COVID-19 AND CLIMATE-SMART HEALTH CARE Country Case Studies CLIMATE INVESTMENT FUNDS © 2021 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, 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. COVID-19 AND CLIMATE-SMART HEALTH CARE Country Case Studies CLIMATE INVESTMENT FUNDS COUNTRY CASE STUDIES The World Bank report, COVID-19 and Climate Smart Health Care: Health Sector Opportunities for a Synergistic Response to the COVID-19 and Climate Crises, describes the actions that the health sector can take during COVID-19 response and recovery efforts to tackle both pandemic and climate change threats. Several examples of countries implementing practical measures to address the combined threats of COVID-19 and climate change were used to inform this report; they are summarized in the case studies in this document. 1. COLOMBIA: SUSTAINABLE and health care systems to better cope with the PROCUREMENT AND COVID-19 health emergency generated by COVID-19. The pandemic has disrupted the global health care HEALTH CARE RESPONSE supply chain leading to shortages of Personal Protective Equipment (PPE), single-use medical Sustainable procurement is a strategy that devices, disinfectants, and cleaning products. the world’s governments recognized as an Other key elements associated with the protection important approach for achieving sustainable of health care workers, as well as the diagnosis development at the 1992 Rio Earth Summit.1 Since and care of COVID-19 patients, have also been then, several United Nations (UN) conferences affected. In response, a number of Colombian and agreements have reinforced the value of health care systems and facilities already imple- sustainable procurement in fostering sustainable menting sustainable procurement policies and production and consumption; as such, action to practices have been able to rapidly develop implement it has grown.2 Governments on every policies and actions prioritizing the use of reusable continent have developed, or are in the process PPE and adapting the formulas for disinfectants of developing, legislations, regulations, policies, and detergents. These same hospitals have also strategies, and action plans to foster sustainable been accelerating the use of telemedicine in public procurement as a means for tackling consultations associated with diagnosing and climate change, chemical pollution, biodiversity preventing non respiratory diseases. Therefore, loss, and more. The health care supply chain their pandemic resilience has also produced that plays a major role in many economies has associated climate benefits by procuring supplies a significant impact on human health and the and services that prioritize reusables (PPE) as well environment. Consequently, the health sector has as decreasing patient and staff transport (telemed- recently become engaged in sustainable procure- icine), thereby enabling health care institutions to ment.3 reduce the carbon and environmental footprint of In Colombia, having a sustainable procurement their COVID-19 response and the health sector in program in place has allowed several hospitals general. 4 | COVID-19 and Climate-Smart Healthcare Laundry for reusable PPEs in Fundación Valle del Lili, Colombia. Photo courtesy of Health Care Without Harm. SUSTAINABLE PROCUREMENT AS tions have played an active role in the strategy’s PANDEMIC PREPAREDNESS development and the implementation of initiatives to achieve its replication in other parts of Colombia Several public and private Colombian health care and the Latin American region. systems are participating in the Latin America regional component of a global program— With the outbreak of COVID-19, health care Sustainable Health in Procurement Project systems in Colombia and the world over found (SHiPP). Financed by the Swedish International themselves facing a severely disrupted supply Development Cooperation Agency (SIDA), SHiPP is chain, shortages of essential goods and devices, implemented by the United Nations Development along with constantly changing and inconsistent Programme (UNDP) and Health Care Without Harm protocols and purchasing standards put in place (HCWH).4 As part of their participation in SHiPP, to address the pandemic. In contrast, the hospitals 54 health institutions in the country to date have and health care systems participating in the SHiPP formally signed a commitment to leverage their project found themselves in a stronger and more purchasing power to reduce the damage to people prepared position because they were able to apply and the environment caused by the manufacture, the principles of sustainable procurement to the use, and disposal of products used in health care pandemic response. and the implementation of health programs. Developed within the framework of the SHiPP Local and state governments that manage health project, Fundación Valle del Lili in Cali and Hospital care systems, as well as groups of hospitals and Pablo Tobón Uribe in Medellín are both not-for- individual facilities, have developed plans, policies, profit institutions of high levels of complexity. and/or regulations for sustainable procurement. Regional leaders in the health care sector, they have The state of Cundinamarca, for instance, issued an cohosted the regional sustainable procurement ordinance that establishes a cross-sectoral strategy workshops that were held in 2018 and 2019 in Cali for sustainable procurement,5 which specifically and Medellin, respectively. These two health care targets the health care sector and promotes institutions have developed initiatives that involve implementation in the sector. Health care institu- avoiding the use of toxic chemicals and promoting Country Case Studies | 5 the purchase of reusable products. They stand out DETERGENTS as leaders in their efforts to minimize the negative The adoption of reusable PPE presented a new impacts of their operations. Both institutions have challenge: how to clean a suddenly much larger a sustainable procurement policy, a program, a load of contaminated gear. The adoption of committee, and criteria developed for sustainable reusable gowns and the increase of patients with procurement. All of these elements have allowed high biological risk contributed to a 25-percent the hospitals to effectively adapt and implement increase in the volume of contaminated clothes changes in their procurement to better cope with at Fundación. Using the sustainability criteria from the health emergency generated by COVID-19. its sustainable procurement program and building cross-departmental collaboration, Fundación PRIORITIZATION OF REUSABLE PPE put in place a strategy to address the increase One way that sustainable procurement in the health in the volume of hospital laundry. Fundación’s sector strives to reduce waste is to promote the team included members of occupational health purchase of reusable products. and safety, biosecurity, infection control, general services, laundry, nursing, process engineering, The Fundación Valle del Lili in the city of Cali and more. The team created a new formula to applied this sustainable procurement approach use natural resources efficiently for washing the as a strategy to overcome the shortage of PPE. clothes of COVID-19 patients. The new formula For example, Fundación bought washable antifluid, allowed for shorter laundry cycles at higher chlorine-resistant, and antimicrobial gowns for temperatures. This effort averted the collapse of health care workers. This measure reduced their the laundry service at the facility. The new formula monthly gown purchase by 36,000 per month, is also saving Fundación more than 3,000 m3 of biological waste from the disposable gowns by water per month, translating into approximately 3.6 tons a month, and CO2 emissions by 5.43 tons USD3,500 in savings in the water consumption of CO2eqa per month. It also resulted in monthly bill every month. financial savings of USD82,700. Similarly, the Pablo Tobón Uribe Hospital of the TELEMEDICINE city of Medellín, incorporating criteria from its The COVID-19 pandemic has also accelerated the sustainable procurement program, mandated the adoption of telemedicine all around the world. purchase of antifluid fabric masks for the adminis- While telemedicine is not directly a procurement trative staff and non-COVID-19 patients, along with strategy, it is fostering more resilient health systems antifluid gowns for non-COVID-19 patient care and that, through a more decentralized approach, can cloth caps. The hospital also extended the life cycle withstand the impacts of large-scale disasters on of medical N95 masks properly by safely decon- their operations. It is also an important tactic for taminating them. This 500-bed hospital estimates reducing health care’s carbon footprint, while that it is avoiding the disposal of more than half a promoting adequate access to health care. million PPE items and nearly nine tons of biological waste per month. On September 30, 2020, the Ministry of Health of Colombia reported a 192-percent6 increase in a Calculation made, using the HCWH’s carbon footprint calculation tool, in terms of avoided waste production and disposal only telemedicine services offered in the country. The 6 | COVID-19 and Climate-Smart Healthcare example of one hospital illustrates the broader- natural resources across the hospitals and their scale impact of this accelerated change. systems. This has, in turn, promoted commitment and innovation among staff, resulting in a resilient In addition to promoting sustainable procurement pandemic response, significant cost savings, and strategies to combat COVID-19’s impacts, the E.S.E reduced environmental harm. Without a doubt, the Hospital San Antonio de Arbeláez and its associated embedded nature of sustainable procurement primary health care centers that serve an average inside these health institutions, which has been a of 10,918 patients annually in the department of fundamental support in enabling them to face the Cundinamarca has maintained a far-reaching tele- pandemic, will allow these institutions to have a medicine approach. The hospital now provides more resilient and sustainable recovery. telemedicine services in 14 specialties to facilitate access as well as improve the opportunity and resolution in patient care, while preventing the 2. THE GAMBIA: MOVING FROM exposure of non-COVID-19 patients. Over the first nine months of the pandemic, the hospital INCINERATION TO SUSTAINABLE and its health care centers carried out 982 tele- HEALTH CARE WASTE SOLUTIONS consultations, as well as 307 Tele-EKG and 2,527 deliveries of X-ray results. Using HCWH’s carbon SUMMARY footprint calculation tool, the hospital estimated The Republic of The Gambia, located in West that the reduction in patient travel reduced carbon Africa, consists of dense woodlands, wetlands, and emissions by 418 tons of CO2eq. savannahs. This topography makes the country vulnerable to the effects of climate change — LESSONS LEARNED flooding, rainfall, rising sea