) Persons < 2,000 2,000 - 5,000 5,000 - 10,000 10,000 - 15,000 15,000 - 30,000 30,000 - 60,000 60,000 - 120,000 120,000 - 200,000 200,000 - 300,000 300,000 - 600,000 PROJECTED (2040–2069) 600,000 - 1,000,000 a SSP2-4.5 Climate-Change Scenario 1,000,000 - 1,500,000 1,500,000 - 2,500,000 (max = 2,200,000) b SSP5-8.5 Climate-Change Scenario Source: adapted from Colón-González et al. (2021), https://osf.io/hpaey/. 22 Current Projected MALARIA Malaria incidence is 3,524 cases Modeled estimates of population risk per 100,000 population, with cer- for malaria infection suggest that, tain areas experiencing expanding under a moderate climate-change transmission. Malaria is responsible scenario (SSP2-4.5), the number of for 2.3 percent of all DALYs in the people living in areas with at least Republic of Yemen, compared with 1 month per year of continuous just 0.3 percent for the MENA region. transmission could surpass 25.2 Aden City, in particular, is a malaria million. Under a high-emissions sce- hotspot (Global Burden of Disease nario (SSP5-8.4), this number could Collaborative Network, 2024; Al- exceed 26 million, with risk areas Eryani et al. 2023). covering the entire nation including the northeastern desert. Climate-driven range expansion of An. stephensi, a vector new to the country, could increase malaria transmission (especially in urban ar- eas and IDP settlements) in the near future beyond predictions based on historical vectors (Al-Eryani, 2023). Climate-Related Health Risks | 23 FIGURE 7. Modeled Historic (1970–1999) and Projected (2040–2069) Persons at Risk of Dengue Infection in Yemen Under SSP2-4.5 and SSP5-8.5 Climate-Change Scenarios. HISTORIC (1970–1999) Persons < 2,000 2,000 - 5,000 5,000 - 10,000 10,000 - 15,000 15,000 - 30,000 30,000 - 60,000 60,000 - 120,000 120,000 - 200,000 200,000 - 350,000 350,000 - 687,000 PROJECTED (2040–2069) a SSP2-4.5 Climate-Change Scenario Persons < 50,000 50,000 - 125,000 125,000 - 300,000 300,000 - 600,000 600,000 - 1,000,000 1,000,000 - 2,000,000 2,000,000 - 3,700,000 b SSP5-8.5 Climate-Change Scenario Source: adapted from Colón-González et al. (2021), https://osf.io/hpaey/. 24 Current Projected DENGUE The Republic of Yemen is one of Modeled estimates of population risk nine dengue-endemic countries for dengue infection suggest that, worldwide with a recent history of under a moderate climate-change severe outbreaks (WHO, 2023). scenario (SSP2-4.5), the number While conservative estimates put of people residing in areas with at annual incidence at approximately least 1 month per year of continuous 24 cases per 100,000 population as transmission could surpass 40.7 of 2021 (Global Burden of Disease million. Under a high-emissions Collaborative Network, 2024), the scenario, this number could decline true burden of disease is likely to 35–36 million, though range ex- much higher. Total suspected cases pansions under climate change will nationwide surpassed 75,000 in cover previously transmission-free 2019, and 50,000 in 2020 – which zones, particularly in the more popu- would suggest incidence can ex- lous central highlands. ceed the above figure by an order of magnitude during outbreak years. Climate change is projected to Al Hudaydah governorate saw more contribute an additional US$39.36 than 70 and 45 percent of suspected million in costs associated with cases in 2019 and 2020, respective- dengue and an additional US$5.39 ly, with Lahj, Taizz, Hajjah, and Marib billion in costs related to malaria, also experiencing high incidence in the year 2050 under a SSP3-7.0 rates (OCHA, 2020; WHO, 2020). scenario (World Bank Group, 2024; World Bank Group, 2024). Heat-Related Morbidity and Mortality Beyond the aforementioned impacts on food and water security, extreme heat is projected to have significant direct impacts on health in The Republic of Yemen. The Republic of Yemeni health officials are particularly concerned about the increased incidence of severe heatwaves in major coastal cities, especially Al Hudaydah, Aden, and Mukalla. Due to limited electricity access (74.9 percent as of 2021), the population is not well-equipped to adapt to extreme heat driven by climate change (Al-Akel, 2020; Moyer, Hanna, Kruczkiewicz, and Kelly, 2023; World Bank Group 2023). Notably, while The Republic of Yemen is familiar with high temperatures, the Climate-Related Health Risks | 25 country’s vulnerability and risk will depend on the capacity of households to manage the heat and adopt cooling mechanisms. Health risks related to extreme temperatures will also depend on humidity levels, which can make temperatures feel even hotter and limit the body’s cooling capacity. People at most risk of extreme heat include IDPs and outdoor workers, including agricultur- al laborers and those employed informally in construction (Al-Akel, 2020). Extreme heat can also exacerbate the effects of malnutrition or undernutrition, especially in children (CSO and UNICEF, 2023). Looking to the future, as the population ages and continues its epidemiologi- cal transition toward a higher proportional NCD burden, the compounding effects of extreme heat on conditions such as cardiovascular diseases are likely to become higher priorities for public health and health policy (Global Burden of Disease Collaborative Network, 2024). Current than five million Yemenis may be exposed to a daily maximum wet- INCREASING Health effects caused by heat in- bulb globe temperature (WBGT) of TEMPERATURES clude a sharp worsening of pre-ex- 35°C or more during a 1-in-20-year isting conditions, such as respiratory heat wave. This also means that this and cardiovascular diseases, as well population has a 5-percent annual as heat rash, cramps, exhaustion, chance of exposure to this WBGT. and dehydration. It is important to point out that the In The Republic of Yemen, high WBGT accounts for both humidity temperatures are a risk factor for and absolute temperature. Index val- road injuries (risk factor attribution ues above 32°C are considered se- of 6.06 percent), lower respiratory vere from a human-health