levels, droughts, and In the case of these Colombian hospitals, having heatwaves, with concomitant impacts on economic a clear environmental policy on sustainable development, food security, and health. Against this procurement in place made it easier for them to backdrop, the COVID-19 pandemic has exposed respond to COVID-19 and continue with a safe weaknesses in the health system and public health environmental approach as part of that response. infrastructure. In response to the mounting rate of COVID-19 cases in The Gambia, the government Throughout the pandemic, the leaders and collab- took the initiative to address the infectious orators of assistance units and support services health care waste generated by the COVID-19 have expressed preferences for reusable supplies pandemic, among various other initiatives that and measures, thus extending the life cycle of the include enhancing case detection, contact tracing, products necessary for the provision of health disease surveillance, and diagnostic capacity. services. While responding to the public health emergency, The leadership from the ShiPP program and the the government has shown that it is possible to leadership within each hospital and the health also maintain a low carbon footprint by using the system’s sustainable procurement program have latest technology developed in health care waste helped to drive this change. Most importantly, management. they have developed attitudes of commitment to Country Case Studies | 7 COVID-19 SITUATION IN THE GAMBIA Additionally, droughts and floods, accounting for 13 percent and 60 percent of climate-related hazards The Republic of The Gambia is the smallest country in the country, respectively, have impacted food in continental Africa. Bordered by the Republic security, and public health, as well as subjected the of Senegal and the Atlantic Ocean, it lies on the population to life-threatening injuries and property west coast of Africa.7 The coastal region is densely damage. populated, with the capital city, Banjul, sitting on an island where the Gambia River reaches the Atlantic. CLIMATE PROFILE OF THE GAMBIA On March 17, 2020, The Gambia reported its first The Gambia, a narrow strip of land surrounding confirmed case of the novel coronavirus disease, the Gambia River, consists of dense woodlands, COVID-19.8 As there was no public health facility wetlands, and savannahs.13 It has a long, dry season equipped to treat COVID-19 cases and no public from November to May and a short, wet season health laboratories for COVID-19 testing, the first from June to October. Average temperatures in confirmed cases were treated at a private facility. the country range from 18°C to 30°C during the dry At that time, the first set of cases was imported, season and 23°C to 33°C during the wet season. though local transmission was also on the rise. As of December 11, 2020, there were 3,779 confirmed However, temperatures have noticeably increased cases in the country, with 123 confirmed deaths.9 since the 1940s in West Africa, and during the period from 1970 to 2010, temperatures have While The Gambia has performed poorly on public risen with even greater magnitude over the last health emergency preparedness and response, 20 years. Specifically, in The Gambia, mean annual it has had an integrated disease surveillance temperatures that have been rising by 1.0°C response implementation process in place since since 1960 are expected to continue to increase. 2003. Additionally, the National Health Emergency Climate projections indicate that mean annual Committee was activated to ensure and oversee temperatures will rise by between 1°C and 3°C by the overall coordination and implementation of the the 2060s. This indicates a substantial increase COVID-19 Response Plan.10 This implementation in the frequency of “hot” days and nights in the has been aligned with other regional responses, country in the not-too-distant future. Addition- including the Regional Disease Surveillance ally, The Gambia experiences several climate Systems Enhancement and the Africa Centers for hazards, including torrential rainfall, storms and Disease Control and Prevention.11 flooding, droughts, heat waves, sea level rises, and However, despite the support and coordination, unseasonal rains. Of these, the most significant challenges remain. Support for innovative coun- climate-related hazards are river flooding, coastal try-wide risk-communication strategies has been flooding, and water scarcity. Floods constituted suboptimal, with declining compliance on wearing 60 percent of climate-related hazards in The masks.12 A lack of reliable internet connectivity has Gambia during the 1990–2014 period, with storms hindered the implementation of electronic surveil- accounting for 27 percent during the same period.14 lance at the National Public Health Laboratories in Around 20 percent of the country is covered by the country. There has also been a notable uptick wetlands and swamps. Flood-prone areas are hit of COVID-19 cases among health care workers. by life-threatening floods annually after heavy rains, 8 | COVID-19 and Climate-Smart Healthcare subjecting populations to injuries, waterborne Health care waste management was one of the disease outbreaks, and losses of life, as well as key constraints health care workers noted in property damage. Additionally, climate-sensitive addition to insufficient ward space and consulta- diseases, such as malaria that are endemic in the tion rooms, the lack of basic drugs and equipment, region, compound the current public health crisis, along with inadequate electricity supply. Moreover, along with threats from other diseases, including when health care waste is not managed properly, COVID-19. it could lead to surface and groundwater pollution as well as the spread of diseases.18 Generally, incin- On November 7, 2016, The Gambia ratified the Paris erators have drawbacks that include the release Agreement and submitted its contributions to the of pollutants into the air, which are hazardous, Agreement, despite being one of the countries particularly when used in populated areas. In contributing the least to climate change though it is Banjul that is densely populated, smoke from particularly vulnerable to its impacts.15 Additionally, burning debris has impacted the quality of life of The Gambia began developing its Strategic Plan residents.19 However, the lack of access to interna- for Climate Resilience in November 2016, outlining tional markets to procure less polluting incinerators key climate priorities that included developing during the implementation of the project posed a climate-resilient food and landscapes, a low-emis- great challenge. sion and resilient economy, health, education, equitable social development, along with managing In light of the COVID-19 response, the government the coast in a changing environment, as well as pursued the recommendation to reduce the impacts infrastructures and waste.16 The infrastructure and of air pollution from health care waste and embarked waste management included developing climate- on a more sustainable practice. Its decision also proof infrastructure, sanitation, and solid waste took into account climate considerations and their management. alignment with the government’s commitment to the Paris Agreement. As a result, under the TRANSITIONING TO SUSTAINABLE WASTE World Bank-financed COVID-19 operation — MANAGEMENT DURING THE PANDEMIC The Gambia COVID-19 Preparedness and Response Project (P173798), the government Noting the poor maternal and child health as well as provided an environmentally friendly, a state-of- nutrition outcomes, combined with laboratory, drug, the-art health care waste treatment machine to and equipment shortages, within the country, the the Sanatorium treatment center in the western government of The Gambia, with financing from the region of the country, where most of the confirmed World Bank, implemented the Maternal and Child cases would be treated, in July 2020. An AMB Nutrition and Health Results Project (2014–20) to Ecosteryl 75 Plus is currently under production increase the use of community nutrition along with and will be delivered in 2021. These health care primary maternal and child health services.17 waste management technologies use microwave In addition to increasing the utilization of maternal disinfection technology as a cleaner method in and child health as well as nutrition services in the management of medical waste treatment and regions with the worst health outcomes, incinera- recycling, thereby providing an environmentally tors were installed in 35 health facilities to address friendly, simple, and reliable solution for the health the public health concerns of health care waste. care waste management industry, particularly in Country Case Studies | 9 urban areas. Additionally, the technology is ener- confirmation of its first two cases on March 12, gy-efficient, requiring little energy, few staff, no 2020. Additionally, the country is vulnerable to the water, steam, and no production of toxic waste. impacts of climate change, including increasing temperatures, droughts, floods, and erratic rainfall. Laboratories and relevant health facilities, which These external shocks have negatively impacted are used for the diagnostic testing and isolation infrastructure, food security, coastal and agricultural of patients, generate biological waste, chemical livelihoods, as well as human health. waste, and other hazardous bioproducts from COVID-19. Therefore, the management and In anticipation of the COVID-19 vaccine, the handling of highly infectious biomedical waste government of Ghana has focused on developing are also critical under the COVID-19 response. a sustainable cold-chain system that takes into Additionally, biohazard bags and plastic pedal consideration climate change and the risks of bins were procured for all health facilities as part natural hazards hindering the distribution of of a comprehensive response. vaccine supplies in the country. By establishing national coordinating committees and an advisory LESSONS LEARNED AND WAYS FORWARD board, as well as obtaining technical assistance from development agencies, Ghana is making Throughout the process, the government of The preparations to be ready for the administration Gambia was engaged in determining initiatives that of vaccines. By taking ownership of the cold-chain would reduce public health hazards and address system, Ghana is mounting a thoughtful response its climate change commitments. In taking the to develop sustainable climate-resilient vaccine initiative, the government was the driving force cold-chain delivery in the country in preparation behind the process — researching the options for receiving the COVID-19 vaccine. available as well as considering environmental and social safeguards to maintain the health of COVID-19 SITUATION IN GHANA the population and the environment. In order to move forward on addressing climate change while Ghana is a country in West Africa that is bordered responding to COVID-19 and future outbreaks, by Togo, Côte d’Ivoire, and Burkina Faso. It has the government’s commitment will be vital for made significant progress in poverty reduction, with ensuring climate-resilient and environmentally a fast-growing economy and solid social capital. friendly approaches. However, the emergence of the novel coronavirus — COVID-19 — has brought on additional challenges that the country has had to address. 3. GHANA: BUILDING A On March 12, 2020, the Ghanaian Ministry of SUSTAINABLE COLD-CHAIN FOR Health confirmed its first two cases of COVID-19, THE COVID-19 VACCINE where by two individuals had returned to Ghana from Norway and Turkey.20 In response to the outbreak, the country has adopted an all-of-gov- SUMMARY ernment approach with high political commitment. Ghana, a country in West Africa, has had to respond The Inter-Ministerial Coordination Committee — to the COVID-19 pandemic since the government‘s made up of the Ministries of Finance; Health; 10 | COVID-19 and Climate-Smart Healthcare Local Government; Gender, Children and Social at risk from floods, coastal erosion, and droughts, Protection; Information; Transport; Interior; and with injuries to human health from flooding and Defense; along with the Office of the President — waterborne diseases, including climate-induced is acting as the apex coordinating body for the waterborne diseases. COVID-19 response.21 For vaccine deployment and the cold-chain process, the National Technical Additionally, flooding and precipitation are likely Coordination Committee (NTCC) and the National to contribute to outbreaks of human and animal Technical Working Group (TWG) on Vaccine diseases, the displacements of human populations, Readiness and Deployment are providing oversight the destruction of property and infrastructure, as and coordination. Additionally, the government well as losses of livelihoods. These climate events has activated activities under the Emergency are also likely to compound the challenges in the Operations Center and set up emergency response delivery of vaccines to the population and hinder teams in all 16 regions and districts of the country. the logistics of the vaccine cold-chain supply.24 As of December 6, 2020, Ghana had 52,738 Each of these climate-related health threats is COVID-19 cases, with 326 deaths.22 also expected to hit the poorest households and communities hardest, with income and health One of the reasons for the country’s success in shocks driving them deeper into poverty. Overall, managing the COVID-19 outbreak has been its the effects of climate change are predicted to aggressive roll out of contact tracing and testing as well as a quarantine program. The country increase the number of Ghanaians living below is currently assessing its readiness to deploy the poverty line by 2–6 percent by 2030.25 COVID-19 vaccines to its population, especially Since the 1980s, the government of Ghana had to the vulnerable and those at risk. This process considered the use of fuel-efficient and envi- will assist the country in identifying existing gaps ronmentally friendly cold-chain systems and in its cold-chain and vaccine-delivery systems in vaccine-deployment processes. One of the order to address them ahead of the COVID-19 assessments of Ghana’s cold-chain system, vaccine delivery. conducted as far back as 1986, recommended the replacement of obsolete cold-chain equipment with CLIMATE PROFILE OF GHANA energy-efficient ones.26 In fact, solar refrigeration Ghana has a tropical climate that is influenced was pilot tested in the 1980s. The plan had been by the West African monsoon.23 Its mean annual to deploy solar refrigerators, especially to areas temperature has risen by 1.0˚C, with the rate of lacking access to the national grid. increase being higher in the northern regions of the country than in the south. Additionally, the average The Ghanaian government approved its first number of “hot” days per year had increased by comprehensive national climate change policy 48 days between 1960 and 2003. In fact, its mean in 2013 that focused on low-carbon growth, annual temperature is projected to increase by adaptation, and social development. In 2015, 1–3°C by the 2060s, with the estimated rate of Ghana’s NDCs presented a comprehensive warming to be the most rapid in the northern inland mitigation and adaptation plan to address key regions of Ghana. Annual precipitation is expected sectors and areas, including energy, transport, to increase by 3.46 mm. Therefore, Ghana is most waste, forestry, agriculture, water, and health.27 Country Case Studies | 11 A significant challenge had been the lack of TWG for Vaccine Preparedness and Delivery have adequate resources for the government to procure convened key donor agencies, such as WHO, the climate-friendly options due to the associated World Bank, and UNICEF, as well as private-sector extra costs. With financing support from the World players, for collective decision-making on the Bank, engaging in a climate-considerate vaccine COVID-19 response, including on COVID-19 vaccine cold-chain has now been enabled, thus also delivery. These platforms could also provide the contributing to the country’s commitments under opportunity for collective discourses on climate the NDCs in mitigating global emissions. mitigation and co-benefits among major partners as part of their COVID-19 cold-chain and vaccine-de- DESCRIPTION OF INNOVATION livery support. In anticipation of the potential challenges from Additionally, there is a health development partner climate change, the government of Ghana engaged group that meets regularly to discuss various with the World Bank to receive additional financing aspects of the health sector in Ghana, share good for the vaccine cold-chain delivery process. It practices, and adopt a collective stance on key entered into agreement with the World Bank Board health sector issues. Specifically, for vaccines, the on November 28, 2020, under the Ghana COVID-19 group also provides an avenue for discussions Emergency Preparedness and Response Project revolving around the procurement and deployment Additional Financing. In this effort, the provision of vaccines and cold-chain-related matters, which of off-grid solar electricity for rural and peri-urban are crucial for a coordinated response to COVID-19. government health facilities, which will avert GHG This group also provides an additional opportunity emissions from them, will be financed. This effort for discourses and collective actions on climate will reequip primary health care facilities to be mitigation measures among key development energy-efficient; enhance existing cold-chain partners involved in COVID-19 vaccine delivery facilities and other logistics infrastructure; provide in Ghana. vehicles that have high fuel efficiency, or run on low-carbon fuels or electric power; and train health care delivery workers to support the deployment of LESSONS LEARNED low-carbon technologies through the cold-chain.28 The recognition and ownership displayed by the While the operation will not finance the purchase government of Ghana in establishing a sustainable of COVID-19 vaccines, it will provide support vaccine cold-chain has been enabled to address for preparatory activities, including technical both COVID-19 and the nation’s commitment to the assistance to access the policy environment as Paris Agreement.29 The World Bank’s financing of well as the immunizations systems capacity and the vaccine cold-chain process and infrastructure infrastructure for any future vaccine delivery. to ensure solar energy and sustainable practices In preparation for vaccine delivery, NTCC and TWG will complement the country’s response to meeting on COVID-19 Vaccine Readiness and Deployment its NDCs and mitigating its emissions, while also are being financed by the World Bank to provide enhancing the resilience of the health system in the needed technical, advisory, and coordination providing care to its population and tackling the support to the government of Ghana. NTCC and COVID-19 outbreak. 12 | COVID-19 and Climate-Smart Healthcare While the leadership of the government is key, services for vulnerable populations like pregnant the engagement of development partners to work women, newborns, and the elderly, while also together with the government is also important for maintaining the internet, data sharing, communi- effective implementation.30 Ensuring the success cation, and information systems. and sustainability of the vaccine cold-chain requires coordination and engagement between the STATE OF CHHATTISGARH: TIMELY ACTION government and development partners working ON COVID-19 AND STRENGTHENING HEALTH collaboratively in the country. Engaging each CENTERS TO MAKE THEM LOW-CARBON, other’s strengths, as has been done in Ghana, PANDEMIC-PREPARED, AND CLIMATE- with technical support from development partners RESILIENT and financing from the World Bank, as well as the Formed in 2001, Chhattisgarh is a small and services of NTCC in the day-to-day coordination, relatively young state in Central India. The southern will ensure the successful implementation of the part of the state is hilly, underdeveloped, and vaccine cold-chain to address COVID-19 and the tribal-dominated. The state, as a whole, has very country’s long-term resilience to climate change. limited human resources dedicated to health, including relatively few doctors, nurses, medical professionals, and specialists. For several years, 4. INDIA: HEALTH FACILITY ENERGY the state has striven to integrate most of the 10 RESILIENCE FOR CLIMATE AND components of the operational framework of COVID-19 RESPONSE climate-resilient health systems, as prescribed by WHO.31 These principles include leadership Energy security is key to better and uninterrupted and governance; a health workforce; vulnerability, health services, given that it helps in improving capacity, and adaptation assessments; integrated equipment functionality, enhancing delivery risk monitoring and early warning; health and systems, ensuring more functional neonatal care climate research; climate-resilient and sustainable units, and finally promoting the retention of staff. technologies and infrastructure; management of In light of the COVID-19 outbreak, the solarization environmental health determinants; climate-in- of health centers has not only saved money but formed health programs; emergency preparedness also provided energy security, and thus, quality and management; as well as climate and health health care to the communities. It has also strength- finance. ened the existing health infrastructure so that it can Outlining the COVID-19 response strategy of the be prepared to face and deal with future health State, former Secretary of Health, Ms. Niharika challenges, epidemics, outbreaks, or any climate Barik Singh, stated that the health department took change-induced adversity. charge of planning for tackling the COVID-19 crisis As