perspec- infections (5.53 percent), diabe- tive (Ridder, Lauwaet, Hooyberghs, tes mellitus (5.37 percent), stroke and Lefebre, 2017). (3.54 percent), ischemic heart disease (2.18 percent), chronic The majority of these people are kidney disease (2.03 percent), and concentrated in Al Hodeidah gover- hypertension (1.91 percent), among norate (2.5 million people), followed others (Global Burden of Disease by Aden (700,000) and Hadramawt Collaborative Network, 2024). (500,000) (Figure 6). Approximately 400,000 of those at risk are children Observed heat index data from 1981 under five years of age. to 2010 indicate that, currently, more 26 Projected that exceed a lethal threshold for moist heat under the global warming Several coastal and interior gov- scenarios of 2°C and 3°C annually ernorates are projected to see (Vecellio, Kong, Kenney, and Hubber, increases in their number of spring 2023). and summer nights with minimum temperatures above 26°C by the Illnesses related to extreme heat mid-century (nighttime temperatures among population 65 years and can affect the quality of the sleep older are estimated to increase from and recovery). Al Hudaydah, Aden, 141 cases in 2020 to nearly 1,400 by Socotra, and Al Jawf are projected 2050, with 350 cases directly attrib- to experience the greatest increases utable to climate change, resulting in (World Bank Group, 2023). more than US$73 million in excess health costs attributable to extreme The cities of Al Hudaydah and Aden heat in 2050 (World Bank Group, will experience some of the highest 2024; World Bank Group 2024). increases in the number of hours FIGURE 8. Population Exposed to the WBGT Index Above 35°C During a 1-in-20-Year Heat Wave, Aggregated by District. Persons < 4,000 4,000 - 12,000 12,000 - 25,000 25,000 - 50,000 50,000 - 100,000 100,000 - 200,000 200,000 - 387,000 (max) Source: adapted from Global Facility for Disaster Reduction and Recovery (GFDRR) (2017), https://datacatalog. worldbank.org/int/search/dataset/0040194/Global-extreme-heat-hazard; WorldPop: School of Geography and Environmental Science, University of Southampton (2024), https://www.worldpop.org. Climate-Related Health Risks | 27 Direct Exposure to Floods In The Republic of Yemen, floods represented around 50 percent of total natural hazards in the 1980–2020 period (Gadain and Libanda, 2023). The International Disaster Database reports that more than one a million people were affected by floods between 2004 and 2024, result- ing in economic costs losses of over USD500 million. Notably, in 2020, flash floods rendered approximately 300,000 people homeless, while in 2022, heavy rains displaced over 100,000 — mainly in areas already affected by conflicts (IDMC and GRID, 2023). Projected flooding Projections suggest that 5.3 million people could be exposed to danger- ous levels of flooding (pluvial, fluvial and coastal)3. Over a third of Sana’a City’s population (35%) live in areas at risk of at least 15 centimeters (cm) of floodwater in a 1-in-100-year flood event. This is equivalent to approximately 1.3 million people, 260,000 of whom are under five years of age. At least 20 percent of the populations of the Al Jawf (161,145 people), Shabwah (136,821), and Aden governorates (259,657 people), among others, are exposed to this same risk. At the district level, over half the population of Amran district in the Amran governorate is at risk (51 percent). Out of 335 districts, 21 (6.3 percent) have more than one-third of their population living in areas with projected 1-in-100-year-event floodwater depths of at least 15 cm while 46 districts (13.7 percent) have at least one-quarter of their populations at risk. When only considering children under five, the Harad district in the Hajjah governorate has the highest proportion at risk (57.7 percent). Densely populated areas such as Sana’a City and districts such as Amran are most at risk, which include large numbers of children under five, whose safety and well-being are particu- larly at stake. Refugees and displaced populations from the ongoing conflict are also especial- ly vulnerable, as they often reside in temporary shelters or areas with limited infrastructure and services. These exposure estimates, however, represent only physical risks: understand- ing the broader implications requires accounting for vulnerability conditions, such as socio- economic status, infrastructure resilience, and capacity to respond to floods. Additionally, flooding can exacerbate further health risks, such as waterborne diseases and malnutrition, compounding its impacts on the most vulnerable populations. 3 These values represent only exposure to floods, and do not account for sensitivity (comprised by vulnerability and adaptive capacity) or compounding risks (i.e. landslides, conflict). This exposure analysis aggregates values from pluvial, fluvial, and coastal flooding types (see annex A for further information). 28 | Climate and Health Vulnerability Assessment: The Republic of Yemen FIGURE 9. Population Exposed to At Least 15 cm of Floodwater Depth During a 1-in-100-Year Event in 2050, Aggregated by District. Persons < 5,000 5,000 - 10,000 10,000 - 15,000 15,000 - 30,000 30,000 - 50,000 50,000 - 100,000 > 100,000 (max= 362,000) Source: adapted from Global Facility for Disaster Reduction and Recovery (GFDRR) (2017), https://datacatalog.worldbank. org/int/search/dataset/0040194/Global-extreme-heat-hazard; WorldPop: School of Geography and Environmental Science, University of Southampton (2024), https://www.worldpop.org. Flood Risks for Health Infrastructure As previously stated, the country is projected to will experience more extreme precipitation by mid-century, putting both people and health facilities already weakened by years of con- flict at greater risk. Under a future climate change scenario (SSP3-7.0), in 2050, a 1-in-100-year flood event would put 433 health facilities (operational as of 2023) in the country at risk of at least 15 cm of floodwater depth. Notably, it is projected that the number of health facilities that will be exposed in