the following examples from two of the early on.32 They focused on the following elements: lowest-income states in India — Chhattisgarh • analysis of the health and infrastructure avail- and Bihar — attest, needs-based solarization can ability in the state; result in the reliable management of cold-chains • training and preparedness of the first for medicines and vaccines as well as efficient care responders in the community; Country Case Studies | 13 • early warning system and health infrastruc- medical issue, but similar to building health- ture preparedness — the procurement of sector climate resilience, it required leadership, supplies, the training of personnel, and the commitment, institutional participation, efficient setting up of additional infrastructure; coordination with various departments, and the • use of an information technology platform support of the citizens for the success of the for contact tracing, data management, and program.33, 34 Nowhere is the connection between the tracking of data on supplies — PPE kits, Chhattisgarh’s COVID-19 response and climate oxygen supply, hospital beds, etc.; as well as change clearer than in its program for the solar- • vulnerability mapping in the community to ization of its health centers. identify the populations who would need additional care. SOLARIZATION OF HEALTH CENTERS COVID-19 vulnerability mapping was done through For the past decade, the State of Chhattisgarh has the state’s non communicable disease clinics in been deploying solar energy to power its health order to identify people with diabetes, hyperten- centers in order to provide resilient, continuous sion, other comorbidities like cancer, and any other services to the population it serves. Energy previous illnesses. Vulnerability mapping was also security is key to delivering better health services by providing a stable delivery system, helping undertaken through the analysis of geography and improve equipment functionality and ensuring more climatic conditions. In the case of COVID-19 regions functional neonatal, intensive-care, and high-de- with high air pollution, vulnerability mapping led pendency units, while contributing to the retention to the close monitoring of people with a history of staff. Recognizing this objective, the state, of respiratory illness. through its agency, the Chhattisgarh Renewable Through its handling of COVID-19 despite being Energy Development Authority (CREDA), has been low on resources, Chhattisgarh was able to implementing the solarization of health centers demonstrate that the pandemic was not a mere throughout the state since 2012. Between 2012 Chhattisgarh Renewable Energy Development Authority (CREDA), Chhattisgarh. Photo courtesy of Sanjeev Jain. 14 | COVID-19 and Climate-Smart Healthcare and 2019, CREDA installed off-grid solar PV rooftop initiative aims to prioritize the Health Sub-centersb systems at 906 health centers across the state.35 in geographically remote areas and regions. These areas regularly experience power supply problems, According to the former health secretary, Ms. such as power failures and voltage fluctuations, Niharika Barik Singh, “Solarization has increased making it difficult to address the health care needs the institutional delivery of health in the State. It has of the community, while also undermining the ensured that mothers stayed for at least 48 hours at retention of health care staff. the facility, which decreased the maternal mortality In addition to the resulting strengthening of the rates, newborn care corners and newborn stabili- health system, thus ensuring that Chhattisgarh zation units in the centers have been functioning is more prepared for the pandemic and more better and thus quality of care has improved. capable of delivering a COVID-19 vaccine, the There is better cold-chain maintenance to ensure aim of the solarization effort is to design solar smooth execution of the immunization program. solutions based on the specific needs of the Solarization has increased the footfall of patients health centers, including their vulnerabilities with and generated trust in the public health systems.”36 respect to prevalent extreme climatic events, such as floods, droughts, heat waves, and air pollution. The Council on Energy, Environment and Water This approach fits into the state’s more compre- (CEEW) conducted a first-of-its-kind quantita- hensive plan to tackle the health impacts of climate tive and qualitative study37 on the impacts of change, as described in its State Action Plan for electricity access via distributed solar energy on Climate Change and Human Health (based on the rural health care services in Chhattisgarh. The guidelines of the National Program on Climate study found that solar-powered primary health Change and Human Health, as prescribed by the care centers (PHCs) in Chhattisgarh admitted National Center for Disease Control, Ministry of over 50 percent more patients and conducted Health and Family Welfare).38 almost twice the number of child deliveries in As part of this initiative, Chhattisgarh also aims to a month compared to power-deficit PHCs that set up model climate-resilient Health and Wellness lack a solar system. The ability of solar-powered Centers (HWCs) throughout the state, with at least PHCs to operate cold-chains, store vaccines and one in each district. These climate-resilient HWCs drugs, as well as run newborn care equipment will include solar-powered electricity, cool roofs also improved significantly in Chhattisgarh. for heat management, rainwater harvesting, solar It is clear that overall solarization has increased b “A Health Sub-centre is the most peripheral and first point of con- the status of most health care indices in the state. tact between the primary healthcare system and the community. A Sub-centre provides interface with the community at the grass-root level, providing all the primary healthcare services. It is the lowest rung Based on these outcomes, in the midst of the of a referral pyramid of health facilities consisting of the Sub-centres, Primary Health Centers, Community Health Centres, Sub-Divisional/ COVID-19 pandemic in 2020, the state ramped Sub-District Hospitals and District Hospitals. The purpose of the Health Sub-centre is largely preventive and promotive, but it also provides a up its commitment. It now aspires to solarize an basic level of curative care. As per population norms, there shall be one Sub-centre established for every 5000 population in plain areas additional 705 health centers, which would allow and for every 3000 population in hilly/tribal/desert areas.” Directorate General of Health Services, 2012. Indian Public Health Standards (IPHS) it to achieve 100-percent renewable electricity in Guidelines for Sub-centres, revised 2012. Ministry of Health & Family Welfare, Government of India. https://nhm.gov.in/images/pdf/guidelines/ the government health centers. This redoubled iphs/iphs-revised-guidlines-2012/sub-centers.pdf. Country Case Studies | 15 Solar roof at one COVID-19 hospital in Chhattisgarh. Photo courtesy of SELCO Foundation & Doctors For You. pumps for drinking water, solar heating for water, MASARHI, BIHAR: A CLIMATE-RESILIENT efficient biomedical waste management systems, COVID-19 CARE HOSPITAL WITH STAFF and a mechanism for the sustainable procurement QUARTERS of medical goods and equipment. Bihar is a state in eastern India. The third largest The COVID-19 pandemic highlights how powering state by population and 12th-largest by territory, health with renewable energy can build resilience Bihar is amongst the poorest states in India, with not only for strengthening the health system and poverty incidence of 42.6 percent. Its per capita climate resilience but also for pandemic prepared- net domestic product has been estimated to be ness. For instance, by making this public-health USD446 — about one-third of the corresponding infrastructure investment in resilient renewable national average (USD1,220) and less than energy, Chhattisgarh is positioning itself to manage one-fourth of that of Haryana (USD2,052), one of cold-chains more reliably for medicines and the richest states in India.39 Bihar generally ranks vaccines. Overall, the state’s focus on solarizing weakest in health outcomes in comparison to other health centers in remote areas will not only provide Indian states.40, 41 energy security, and thus, quality health care to Bihar relies heavily on privatized hospitals to the communities but also strengthen the existing provide health care to the public and has the health infrastructure so that it can be prepared second-highest ratio among Indian states for to face future health challenges that will not only private-to-public spending and high levels of include climate change-induced adversity but also corruption.42 As a result, there are also slower epidemics, other outbreaks, and/or disasters, and health care delivery and steep health care deal with them. costs.43,44,45,46 Given the high population density of the state, Bihar lags behind other states in the number of health care professionals who should 16 | COVID-19 and Climate-Smart Healthcare be employed for adequate care.47,48 The Ministry This presented a need for staff accommodations, of Health estimates that the biggest shortfall in along with beds dedicated for other non-COVID-19 the state, almost up to 75 percent, is in physicians care needs. and specialists.49 Lockdown measures had also limited markets, Masarhi is a rural region in Bihar, about 25 km south workforces, and transport for building materials. west from the state capital, Patna. The village is The crisis of manpower and resources was further so steeped in grinding poverty that its people are exacerbated by the increasing number of cases of known to hunt rats in their fields and eat them. The COVID-19 and the urgency of providing specialized government-run PHC that is meant to serve Masarhi infrastructure for COVID-19 care. The circumstances is ill-equipped to handle patients. Although Patna, necessitated innovations, particularly for tackling located just 25 km away, has hospitals, getting the lack of materials and labor supplies essential there means a difficult journey of more than an for building construction. hour because of broken roads and the absence A prefabricated construction solution was of ready transportation.50 developed where the entire facility was built in a Implemented by the Indian NGOs, the SELCO warehouse and assembled on site. This innovation Foundation and Doctors for You (DFY), the Masarhi allowed for the construction of a 5,000+ square-foot hospital is a new solarized COVID-19 Care facility building in only two months, cutting construction in Bihar with a six-bed inpatient department (IPD),c time by half. two procedural rooms, and 15 staff accommodation rooms. It is built with sustainable materials and SYNERGY OF 100-PERCENT RENEWABLE powered 100 percent by renewable energy. It is a ELECTRICITY AND ENERGY-EFFICIENCY potentially scalable example of how the COVID-19 MEASURES response, climate resilience, cost savings, and As mentioned before, energy security is essential achieving greater access to care can be embodied for uninterrupted health services. In times of climate by a single health facility.51 crisis, the health center needs to be the last building Built in August 2020, the hospital building itself is standing with its functioning unhampered. Energy a greenfield construction, that is, new construc- resilience in the health center does not come with tion unconstrained by prior work. The construction the installation of renewable energy solutions alone incorporated the special needs of the hospital but also through the incorporation of energy-effi- staff and personnel. For instance, the COVID-19 cient measures in the design and building of the pandemic disrupted systems around the facilitation facility itself. of health care, with the lockdown hindering the In the Masarhi hospital model, a holistic approach mobility of the health care staff and requiring more to climate resilience has been adopted wherein in-residence staff to tend to COVID-19 patients. energy-efficiency measures have been deployed in c “An inpatient department or IPD is a unit of a hospital or a healthcare combination with the renewable energy infrastruc- facility where patients are admitted for medical conditions that require appropriate care and attention. An Inpatient Department of the hospital ture. Given the precarious situation of the electricity is equipped with beds, medical equipment, round the clock availability of doctors and nurses.”. Hinfoways, 2016, “Understanding the Healthcare supply in the region, the hospital is fully powered Terms: What is an Inpatient Department (IPD) or Ward?” Hinfoways Healthcare Pvt. Ltd. (blog), June 16, 2018, https://www.hinfoways.com/ by a 15-kilowatt (KW) Solar PV array with battery blog/availing-healthcare/ what-is-an-inpatient-department-ipd-or-ward/. Country Case Studies | 17 Efficient Inefficient Inefficient appliances with appliances with appliances with System green building green building standard typical design design building designs Total Load 4,290 W 5,749 W 5,749 W Connected Total Units 21.8 Units 30.63 Units 52.34 Units Required Solar Panel 12 kWp 16.2 kWp 26 kWp Capacity 28.82% (Solution without energy-efficient appliances and % of with green building design) Energy Savings 58.34% (Savings with both energy efficiency and green building design) Energy savings at Masarhi Hospital. Photos courtesy of SELCO Foundation. backup. Though it is connected to the grid, it can • addition of skylights and turbo ventilators continue to operate fully, even in the event of grid to the roofing; power disruptions. In addition, the hospital has • windows with exhaust fans; along with incorporated diverse innovative measures that • cool-roof solutions, such as cool-roof paints, have enabled it to reduce its energy footprint and Mod roof, and false ceilings to reduce the heat gained through roofing. minimize energy needs. The Masarhi facility saves about 58 percent in The facility has ecofriendly walling and flooring energy by shifting to solar. The table offers a made from compressed Agri Fiber panels that comparison of the energy savings that the hospital are manufactured by using crop residue. The has been able to achieve with its efficient appliance walling infills in this innovative approach insulate and green building efforts. the building and protect it from heat stress. According to Dr. Ravikant Singh,52 founder of According to the field data, these panels provide DFY, “solarization of the health center has helped better insulation than conventional walling and cut electricity costs by almost 58 percent in the flooring panels. Better insulation will lead to a facility. Given the unknowns around COVID-19 reduced requirement of air conditioning during especially about how long the pandemic would the summer months. Other incremental building last, cost uncertainties are plaguing health facilities. solutions were added to improve the quality of the To top this, COVID-19 care itself is an expensive space, with respect to natural lighting, ventilation, proposition. Solarization of health center helps and the thermal comfort, thus leading to the early reduce and balance the costs for a COVID-19 Care recovery of patients: hospital.” 18 | COVID-19 and Climate-Smart Healthcare Dr. Singh also points out that the biggest advantage lungs, such individuals are likely to face greater of stable solar power in the facility is its ability complications and experience more susceptibility to keep equipment safe. Fluctuating voltage to severe forms of COVID-19.58,59 The use of Agri from an unstable grid in rural India is one of the Fiber panels to build health facilities providing care major causes of equipment damage. The CEEW and healing from COVID-19 and other diseases study in Chhattisgarh revealed that more than 21 is also an effort to close the loop on air pollution percent of the PHCs reported medical equipment and use the material for healing diseases, rather damage due to voltage fluctuations.53 According than causing them. to Dr. Singh, equipment once damaged are often The climate-resilient COVID-19 care hospital left unattended due to the scarcity of trained at Masarhi is a small example of what health biomedical engineers and their hesitation to travel facilities could look like in the climate-uncer- long distances in rural areas. Dr. Singh observes tain future. However, such initiatives come with that one of the biggest advantages of a solar-pow- inherent limitations: they are dependent on donors ered hospital is the safety of expensive medical for resources and sustained purely through the equipment worth hundreds of thousands of rupees, public spirit of physicians associated with NGOs, which is critical to the provision of patient care. in this case, DFY. It is important that governments Solar PV at the Masarhi hospital is powering, see this initiative as a good practice that could be among other things, ventilators for COVID-19 care, scaled up and institutionalized in larger health care a laboratory for testing and analysis, and a water systems. Ultimately, it is only the government that pump for the facility. Solarization has ensured can provide the holistic foundation for a sustainable 24-7 power to the hospital, therefore resulting in health care system that a country with a diverse better staff retention and more trust from the public; patient load like India requires. The Masarhi hospital women patients are more willing to stay back at shows that it is indeed possible to provide health the hospital for care because they feel safe there. care to those who need it the most, if the solutions have innovation, futuristic thinking, dedication, and CROP RESIDUE: CLOSING THE LOOP ON commitment. POLLUTION TO HEALING In addition to its energy-efficient properties, the 5. NEPAL: SUSTAINABLE HEALTH Agri Fiber panel provides an alternative use for CARE WASTE MANAGEMENT TO crop residue. The common practice of burning REDUCE COVID-19 RESPONSE this residue is a major cause of air pollution in India (especially in the Indo-Gangetic Plains during POLLUTION the onset of winters).54,55 Research indicates that air pollution is likely to exacerbate morbidity The COVID-19 pandemic has caused concern about and mortality from COVID-19.56,57 Exposure to air waste being generated in homes and hospitals.60 pollution in the long term reduces the capacity Careless disposal is causing it to litter the streets of organs to function fully and makes it more and beaches, and nervous governments are vulnerable to infections and diseases. Given that resorting to burning it,61 despite the pollution and the COVID-19 virus also enters the body via the carbon emissions as well as the fact that there Country Case Studies | 19 are better alternatives. Vaccine delivery will bring When the COVID-19 vaccine becomes available, another stream of waste — much of it potentially a surge of vaccination waste is also anticipated. at small, remote vaccination centers. Although almost all of it is recyclable, vaccination waste is often burned as well. Burning waste emits As this case study from Nepal demonstrates, significant amounts of CO2 and other pollutants, investments in safe and environmentally sustainable including dioxins and furans as well as carcinogens health care waste management systems can and endocrine disruptors. These pollutants that safely deal with COVID-19 waste, while bolstering persist in the environment for hundreds of years long-term waste management capacities and and build up in the food chain can be passed from health system resilience. Investments in integrated mother to child.63, 64, 65 systems, based on careful waste segregation, the autoclave disinfection of waste, and the recycling SUSTAINABLE HEALTH CARE WASTE of as much waste as possible, offer the greatest MANAGEMENT all-round benefits. The bio digestion of organic Untreated or improperly managed, health care waste completes the portfolio of climate-smart and waste can cause injury, infection, and chemical resilient waste treatment technologies for health poisoning to patients, health care professionals, care facilities in low- and middle-income countries. and the community, as well as interfere with human rights,66 pollute the environment, and contribute Investments in these systems can now address to climate change. In contrast, sustainable health COVID-19 waste treatment and vaccination waste care waste management can help protect people challenges, while developing the infrastructure from health care-associated infections, reduce the that can continue to be useful once the pandemic number of needlestick injuries, and contribute to abates, thereby presenting potential long-term the delivery of SDG, including Goal 3 on health, benefits from actions taken to counter the spread Goal 6 on safely managed water and sanitation, of the virus. Goal 7 on climate change, along with Goal 12 on sustainable consumption and production.67 THE COVID-19 WASTE CRISIS The knowledge that SARS-CoV-2 can be spread by AN EMERGING MODEL IN NEPAL contaminated articles (fomites) has led to consider- A multiparty partnership in Nepal is demonstrating able concern about the potential hazards of waste that climate-smart health care waste management from hospitals and similar facilities, despite a lack is the best approach, both for carrying out normal of evidence of waste acting as a route of infection. operations and taking on COVID-19 waste issues. During the first wave of the coronavirus pandemic, The Sukraraj Tropical and Infectious Disease some countries (for example, Spain, Italy, and China) Hospital in Kathmandu — the nation’s capital — is changed their health care waste classifications Nepal’s only dedicated infectious disease hospital. to categorize all health care waste as infectious. Operated by the government of Nepal, it has 100 This overloaded their management systems and beds, with