the three governorates is as follows: Al Hodeidah (52), Hadramawt (45), and Shabwah (40). Out of the 335 districts, 190 (56.7 percent) will have at least one health fa- cility exposed to this risk. Of these, 21 districts (11.1 percent, or 6.3 percent of the total) will have five or more facilities at risk. The Sayun district in Hadramawt and the Hamdun district in Sana’a have the highest numbers of facilities projected to be at risk at 12 and eight facilities, respectively. In several districts in the Sana’a governorate, half or more of their facilities are projected to be at risk: for example, six out of nine facilities in the Shu’ub district, as well as all three facilities in Sanhan wa Bani Bahlul (Sana’a City outskirts), are at risk. In total, 30 percent or more of the facilities are projected to be at risk in 26 districts (7.8 percent) (see Figure 10 below and Annex C for a list of districts). Notably, eight tertiary-care facilities are projected to be at risk: in particular, the interdistrict Mohammed Alotair Charity Hospital could experience floodwaters of more than 1m during a 1-in-100-year event by the mid-century. Climate-Related Health Risks | 29 While these numbers provide critical insight into physical exposure, they do not account for the varying vulnerabilities of facilities, such as access to lifeline infrastructure like electricity, water, and sanitation systems, which are essential to maintaining healthcare services during emergencies. The impacts of flooding also vary by facility type; for instance, tertiary-care fa- cilities like the Mohammed Alotair Charity Hospital, projected to face floodwaters exceeding 1 m, are particularly critical as they serve multiple districts and provide specialized care that cannot easily be replaced. Facilities in rural or conflict-affected areas often face additional challenges, including limited road access and supply chain disruptions, further constraining their capacity to adapt and respond to floods. FIGURE 10. Health Facilities at Projected Risk of At Least 15 cm of Floodwater Depth (100-Year Return Period, 2050). Karyo HU 4.4 m Dhi humd HU Proportion of Health 8.7 m Facilities Facing Flood Risk Al Jodhaa HU 6.8 m < 5% 5 - 15% 15 - 30% 30 - 50% 50 - 100% Hamumh HU 5.4 m Hamumh HU 5.7 m Source: adapted from FATHOM Version 3 (2023), https://www.fathom.global; World Health Organization (WHO) Health Resources and Availability Monitoring System (HeRAMS) (2023), https://www.who.int/initiatives/herams 30 | Climate and Health Vulnerability Assessment: The Republic of Yemen SECTION III. Adaptive Capacity and Readiness T he extent to which The Republic of Yemen’s health system is prepared for changes in climate-related hazards and has the capacity to manage them will determine the coun- try’s resilience in the coming decades. This section analyzes the adaptive capacity and readiness of the country’s health system to prevent and manage climate-related health risks across four key building blocks while assessing equity as a cross-cutting component. This analysis used the Adaptive Capacity Tool (see Annex A) and was based on the review of policy documents and grey literature. These findings should be taken as preliminary and require fur- ther consultations and validation with key stakeholders. The building blocks are as follows: Leadership and Health Health Health Governance Information Service Financing Systems Delivery Adaptive Capacity and Readiness | 31 Leadership and Governance FIGURE 11. Leadership and Governance Capacity Scores While the country has developed several key climate policies in line with international agree- ments, including its National Adaptation Programme of Action (NAPA) in 2009 and Nationally Determined Contribution (NDC) in 2015, The Republic lacks a cohesive climate and health strategy or authority. Furthermore, its National Health Strategy 2010-2025 makes only cursory references to climate and environmental considerations. Fortunately, the country’s latest key climate policy document — the 2018 Third National Communication to the UNFCCC (TNC) — pays special attention to climate and health, with an entire vulnerability and adaptation planning section dedicated to public health. This doc- ument, combined with sections of the NAPA, forms a workable foundation on which to build a future climate-health adaptation strategy in the country. As articulated therein, the Republic of Yemen’s priorities for climate and health and enhancing associated adaptive capacity are (1) surveillance of disease vectors, (2) preparedness for climate-health disasters, (3) access to essential medicines and care, (4) routine vaccinations, and (5) prompt treatment of cli- mate-sensitive diseases, such as malaria and enteric infections (Noaman, 2018). While the Republic of Yemen’s TNC outlines key building blocks for climate action in the health sector, mechanisms to ensure effective implementation, cross-sectoral coordina- tion, and monitoring and evaluation remain underdeveloped. Leadership roles in climate and 32 | Climate and Health Vulnerability Assessment: The Republic of Yemen health action are poorly defined, thus limiting the effectiveness of health programs across sectors and generating competing mandates for health system performance. Moreover, the country’s dependence on international development partners for climate-health funding and technical expertise has resulted in fragmented efforts and uncoordinated authorities. Finally, there is no centralized system to monitor the implementation progress and results of differ- ent projects undertaken by development partners, the public health system, and the private sector. Health Information Systems FIGURE 12. Health Information Systems Capacity Scores National data on health and climate in the Republic of Yemen are scarce — a situation com- pounded by limitations in technical capacity and infrastructure availability. Policy documents and external assessments consistently rank data and information systems as a top adaptation priority for both climate and health. The development of a high-performing