half of them now dedicated to COVID-19. decision-makers turned to environmentally unsus- It is the country’s first COVID-19 hospital, serving tainable techniques, particularly incineration.62 more than 1,000 Outpatient Department (OPD) 20 | COVID-19 and Climate-Smart Healthcare Left: Layout of the waste management center at Sukraraj Hospital. Right: Waste autoclave in operation. cases per day, while also collecting and handling Fight AIDS, Tuberculosis and Malaria as well as more than 900 swabs per day for COVID-19 tests. Save the Children Nepal, along with technical support from HECAF360 and HCWH. The DICs The Sukraraj Hospital has a small waste have been searching for a safe way to dispose of management center, with an autoclave provided their waste. With neither the space nor resources to help treat COVID-19 waste through a project for the equipment and personnel to treat the HIV under the Management Division of the Department test kits and used syringes from their clients, the of Health Services and WHO Nepal. This project DICs have accumulated substantial stockpiles of is supported financially by the Support to Health waste, while awaiting a solution. Sector Program/GiZ (Deutsche Gesellschaft für Internationale Zusammenarbeit) Nepal and In response to this situation, the facilities, their technically by the Health Environment and Climate backers, and technical support teams are now Action Foundation (HECAF360). This autoclave is cooperating to create a system that meets the only large enough to cope with the COVID-19 waste; needs of both the hospital and the DICs. This so the other infectious waste from the hospital is sustainable health care waste management system not yet being treated. has the following three characteristics: Nearby, spread across the Kathmandu Valley are Segregation: At each of the participating facilities, five drop-in-centers (DICs) offering harm reduction waste will be strictly segregated to minimize the services, including Human Immunodeficiency Virus amounts requiring treatment. Needle cutters (also (HIV) testing and syringe exchanges to persons called hub cutters) destroy syringe needles so that who inject drugs. The DICs are operated by diverse they cannot cause injury and cut the tips off the Nepali community-based organizations and NGOs, syringes so that they can never be reused. with financial support from the Global Fund to Country Case Studies | 21 Schematic of a dual-chamber biodigester designed for pathological and food waste. Treatment: Autoclaves that use high-temperature, sent for recycling. After treatment in the “red” high-pressure steam to kill pathogens will disinfect section, some of the previously infectious waste the waste. can also be recycled. In previous research, HCWH and HECAF360 were able to recycle immunization An expanded health care waste management waste, including vaccine vials and packaging; the center at the Sukraraj Hospital will include an only exception was the cut needles.69 autoclave for the DICs’ waste that has been provided by the development partners supporting the DICs. Cut syringes from the DICs will be CLIMATE-SMART HEALTH CARE WASTE transported to the Sukraraj Hospital in lockable MANAGEMENT aluminum containers designed to fit directly into Autoclaving vaccination waste in Nepal, where the autoclave. The new autoclave will not only much of the electricity is derived from renewable be able to treat all the DIC waste but also add (hydroelectric) sources, has carbon emissions much-needed capacity for the Sukraraj Hospital 3,000–4,000 times lower than burning it. If the itself. power is from fossil sources, autoclaving still has This “hub-and-cluster model” is effective in CO2 emissions 15–20 times lower than burning it.70 locations where there is no centralized waste While the partnership between the Sukraraj management facility.68 Larger health care providers Hospital and the DICs is focused on syringes and with the technical expertise to treat waste safely the so-called “soft” infectious waste, other facilities also treat that of smaller facilities nearby. They generate large quantities of pathological waste provide a valuable service and, in turn, can (placentas) and kitchen/food waste. HCWH and subsidize the use of their staff and equipment by HECAF360 have been assisting them to install charging waste treatment fees. biodigesters to complement the autoclaves. Biodi- Recycling: Much of the waste from the Sukraraj gestion uses bacteria (often derived from cow Hospital can be recycled. Noninfectious waste, dung) to break down organics in underground including paper, plastics, and glass, which have chambers, whereby the methane generated is been segregated at source, will be brought directly captured for use as a fuel. Since methane has high from the Sukraraj Hospital’s wards to the “green” GWP, burning it has a lower carbon footprint than section of the waste treatment center, and then allowing it to be released into the atmosphere.71 22 | COVID-19 and Climate-Smart Healthcare At the Tribhuvan University Teaching Hospital, 6. THE PHILIPPINES: Nepal’s largest teaching hospital, two autoclaves LEVERAGING MULTIHAZARD disinfect waste, and the biogas plant treats 27 tons DISASTER PREPAREDNESS FOR of organic waste yearly, which would otherwise be sent to landfills, thereby avoiding methane COVID-19 RESPONSE emissions of 1,386 m3 per year. The Philippines, one of the first countries to As well as being safe and climate-smart, the report cases of COVID-19, has enforced what system has proven to be resilient. Hospitals with was described as one of the strictest and these systems were able to continue treating longest lockdowns in the world. Despite its their waste, even after the magnitude-7.8 Gorkha myriad challenges in containing the spread of earthquake in 2015, when patients were moved the coronavirus, the Philippines is no stranger to outdoors for safety, and waste quantities trebled. It emergency situations. Its experience with disaster is highly scalable because expertise and national responses has thus allowed it to mount a multi- government support are available. sectoral and multilevel response to the COVID-19 The primary barrier is resource limitations: only pandemic. around one percent of Nepal’s hospitals have Visited by approximately 20 typhoons each integrated systems of this type. Of these, most year, the Philippines is one of the world’s most are designed for a facility to treat its own waste. climate-vulnerable countries. In 2020, the think Thus, the “hub/cluster” model being created at tank, German Watch, ranked the Philippines as the Sukraraj Hospital, where one hospital treats number 2, in terms of losses in human lives and waste from smaller facilities nearby, is a valuable the gross domestic product (GDP) resulting from option that deserves more attention. Standalone extreme weather events.72 For instance, in 2013, “centralized” systems can also be viable in larger the country was hit by Typhoon Haiyan, considered cities. to be the strongest ever to hit land in recorded COVID-19 has increased pressure on waste history. The typhoon claimed more than 6,000 management systems at hospitals like the Sukraraj lives and affected nearly 16 million people.73 The Hospital around the world. It is overloading years spanning 2011 to 2020 saw a much higher facilities that are already challenged in dealing with number of typhoons (91 versus 63) and deaths existing health care waste streams. The integrated (12,376 versus 6,198) than in the previous decade.74 response in Nepal shows the potential of a system These extreme weather events are in addition to that could be scaled, with support from donors and the slow-onset, long-term changes expected in development partners to strengthen the national the country, such as sea-level rises exceeding the capacity, particularly projects on water, sanitation global average rate in certain parts of the Philip- and health (WASH) at health care facilities, immuni- pines.75 These slow-onset events will generate a zation campaigns, as well as initiatives on maternal wide range of health effects, including climate-sen- health, HIV, tuberculosis, and malaria. sitive infectious diseases, such as dengue and malaria,76 along with heat-related illnesses.77 Country Case Studies | 23 Disaster response training among volunteers in a Philippine municipality. Photo courtesy of Health Care Without Harm. DISASTER PREPAREDNESS AND CLIMATE natural and human-made hazards addressed by CHANGE ADAPTATION the Disaster Act and its associated mechanisms. For instance, being in the Pacific Ring of Fire, Given the country’s vulnerability to climate change, the Philippines faces the perennial threats of particularly the extreme weather events and the earthquakes, landslides, and volcanic eruptions. slow-onset health effects, the Philippines instituted The same disaster infrastructure is mobilized when several national policies, such as the Climate human-made emergencies, such as armed conflicts Change Act of 2009 — once lauded by the UN or stampedes, occur. Nonetheless, while not all as one of the best climate laws in the world78— disasters are related to climate change, there has and the Philippine Disaster Risk Reduction and been an increasing effort to harmonize disaster risk Management Act of 2010. reduction and climate change adaptation activities, including in the health sector, by recognizing the The country’s framework for disaster risk conceptual, technical, and operational synergies reduction and preparedness adopts an all-hazard between the two.79 approach. While the Philippines is frequently beset with climate-related typhoons, flooding, Since the Philippines has a devolved system of and storm surges, there are other types of governance, both laws highlight not only the roles 24 | COVID-19 and Climate-Smart Healthcare and responsibilities of the national government but of strict COVID-19 protocols in local communities. also those of local governments. For instance, the Pre-pandemic disaster mechanisms were activated. Disaster Act requires municipalities to establish a For instance, the Local Disaster Risk Reduction Local Disaster Risk Reduction and Management and Management Council is composed of the Office that is tasked to develop, implement, municipal mayor; all relevant appointed officials and coordinate local disaster risk management (including the municipal health officer); the chiefs programs, including conducting risk assessments, of police, fire protection, and military; along with setting up a multihazard early warning system, sectoral representatives from the civil society and training first responders, and coordinating response the private sectors. and recovery efforts, among others. Meanwhile, Since national mandates compel local the Climate Change Act requires municipalities to governments to invest in disaster preparedness, formulate and implement Local Climate Change local governments were also quick to realign Action Plans prioritizing local climate-related local budgets