climate change database capable of generating sector-relevant insights, as recommended by the Republic of Yemen’s NAPA, could have critical implications for adaptive capacity and evidence-driven planning and decision-making (Al-Akel, 2020; Al-Saidi, 2020; Noaman, 2018; YFCA, 2023). The Adaptive Capacity and Readiness | 33 Republic of Yemen’s last Demographic and Health Survey (DHS) was published in 2013 and includes no specific climate-sensitive disease data. Nonetheless, the Electronic Disease Warning System (eDEWS), launched in 2013 and integrat- ed with paper-based surveillance efforts in the country, has proven to be an effective and well-functioning surveillance system (Dureab, Ahmed, Beiersmann, Standley, Alwaleedi, and Jahn, 2020; WHO, 2019; MoPHP, CSO, PAPFAM, and ICF, 2015). This is the case despite some challenges with stability and timeliness. A 2020 investigation found that the eDEWS was func- tioning in 83 percent of all operational facilities (37 percent of total health facilities) nation- wide at the time. The Republic of Yemen’s strong potential for improved surveillance has been demonstrated by the launching of its eDEWS and COVID-19 response efforts. Nonetheless, the country is still hamstrung by limited technical capacity and financial resources, leading to a lack of integration of climate and weather data, with information on climate-sensitive health chal- lenges such as malaria, diarrhea, extreme heat, and stunting. For example, though the coun- try has developed early warning systems for specific climate-sensitive diseases, particularly cholera, they have not been implemented on a national scale. This is due to the following weaknesses: (a) the lack of integration of climate parameters, (b) the limited use of disease models, and (c) the absence of real-time insights. The country also strengthened its capacity for surveillance and information systems during the COVID-19 pandemic. It enhanced its laboratory network and capacity as well as adminis- tered training modules to health personnel. Nevertheless, these efforts were focused exclu- sively on COVID-19 as a standalone challenge (Bashir, Al-Waleedi, Al-Shaibani, Rajamanar, Al-Akbari, Al-Harazi, and Aliwah, 2024). Overall understanding of climate change and its effects on health is lacking among the Republic of Yemen’s leadership and the general public. Despite the leadership of the Ministry of Public Health and Population (MoPHP) having an overall good awareness of climate change and health, policy documents still prioritize both targeted and mass messaging efforts, high- lighting the need to raise overall awareness of climate change topics in the Republic of Yemen. In fact, a climate change awareness campaign was listed as the third-highest priority adapta- tion strategy on the NAPA, after coastal management programs and water conservation. In spite of this, there are no strategies for climate and health outreach specific to priority communities or health policymakers or personnel (Saghir, Ahmed, Dhaiban, Osman, and Abduljabbar, 2022; Al-Akel, 2020; Noaman, 2018). Targeting such information campaigns could lay the groundwork for better adaptive capacity through enhancing motivation and coopera- tion to address climate-health challenges among key stakeholders. The current policy prioritizes promoting climate-health research to fill critical knowledge gaps on water resource management (WRM) and agricultural technology, as well as the health 34 | Climate and Health Vulnerability Assessment: The Republic of Yemen effects of extreme heat and infectious diseases. In addressing these gaps, investment in in- stitutional capacity, technical skills, and laboratory infrastructure for research could help na- tional researchers address issues as they arise. A supported scientific community could also assess national adaptation policies and strategies and tailor existing data, tools, and insights to the Republic of Yemen’s unique context. A possible framework for supporting domestic research capacity already exists under the proposed Yemen Climate Impacts and Adaptation Research Network (YCIARN) and National Climate Change Research Centers (NCCRC), with sections focusing on water, agriculture, and coastal resilience (Noaman, 2018; Saghir, Ahmed, Dhaiban, Osman, Abduljabbar, 2022). Health Service Delivery FIGURE 13. Health Service Delivery Capacity Scores The Republic of Yemen’s health system has been damaged due to nearly a decade of armed conflict, hindering its emergency response capacity. Additionally, the basic services infra- structure — especially water and sanitation — are stretched and vulnerable to climate-driven shocks. Existing administrative and logistic challenges have been severely exacerbated by the war, resulting in coverage and quality-of-care losses: an estimated 16.4 million people in Adaptive Capacity and Readiness | 35 the Republic of Yemen lacked access to health services in 2017 (Sowers and Weinthal, 2021; Noaman, 2018). Coupled with the impacts of conflict, climate hazards such as floods can further disrupt health facilities and services. By 2050, climate projections suggest that as many as 433 health facilities may face a 1 percent annual risk of at least 15 cm of floodwater depth (see Figure 8 and Section II). The lack of planning at both health facility and the health systems levels, in the face of climate-related hazards compounds these issues. While these pose a significant challenge to overall adaptive capacity, ongoing efforts and in- vestments by development partners (that is, the World Bank, WHO, UNICEF, and the United Nations Office for Project Services [UNOPS]) in rebuilding and expanding healthcare in the Republic of Yemen present an opportunity to integrate new climate-health considerations in, for example, facility siting and design, workforce training, and supply chain resilience (UNOPS, 2024; World Bank Group, 2024e). After years of responding to humanitarian crises, the Republic of Yemen’s emergency re- sponse systems are also strained. Infrastructure access is limited in many