and mobilize initial financing for issues that are consistent with the provisions of COVID-19-related activities. The Disaster Act the National Climate Change Action Plan. While requires municipalities to allocate at least five the law requires municipal mayors to appoint one percent of their annual revenue for a Local municipal staff member to lead the design and Disaster Risk Reduction and Management Fund. implementation of the climate plan, many munici- Thirty percent of this fund must be allocated as a palities across the country have also created task “Quick Response Fund” that can be immediately forces. They comprise various relevant appointed mobilized when a calamity strikes. The rest of officials (for example, disaster officer, agriculturalist, the fund (70 percent) is used for preparedness environment and natural resource officer, planning and risk-reduction activities, such as awareness officer, and health officer) to develop local climate raising, the purchasing of rescue equipment, and plans. the payment of premiums for calamity insurance. These disaster funds were mobilized in response to SPRINGBOARD FOR COVID-19 RESPONSE the pandemic, complementing the budget increase The COVID-19 pandemic exposed the weaknesses already allocated by local governments for health of the Philippines’ devolved health system, as services. However, overall, these funds remained well as a lack of explicit programs for enhancing limited, and additional assistance was needed from pandemic preparedness and the management at the national government. the local level. Nonetheless, the local governments While certainly not adequate for the magnitude were able to take advantage of the local emergency and long duration of the COVID-19 pandemic, response systems designed for climate-related these multisectoral governance and anticipatory disasters, such as typhoons and extreme flooding, budgeting mechanisms helped local communities by utilizing these existing capacities to organize to mobilize early in response to the pandemic. multisectoral responses to the COVID-19 pandemic. Having been sensitized to previous emergency situations related to climate change, local government staff and communities alike were thus quick to shift to disaster mode in their enforcement Country Case Studies | 25 RESPONDING TO THE COMPOUND EFFECTS recognized the complexity of evacuating thousands OF COVID-19 AND CLIMATE CHANGE of people and relocating them to temporary shelters while observing physical-distancing measures to While tackling COVID-19, the Philippines was also prevent the spread of the virus. Meanwhile, families hit by three major typhoons, further complicating affected by climate-related disasters were faced the pandemic response. On May 14, 2020, while with a dilemma — either stay at home and protect the Philippines was still struggling to contain the themselves from the coronavirus, while their virus and under a nationwide lockdown, Typhoon houses were inundated if not destroyed, or move Vongfong slammed the Eastern Visayas region, to cramped evacuation centers, usually in public displacing approximately 150,000 residents.80 Then schools or other public buildings, to escape flooding in November, the country was hit by two major at the expense of breaking physical-distancing typhoons back to back. Super Typhoon Goni measures, and worse, contracting the virus. struck Luzon — the country’s biggest island — on November 1 killing at least 20 people and displacing One part of the country that experienced the more than 517,000 people.81 Local governments compound effects of COVID-19 and climate change reported that approximately 170,000 houses were is Albay — one of the provinces highly vulnerable to either damaged or destroyed. The typhoon left both climatic and geologic hazards. For the past two substantial damage in the order of USD230 million. decades, the province has largely achieved its goal Not much more than a week later, Typhoon Vamco of zero casualties from disasters, such as typhoons, wreaked havoc across the same island with more storm surges, earthquakes, and volcanic eruptions.83 than three million people affected and another Its innovative approaches to tackling disaster risk 283,656 people seeking refuge in 2,205 evacuation reduction and climate change adaptation have centers.82 By the time the second typhoon arrived, been lauded both nationally and internationally, more than 82,000 people remained displaced in including by UN and the World Bank.84 Some of its the provinces affected by the first typhoon. In all pioneering efforts in mainstreaming climate change these disaster events, residents had no choice adaptation into disaster risk reduction include but to break quarantine and relocate to makeshift the introduction of climate change and disaster evacuation centers for fear of possible landslides, preparedness modules into the curriculum of K-12 storm surges, and floods. students, hence enhancing disaster and climate awareness among the populace.85 The province The capacity and resources of both national and has also invested in strengthening its capacity to local governments were put under tremendous use modern technology for climate forecasting, stress by the joint occurrences of both the pandemic early warning, and land use planning, as well as and the climate-induced disasters. Climate-related established programs for resilient livelihoods as disasters are not new to emergency responders, part of climate change adaptation. but responding to a disaster during the time of a pandemic is certainly a new experience that Facing the Pacific Ocean, Albay and its adjacent governments in a number of developing and provinces are on the typhoon track. Since the developed countries (such as India, Bangladesh, beginning of the pandemic, Albay, despite being and the United States) have had to endure during the 20th-biggest province (out of 81) in the country, COVID-19. In the Philippines, government officials has maintained some of the lowest incidence of 26 | COVID-19 and Climate-Smart Healthcare COVID-19 cases in the country.86 When the three Disaster risk reduction and response plans can be major typhoons hit the Philippines during the revised to incorporate epidemic control, for instance COVID-19 pandemic, local governments were in preemptive evacuations before the typhoon already mobilized for the continued provision arrives. Such anticipatory planning will ensure safe of COVID-19-related services. As a result, and orderly relocation that will eventually save lives advanced risk communication and preemptive from both the infectious disease and the calamity. evacuations were easily deployed in a timely The relationship between climate- and pandemic- manner. While Albay managed to keep its zero-ca- resilience building is bidirectional. As countries sualty target intact in the aftermath of Typhoon like the Philippines are able to leverage climate Vongfong,87 Typhoon Goni resulted in at least adaptation and resilience efforts for tackling 10 reported deaths, as of November 10.88 While COVID-19, lessons from the pandemic response the existing disaster preparedness and response can also potentially inform their climate adaptation systems certainly contributed to minimizing and resilience strategies in return. mortality, whether due to COVID-19 or typhoons, COVID-19 has shown the limitations of pre- pandemic mechanisms when multiple emergencies 7. THE REPUBLIC OF YEMEN: occur at the same time. STRENGTHENING DISEASE LESSONS LEARNED SURVEILLANCE TO COMBAT COVID-19 AND CLIMATE IMPACTS The early experience of the Philippines in tackling COVID-19 has demonstrated that pre-pandemic investments in disaster risk reduction and climate SUMMARY change adaptation can be harnessed for mounting Globally, violent conflict has spiked dramatically an immediate response to an unprecedented viral since 2010 according to the World Bank,89 with pandemic. While the physical manifestations of climate change compounding the world’s fragility. climate-related disasters and infectious disease Against this backdrop, the COVID-19 pandemic has epidemics may vary, there are principles, capacities, added even greater stress to the already complex and resources common to both. However, the situation in the Republic of Yemen. Despite the Philippine experience also showed that disaster challenges and the first confirmed COVID-19 case preparedness and climate adaptation plans do not reported on April 10, 2020, the electronic integrated often take into consideration infectious disease disease early warning system (eIDEWS) — the only outbreaks, whether they are climate-related or not. surveillance system in the Republic of Yemen to detect disease outbreaks, including cholera — has As climate change accelerates, climate-related been utilized effectively for the COVID-19 response. disasters, such as typhoons and extreme flooding, are expected to continue afflicting the Filipino The functionality, utility, and universality of the people in the future, even before the pandemic surveillance system have been shown to not only is over. Lessons from epidemic control should, respond to disease outbreaks from escalating therefore, be incorporated into existing emergency conflict and climate vulnerabilities in the Republic response systems in preparation for future shocks. of Yemen, but also in its ability to capture relevant Country Case Studies | 27 data in its COVID-19 detection and response. This within the country have been stymied by cholera has enabled rapid response mobile teams in the outbreaks and medical shortages.91 A 2019 Human- country to investigate and rapidly respond to itarian Needs Overview Report92 estimated that two the outbreak and monitor disease trends across million children under the age of five years along various levels — district, governorate, and national. with more than one million pregnant and lactating women were suffering from acute malnutrition. COVID-19 SITUATION IN THE Additionally, 17.8 million people lack access to safe REPUBLIC OF YEMEN water and sanitation, while 19.7 million are unable to obtain adequate health care.93 Compounding the The Republic of Yemen—one of the poorest situation, the coronavirus outbreak has impacted countries in the Middle East—has experienced the fragile health system and infrastructure, which increasing violence that has disrupted millions are heavily reliant on foreign aid. of lives, resulting in mass casualties and massive displacement. Twenty-four million civilian Yemenis The first confirmed case of COVID-19 in the are in need of humanitarian assistance, according Republic of Yemen was reported on April 10, to the United Nations Office for the Coordination of 2020.94 As of November 5, 2020, there have been Humanitarian Affairs.90 As a result of the humani- 2,063 COVID-19 cases in the Republic of Yemen, tarian crisis, medical assistance and capacity with 601 deaths.95 However, the actual number of 28 | COVID-19 and Climate-Smart Healthcare cases is unknown due to the low levels