areas. In particular, as discussed in the section above on WBDs, water and sanitation services are especially lack- ing, even in some major urban centers (Sowers and Weinthal, 2021). On top of infrastructure limitations, the country also suffers from a shortage of health per- sonnel and limited planning for health workforce development. As of 2021, there were 2.94 medical doctors per 10,000 population, well below the world average (17.2) and below the east- ern mediterranean average (11.6). Likewise, there are 7.27 nurses per 10,000 population, ob- serving a decreasing trend since 2013 (0.79) (WHO, 2024). While the country has prioritized the expansion and strengthening of bolstering primary healthcare services, these efforts have not addressed their resilience to the effects of cli- mate-change. Moreover, there is limited capacity for expanding primary health services for climate-sensitive diseases such as stunting, maternal and child health, malaria, dengue, and diarrhea, among others. However, the country’s experience of handling humanitarian emer- gencies due to both the ongoing conflict and COVID-19 highlight areas of opportunity for further workforce development and health service provision planning in the face of climate change (Al-Awlaqi, Dureab, Tambor, 2022; Lebbos and Duran, 2021). 36 | Climate and Health Vulnerability Assessment: The Republic of Yemen Health Financing FIGURE 14. Health Financing Capacity Scores The Republic of Yemen’s fiscal policy on health leaves significant baseline shortfalls; fur- thermore, it does not include any climate-related funding commitments. These gaps perpet- uate the country’s dependence on development partners for climate adaptation and mitiga- tion financing in the health sector. Public spending on health in the Republic of Yemen is far below that of neighboring countries, regional averages, and global benchmarks. In 2015, prior to the conflict, (pre-conflict), health spending accounted for 2.23 percent of total government expenditure and 4.25 percent of the GDP — constituting significant downward trends since 2009 (WHO, 2017). Concomitantly, both out-of-pocket expenditure and foreign aid grew as proportions of total health spending in the Republic of Yemen since 2000, reaching almost 90 percent collectively by 2015 (Gadain and Libanda, 2023; Al-Awlaqi, Dureab, and Tambor, 2022). Compounding existing funding challenges, conflict has diverted and disrupted most public funds over the last decade, fragmenting and limiting capacity for improvements in the fiscal space. As the Republic of Yemen reconfigures its fiscal policy and funding mechanisms for health, opportunities exist for integrating climate change priorities into dedicated budgets under the TNC’s priorities: (1) surveilling, controlling, and preparing for climate-sensitive disease Adaptive Capacity and Readiness | 37 outbreaks; (2) training healthcare workers on climate-change priorities; (3) developing cli- mate-health emergency response plans; and (4) stockpiling essential medicines and health- care supplies (Noaman, 2018). The country’s dependence on development partners for climate financing has reduced ef- forts to increase funding health system resilience. Moreover, most development partner proj- ects are focused on emergency responses and humanitarian aid, with limited planning for the further development of the health system in the face of climate change. Limited centralized strategic planning for climate and health hinders efficient resource al- location. Even in the case of programs dealing with climate-sensitive diseases (such as chol- era) that have dedicated funding, their budgets and financing are unclear. A lack of national health insurance further restricts the capacity of the population people’s ability to respond to any health challenge, let alone climate-related shocks, thereby perpetuating cycles of pover- ty and vulnerability. While climate resilience may not be considered a conventional develop- ment priority for poverty alleviation, public health certainly is. Integrating the two into the Republic of Yemen’s economic and fiscal policy can ensure the use of public funds for long- term development priorities and take into account climate-change priorities to build lasting adaptive capacity (Garrison, Soebiyanto, Hutchinson, Anyamba, and Steen, 2020). 38 | Climate and Health Vulnerability Assessment: The Republic of Yemen FIGURE 15. Yemen Health System Capacity Scores Adaptive Capacity and Readiness | 39 SECTION IV. Proposed Actions T his section outlines a set of recommendations to enhance the Republic of Yemen’s health sector resilience and adaptation to climate change. The recommendations are based on an assessment of both the magnitude of the current and projected cli- mate-related health risks and the existing gaps in adaptive capacity to manage and prevent these risks.  It is important to point out that these recommendations are derived from desktop research and data analysis; therefore, they constitute suggestions requiring further valida- tion and prioritization by key stakeholders from the MoPHP, development partners, and the private sector. Finally, this section also offers a proposed research agenda for strengthening the country’s analytical and technical capacities related to climate change and health.   The four key pillars of the Adaptive Capacity Assessment Tool (Leadership & Governance, Health Information Systems, Health Service Delivery, and Health Finance) have been used to organize the section. They offer entry points for addressing climate and health actions rele- vant to the Republic of Yemen. Leadership and Governance • Create a Climate and Health Coordinating Office within the MoPHP to oversee work across the sectors and government agencies. This office would serve as the central authority and point-of-contact for development partners, private-sector entities, and other organiza- tions seeking to address climate-health challenges. 40 | Climate and Health Vulnerability Assessment: The Republic of Yemen • Develop a Health National Adaptation Plan (HNAP), outlining the key climate adaptation policy and investment priorities for the health sector. As the Republic of Yemen prepares for its next National Health Strategy, the HNAP could provide critical input for mainstream- ing climate and health challenges in the overarching national health-sector strategy. • Establish a partnership framework for internationally funded scale-up implementation pilots on vector-borne diseases vaccinations programs, such as Sanofi’s Dengvaxia for dengue, or Wolbachia-infected mosquitoes for dengue, chikungunya, and Zika. This could be a public-private partnership, leveraging the latest advancements in VBD vaccinations. Health Information Systems • Develop a methodology that includes key climate-health endpoints and indicators as part of the next DHS. This methodology could be developed in collaboration with commu- nity organizations, subnational governments, and international agency partners such as UNICEF and WHO. • Expand and integrate the eDEWS with new data streams and data types, ensuring cli- mate-vulnerable populations are prioritized for data collection. This system could benefit from integrating its existing sentinel surveillance data with climatological and meteoro- logical data and incorporating them into new predictive models that facilitate true fore- casting capabilities for climate-sensitive diseases (especially VBDs such as malaria and dengue and WBDs like diarrheal infections). Health Service Delivery • Develop a Health Infrastructure Plan (HIP) to ensure that ongoing and future investments in building and repairing healthcare facilities (as well as auxiliary infrastructure and sup- ply chains) contribute to climate-change adaptation and mitigation goals. The current ongoing health-infrastructure reconstruction efforts, in response to major system dam- ages from the conflict represent opportunities to operationalize climate-health resiliency. The Ministries of Planning and International Cooperation as well as Electricity and Energy would be important collaborating partners in developing a HIP that prioritizes sustainable construction, energy efficiency, and resilience to climate shocks. • Design and conduct a nationwide health workforce training campaign for climate-health preparedness, focusing on operational continuity during extreme weather events and Proposed Actions | 41 the management of climate-sensitive diseases. Training modules should be designed and implemented in line with findings from workforce needs assessments and in close collab- oration with international partners through the National Health Cluster. • Use measures of climate and health vulnerability as criteria for additional or prioritized service delivery. As stated in the TNC, several dimensions of health service access and uti- lization use are essential factors in climate adaptation for the Republic of Yemen. Service- delivery enhancements should include deploying additional health workforce capacity in extreme weather events, such as heatwaves and floods. Vulnerable communities would include IDP populations, rural women and children, and outdoor workers. • Formulate detailed plans for the procurement of essential medicines amid extreme events such as floods, heatwaves, and outbreaks. These plans should include pre-positioning protocols for essential medicines and other consumables necessary for prevention and control in climate-vulnerable communities. Preparedness for key climate-sensitive dis- eases — such as dengue, malaria, or diarrhea — might be the most important to prioritize. Roles and channels for coordination with key development partners should also be clearly set out in emergency plans. Finally, contingency plans should undergo regular stress test- ing and re-evaluation based on learnings from previous events. • Design and implement a strategy for the adoption and use of digital health tools, such as telemedicine for health service provision amid extreme weather events. The use of digi- tal health tools can increase the resiliency of the health system, bringing co-benefits for health service provision amid conflict-related hazards. Health Financing • Harness financing from global climate funds, such as the Green Climate Fund or the Climate Investment Funds, for climate adaptation and mitigation projects in the health sector. These financing opportunities would be especially useful for investments in the re- construction of health facilities affected by the conflict through a climate-resilient approach.   • Explore additional grant-based financing mechanisms such as the Global Financing Facility (GFF), of which the Republic of Yemen is not a partner, despite its eligibility. Through GFF, additional resources could be directed to resilient health-system strength- ening, sustainable health financing, nutrition, along with maternal and child health, among other focus areas.   • Explore options for climate and disaster risk finance and insurance to ensure flexible funds are rapidly available to national and subnational government agencies in the event of a 42 | Climate and Health Vulnerability Assessment: The Republic of Yemen climate-health emergency. Direct funding flows for disasters would provide the Republic of Yemen with independence and ownership over important aspects of climate-health disaster preparedness and response.   