of both droughts, sea-level rises, and landslides, which are testing capacity and sharing of information. WHO compounded by climate change.100 These climate is supporting 37 isolation units (out of 59) through events threaten food security, water, agriculture, the Republic of Yemen Emergency Crisis Response development, and adversely affect human health Project, with partners supporting or running other by increasing the likelihood of diseases, including isolation units throughout the country. In May cholera, dengue, malaria, and others.101 Additionally, 2020, WHO commenced the monthly mapping water resources are scarce with rapid groundwater of COVID-19 measures in non-COVID-19 health depletion. facilities through other partners.96 The Republic of Yemen has experienced at least By the end of July 2020, more than 19,680 commu- one natural disaster every year for the last 20 nity-based volunteers were mobilized to educate years.102 Climate variability is likely to increase, the community on the coronavirus, its transmission, leading to negative impacts on agriculture, while along with the ways of suppression and protection. intense rainfall events increase the risk of floods Additionally, UN procured more than 14,300 metric that will, in turn, heighten the risk of waterborne tons of medical equipment and supplies, with a total diseases, thereby weakening the health of the of 11,380 metric tons already present in the country population. For example, heavy rains, occurring and another 2,936 metric tons in the pipeline.97 earlier than usual in mid-February 2019, resulted in a resurgence of cholera in the country. CLIMATE PROFILE OF THE Susceptibility to disease further weakens the REPUBLIC OF YEMEN resilience of the population to future outbreaks, Despite the ongoing conflict, the Republic of Yemen including pandemics, such as COVID-19. It was submitted its climate action plan to the United recognized that strengthening the national disease Nations Framework Convention on Climate Change surveillance system — eIDEWS — would be key (UNFCCC) in 2015.98 The plan outlined its intended to enhancing the ability of the health system nationally determined contributions (INDCs). It is to detect future outbreaks and target interven- important to point out that the economy of the tions, particularly in a humanitarian emergency. country is largely dominated by the oil sector.99 Public health surveillance systems can become However, the ensuing war in 2015 destroyed the fragmented or overwhelmed in times of a human- economy across various sectors, subsequently itarian emergency, thus impacting the timeliness disrupting supplies of food, fuel, and medicines, and quality of data. This is exacerbated in the which are dangerously low or not available. Republic of Yemen that is also vulnerable to the effects of climate change and disease outbreaks, In addition, nearly 10.6 million, or 41 percent of thus further impacting the health of the population. the population, are food insecure. This can be partially attributed to the country’s geograph- STRENGTHENING DISEASE SURVEILLANCE ical location. Located at the southern end of the Arabian Peninsula, the Republic of Yemen is a Under World Bank financing, eIDEWS was Middle Eastern country with a largely tropical expanded in 2017 to cover 1,991 sites consisting and subtropical desert climate. The country of 22 governorates and 333 districts in 2019.103 experiences extreme heat of up to 40°C, floods, An additional 450 new sites have been planned Country Case Studies | 29 for 2021. Initially designed as an early warning probable coronavirus cases and/or districts where system, eIDEWS was established to strengthen contact tracing and contact follow-ups needed to routine disease surveillance, predominantly in be initiated. While the main district rapid response the early detection of epidemic-prone diseases.104 teams (DRRTs) have been deployed in the past to eIDEWS collects data on 28 diseases from health contain outbreaks, such as cholera, and continue facilities, vector control, and disease outbreaks, to be deployed for both COVID-19 and other including cholera, dengue fever, and malaria. It is disease outbreaks, they have been initiated to directly implemented by the Republic of Yemen’s supervise and deploy mobile-specific COVID-19 Ministry of Public Health and Population at various teams in the affected districts. It has been decided levels (health facility, district, governorate, and that once additional mobile teams are activated, central), with the close support of WHO.105 The aim the governorate rapid response teams (GRRTs)/ of eIDEWS is to reduce morbidity and mortality main DRRTs will conduct on-the-job training for the through early detection and rapid responses to additional mobile teams. In those governorates and disease outbreaks. It does so by generating alerts districts where the GRRTs/main DRRTs are unable that flag the need for epidemiological investiga- to train the recruited mobile team, the central RRTs tions to take place in affected districts and through and the eIDEWS team have been requested to the issuance of weekly eIDEWS bulletins that are provide support.107 published and shared among health partners and other stakeholders. This has allowed for the LESSONS LEARNED reporting of notifiable diseases in a timely manner. For example, in 2017, a total of 134,456 alerts were Under extremely tenuous circumstances, involving generated by eIDEWS; 128,190 alerts were verified multiple outbreaks, including cholera and COVID-19, as true alerts, with the detection of five disease the eIDEWS disease surveillance system in the outbreaks, indicating a positive predictive value Republic of Yemen has kept the fragile health of 95 percent.106 system of the country functioning. Based on the scientific literature assessing its functionality, it eIDEWS has now been galvanized in the COVID-19 was reported to be stable and able to collect and response. In anticipation of the second wave, the health care staff in 21 COVID-19-specific facilities manage data without any major disturbances.108 were trained on case management. In addition, Even with unstable internet connectivity, data can surveillance trainings (such as contact tracing still be received via phone calls, with focal points and case definition) were conducted. Further, trained to input the data received, thus allowing Governorate Rapid Response Teams and Rapid for the flexibility of the surveillance system.109 Addi- Response Teams (RRTs) were mobilized through tionally, it is available 24/7, with access available the World Bank financing to respond to COVID-19. any time when needed. Despite the global These RRTs function at different levels (district, pandemic of COVID-19 causing severe disruptions, governorate, and central) as firstline responders eIDEWS has continued to follow other disease for the investigation and rapid response to any outbreaks, including cholera, while being utilized outbreak. COVID-19-specific RRTs were activated in the COVID-19 response. Disease trends can be in 84 priority districts, based on the criteria that monitored and changes to the number of cases included districts declaring confirmed and/or easily observed. The system can also generate 30 | COVID-19 and Climate-Smart Healthcare short message service (SMS) alerts if the number of cases exceeds predetermined thresholds. These key findings indicate that eIDEWS is a robust and resilient system, and despite the humanitarian crisis, the system is still functioning. It is the only surveillance system in the Republic of Yemen that provides early warnings to trigger investigations, along with containment or control, which are vital for the early detection of disease outbreaks in a country vulnerable to the negative effects of climate change and the COVID-19 pandemic. The utility of a national surveillance system for disease detection, such as eIDEWS in a conflict zone, indicates the value of investing in such infrastructure, not just for the strengthening of health systems or solely for the monitoring of disease outbreaks due to a changing climate but also for its universality. Country Case Studies | 31 ENDNOTES 1 United Nations Sustainable Development, 1993, Agenda 21. United Nations Conference on Environment & Develop- ment. Retrieved from https://sustainabledevelopment.un.org/content/documents/Agenda21.pdf. 2 One Planet Network, 2020, “The SPP Programme,” March 27, 2020, https://www.oneplanetnetwork.org/sustainable-pub- lic-procurement/spp-programme. 3 UN Informal Interagency Task Team on Sustainable Procurement in the Health Sector, 2021, https://savinglivesustainably. org/ 4 United Nations Development Program, 2019, “The Sustainable Health in Procurement Project (SHiPP). Health Care With- out Harm,” https://noharm-global.org/sites/default/files/documents-files/6178/SHiPPBrochure.pdf. 5 Asamblea Departamental de Cundinamarca, 2019, “Ordenanza No. 0108/2019: Por la cual Se Adopta la Estrategia de Compras Publicas Sostenibles en el Departamento de Cundinamarca. Ordenanza Cundinamarca,” https://www.hospital- esporlasaludambiental.net/wp-content/uploads/2019/12/Ordenanza-Cundinamarca.pdf. 6 Ministry of Health of Colombia, 2020, “During the Pandemic, Telemedicine was Consolidated in the Country,” Press Release, https://www.minsalud.gov.co/Paginas/Durante-la-pandemia-se-consolido-la-telemedicina-en-el-pais.aspx. 7 World Bank Group, 2021, “The Gambia: Climate Data Projections,” https://climateknowledgeportal.worldbank.org/coun- try/gambia/climate-data-projections. 8 Ministry of Health, Government of The Gambia, 2020, Report No. 4/2020, World Health Organization, Washington, DC, March 22, 2020, http://www.moh.gov.gm/wp-content/uploads/2020/03/Final_Sitrep-21st-22nd-March-2020.pdf. 9 Johns Hopkins University, n.d., “Coronavirus Resource Center,” https://coronavirus.jhu.edu/map.html. 10 United Nations Fund for Population Activities, n.d., “The Gambia COVID-19 Response Plan,” https://gambia.unfpa.org/ sites/default/files/pub-pdf/UNFPA%20The%20Gambia-%20COVID19%20Response%20Plan%20Final_0.pdf. 11 World Bank Group, 2020, The Gambia COVID-19 Preparedness and Response Project: Project Appraisal Document. Washington, DC: World Bank, http://documents1.worldbank.org/curated/en/925521585951567235/pdf/Gambia-COVID- 19-Preparedness-and-Response-Project.pdf. 12 Ministry of Health, Government of The Gambia, 2020, Situation Report 198. World Health Organization, Washington, DC, November 17, 2020, http://www.moh.gov.gm/wp-content/uploads/2020/11/Gambia_The_COVID-19_Sitrep-17th- Nov-2020.pdf. 13 World Bank Group, 2021, “The Gambia: Climate Data Projections,” https://climateknowledgeportal.worldbank.org/coun- try/gambia/climate-data-projections. 14 World Bank Group, 2021, “The Gambia: Climate Data Projections,” https://climateknowledgeportal.worldbank.org/coun- try/gambia/climate-data-projections. 15 Department of Water Resources, n.d., Intended Nationally Determined Contributions of The Gambia. 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