Proposed Actions for Further Research • MoPHP and development partners could expand further analytics and technical assis- tance for strengthening evidence-based decision-making and resource allocations for current and future projects and operations, such as: 1. Developing climate-informed disease forecasting models unique to the Republic of Yemen (with subnational spatial resolution and seasonal and single-event resolutions for temporal dimensions) to complement and improve upon existing sentinel surveillance systems with new predictive capacities; 2. Engaging the WHO-World Meteorological Organization Joint Office for Climate & Health as a technical and advisory partner on the aforementioned projects; 3. Conducting modeling on key disease vectors in the Republic of Yemen (including but not limited to An. arabiensis, An. culicifacies, An. sergenti, An. stephensi, and Ae. aegypti), focusing on projected changes to vector biology, disease ecology, and transmission pat- terns under multiple climate-change scenarios; 4. Capitalizing on robust existing data (and international funding and attention) for chol- era epidemiology and drinking water resources in the Republic of Yemen to support and investing further in domestically led research on WBD threats specific to the country, including projected shifts under multiple climate-change scenarios; 5. Developing research on heat-related illnesses and NCD exacerbations in the Republic of Yemen, particularly among vulnerable communities (that is, outdoor laborers and IDPs) and including projected shifts under multiple climate-change scenarios; 6. Conducting research on the epidemiology of food and nutrition insecurity in the Republic of Yemen, focusing specifically on downstream maternal and child health outcomes; 7. Establishing new regional and international partnerships while leveraging existing ones to enhance the exchange of ideas, data, funding, and training programs between the Republic of Yemen and the global climate-health research community. Proposed Actions | 43 Annexes Annex A. Methodology Aims of Assessment and Conceptual Framework The objective of this CHVA is to assist decision-makers with planning effective adaptation measures to address climate-related health risks. Where available, these measures are pro- vided at a subnational level to assist regional health planners. The recommendations of this CHVA are aimed at the health sector and related sectors that influence health risks from cli- mate change, such as disaster risk management. Adaptation priorities need to run alongside fundamental and urgent action to mitigate cli- mate change. It is important to stress how complex the climate change challenge is and how hard it is to precisely predict the magnitude and severity of climate exposures that people are facing populations. Many factors could slightly slow or speed up rates of change, including positive feedback effects and, most worrying of all, cascading climatological tipping points. For this reason, mitigating existing greenhouse gas (GHG) emissions and developing and im- plementing measures to protect human development from the changing climate are, in addi- tion to adaptation measures, of paramount importance. Investment 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 in place to deal with these risks, and recommen- dations to meet identified gaps. The primary focus of this assessment is, therefore, on cli- mate adaptation and resilience measures. However, as the Sixth Assessment Report of the Intergovernmental Panel on Climate Change (IPCC) makes clear, “Global surface temperature will continue to increase until at least the mid-century under all emissions scenarios consid- ered.” Mitigation is no longer a sufficient strategy, regardless of the pace at which govern- ments 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 pos- sible, also includes recommendations that reduce GHGs or facilitate the decoupling of emis- sions for progress toward human development goals. 44 | Climate and Health Vulnerability Assessment: The Republic of Yemen This assessment follows a stepwise linear approach. The first step characterizes the climatolo- gy in The Republic of Yemen, highlighting the observed and future climate exposures relevant to health. The second step examines climate-related health risks, including identifying vul- nerable populations most at risk. The final step assesses the adaptive capacity of the health system, identifying gaps to manage current and future climate-related health risks. The as- sessment was conducted by using desk-based available sources such as scientific published literature, and open-source data. Geospatial Analysis of Climatology and Health Risks This section describes observed climatic changes and projected climate trends, highlighting priority climate-related hazards in relation to human-health risks in The Republic of Yemen. Climate information was acquired from the World Bank Group’s Climate Change Knowledge Portal (CCKP). Observed climate data are presented at a 50 km x 50 km spatial resolution for 1991–2020, aggregated by governorate (Figures 2–5). Model-based climate projection data are derived from the Coupled Model Intercomparison Project Phase 6 (CMIP6), with projections shown through five shared socioeconomic pathways (SSPs). This assessment explores projected climate change under SSP3–7.0 for the short term (2030s; 2020–2039) and the medium term (2050s; 2040–2059). The SSP3–7.0 is a high-GHG emission scenario in which countries are increasingly competitive and emissions continue to climb, dou- bling from the current levels by 2100. The spatial analysis of climate-related risks to population health and health infrastructure (Figures 6–10) was performed using ArcGIS Pro (Version 10.8.2). Open-source modeled population risk data for dengue and malaria were published by Colón- González et al. (2021) and retrieved from the Open Science Framework (OSF) in April 2024 (Colón González, et al. 2021). These models incorporate population-density data with historic and projected climatology data into existing disease transmission models including the statis- tical dengue model (DGM), the Liverpool Malaria Model (LMM), the Lancet Countdown Malaria Indicator (LCMI), and the VECTRI malaria model. For this analysis, population risk data were averaged across the three different malaria model outputs. This analysis used only model outputs for the historical (1970–1999) and mid-century (2040–2069) timepoints, as well as the moderate and severe climate scenarios (SSP2-4.5 and SSP5-8.5, respectively). Counts for the population-at-risk are reported for each infection in a 0.5-by-0.5-degree grid across the entire globe. Grid squares were restricted to intersections with the borders of the Republic of Yemen; then corresponding at-risk population counts were summed. More methodological details on the models can be found in the original publication (See Colón González, et al. 2021). Flood extent and depth data, licensed from Fathom’s Global Flood Map (Version 3), were fore- cast for the year 2050. Flood extent and depth data at a 30 m x 30 m spatial resolution for a Annexes | 45 100-year return period (that is, a 1-in-100-year flooding event or a flood event with 1-percent annual probability) were combined across pluvial, fluvial, and coastal models. A threshold of 15 cm for modeled flood depth was used to define flood extent. Yemen population densi- ty data for 2020 were licensed from WorldPop (constrained model, 100 m x 100 m resolution). Population density data were restricted by flood extent and then by district to generate dis- trict-level at-risk population aggregates. Open-source wet-bulb global temperature (WBGT) data were downloaded from the World Bank’s Global Extreme Heat Hazard Index (Version 2). It presents current projections based on 1981–2010 observed temperature and humidity data worldwide. Heat index data at a 10 km x 10 km resolution for a 20-year return period (that is, a 1-in-20-year extreme heat event or a 5-percent annual probability of maximum heat) were classified into heat index range bands and vectorized into heat-risk zone polygons. Population density data were then restricted to the highest-heat risk zone (greater than or equal to 35°C and then by district to generate dis- trict-level at-risk population aggregates). Adaptive Capacity The extent to which the health system in The Republic of Yemen is prepared for changes in hazards, exposure, and susceptibility, and has the capacity to manage them will impact its resilience in the coming decades. In this assessment, The Republic of Yemen’s adaptive capac- ity to prevent and manage climate-related health risks was examined by using the Adaptive Capacity Assessment Tool. It focuses on four main building blocks while considering Equity as a cross-cutting component: (1) Leadership and Governance, (2) Health Information Systems, (3) Service Delivery, and (4) Health Financing. In this assessment, The Republic of Yemen’s adaptive capacity to prevent and manage cli- mate-related health risks was analyzed by using the Adaptive Capacity Assessment Tool which focuses on the four main building blocks stated above while considering Equity as a cross-cut- ting component. The assessment was based on a desktop review of available reports, research, and key policy documents, requiring further consultations and validation with key stakehold- ers. The Adaptive Capacity Tool is comprised of a total of 55 items using a Likert scale ranging from 1 to 4. Lower scores are highlighted as nascent or latent, showing vulnerabilities and areas in need of action plan. While higher scores indicate an advanced level of awareness and exis- tence of efforts with room for further improvement in the efforts or services provided. It should be noted that several factors outside the scope of the health sector can also drive reductions in adaptive capacity to manage the health risks of climate change in the coun- try’s institutions and people. These include the country’s economic challenges, changing de- mographic patterns, and slowly improving social conditions. The promotion of equity as a cross-cutting theme for enhancing adaptive capacity and resilience to the health risks of cli- mate change is also critical. Adaptive capacity is likely to be greater when access to resources within a community, nation, or the world is equitably distributed. 46 | Climate and Health Vulnerability Assessment: The Republic of Yemen Annex B. Population Exposed to Extreme Temperatures TABLE 1. Population Exposed to the Daily Maximum Wet-Bulb Globe Temperature (WBGT) Index Above 35°C During a 1-in-20-Year Heat Wave, Aggregated by Governorate DATA GOVERNORATES SUM OF POPRISK SUM OF U5POPRISK SUM OF POPRISK Abyan 187,023 12,561 214,615 Ad Dali’ Aden 707,219 82,774 1,232,175 Al Bayda Al Hodeidah 2,527,072 413,970 2,952,313 Al Jawf Al Maharah 108,657 17,752 174,575 Al Mahwit 88,668 Amran Dhamar 1,443 250 75,548 Hadramawt 553,494 59,428 1,295,157 Hajjah 473,188 63,285 984,415 Ibb Lahj 84,176 4,575 291,421 Ma’rib Raymah 407 54 18,109 Sa’dah 3,620 743 29,939 Sana’a Sana’a City 253,289 39,329 340,221 Shabwah 88,908 12,325 191,863 Annexes | 47 DATA GOVERNORATES SUM OF POPRISK SUM OF U5POPRISK SUM OF POPRISK Socotra Ta’iz 89,311 10,589 142,808 Grand Total 5,077,807 717,635 8,031,827 48 | Climate and Health Vulnerability Assessment: The Republic of Yemen Annex C. Districts with More than 30 Percent of Health Facilities at Risk of Flooding TABLE 2. Districts with More than 30 Percent of Health Facilities at Projected Risk of At Least 15 cm Floodwater Depth During a 1-in-100-Year Flood Event (2050, SSP7-3.0) GOVERNORATES DISTRICTS FACILITIES AT RISK FACILITIES AT RISK (%) (NUMBER) Abyan Sarar 4 40%   Zinjibar 2 33.3% Abyan Total   6 73.3% Aden Al Mu’alla 1 50% Aden Total   1 50% Al Bayda Al Bayda City 1 50% Al Bayda Total   1 50% Al Hodeidah Al Mighlaf 4 30.7%   Al Munirah 3 30%   Az Zaydiah 5 31.2% Al Hodeidah Total   12 Al Jawf Al Humaydat 1 33.3%   Al Mutun 1 33.3% Al Jawf Total   2 Al Maharah Qishn 1 33.3% Al Maharah Total   1 33.3% Amran Dhibain 4 30.7% Amran Total   4 30.7% Dhamar Dhamar City 6 50.% Dhamar Total   6 50% Hadramawt Sayun 12 41.3% Hadramawt Total   12 41.3% Hajjah Harad 3 33.3% Annexes | 49 GOVERNORATES DISTRICTS FACILITIES AT RISK FACILITIES AT RISK (%) (NUMBER) Hajjah Total   3 Sa’dah Al Hashwah 3 42.8%   Kitaf wa Al Boqa’ 5 38.4%   Majz 3 33.3% Sa’dah Total   11 Sana’a City Al Wehdah 2 50%   As Sab’in 5 45.4%   Old City 2 50% Sana’a City Outskirts 100%   -Sanhan wa Bani Bahlul 3   Shu’ub 6 66.6% Sana’a City Total   18 Shabwah Arma’a 3 33.3%   Bayhan 5 38.4%   Dahr 3 42.8% Shabwah Total   11 Ta’iz Al Makha 7 36.8% Ta’iz Total   7 50 | Climate and Health Vulnerability Assessment: The Republic of Yemen References Al-Akel, A. 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