World Bank Group Climate Change and Health Approach and Action Plan Investing in Climate Change and Health Series World Bank Group Approach and Action Plan for Climate Change and Health © 2017 International Bank for Reconstruction and Development/The World Bank  The World Bank  1818 H St. 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. Because the World Bank encourages dissemination of their 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 St. NW, Washington, DC 20433, USA; fax: 202-522-2422; email: pubrights@worldbank.org. This document is part of the “Investing in climate change and health” series, which aims to enable management and task teams with the tools and resources necessary to improve World Bank action on climate change and health. Current documents in this series include: • “World Bank approach and action plan for climate change and health” • “Geographic hotspots for World Bank action on climate change and health” • “Climate-smart healthcare: low carbon and resilience strategies for the health sector” Acknowledgements This action plan is a joint production of the World Bank Group Health Nutrition and Population Global Practice and Climate Change Cross-Cutting Solutions Area. Montserrat Meiro-Lorenzo led with work, with key advice and input from Timothy Bouley, Gary Klei- man, Patrick Osewe, Tamer Rabie, Richard Seifman, and Hui Wang. The Nordic Development Fund (NDF) provided resources, and the team is indebted to the goodwill and support of the NDF team, particularly Pasi Hellman, Martina Jagerhorn, and Leena Klossner. The concept and impetus for this work originated at a meeting of the Prince of Wales’ Charity Foundation’s International Sustainability Unit, convened by HRH The Prince of Wales and with support from Justin Mundy, Eric Chivian, Andy Haines, Hugh Montgomery, and Laura Partridge. Overall guidance within the World Bank was provided by John Roome, Tim Evans, James Close, Olusoji Adeyi, and Stephen Hammer. Important contributions were also made by Sameer Akbar, Perpetual Boateng, Laura Bonzanigo, Shun Chonabayashi, Jane Ebinger, Paula Garcia, Stephane Hallegatte, Yin Qiu, Meerim Shakirova, and Sanjay Srivastava. Damian Milverton of GlobalEditor.org performed the final edit and review. Formatting and graphic development were undertaken by Shepherd Incorporated. iii Contents Foreword vii Acronyms ix Introduction 1 Scope and Limitations 2 1. The Scope of the Climate Challenge to Health Development 3 Climate Change Pathways and Climate Drivers 5 2. Evolution of the Climate-Health Imperative 7 The Global Perspective 7 The World Bank Perspective 9 The Conceptual Framework: Making UHC Climate Smart 3.  for World Bank’s Clients’ Population 13 The World Bank Climate Change and Health Conceptual Framework: Climate-Smart UHC 14 4. Operational Framework for WBG Approach to Health and Climate 21 Strategic Objectives: Integrating Climate and Health Considerations in WBG Operations 22 Operational Pillars 23 Transversal Support Areas 26 5. The Climate Change and Health Plan of Action FY2017–2020 29 Implementation Roles and Arrangements 30 Conclusion and Next Steps 35 Annex A. References 37 Annex B. Health Sector Interventions in Response to Climate Change 39 Mainstreaming/Integrating Climate-Health Dimensions Annex C.  across World Bank Operations 43 v Foreword Climate change is a risk multiplier that threatens to unravel decades of development gains. Among the most critical and direct risks to humans is the impact of climate change on health. Heat stress will worsen as high temperatures become more common and water scarcity increases; malnutrition, particularly in children, could become more prevalent in some parts of the world where droughts are expected to become more frequent; and water- and vector-borne diseases are likely to expand in range as conditions favor mos- quitoes, flies, and water-borne pathogens. Worse still, these threats will be greatest in regions where the population is most dense, most vulnerable, and least equipped to adapt, pushing more people in poverty and reinforcing a cycle of environmental degradation, poor health and slow development. Addressing these climate-associated health risks is critical. Alongside risk, there is opportunity. Responses to climate change have unearthed significant potential for improving both human health and the environ- ment. Low carbon hospitals can draw upon the many advances made by the energy sector in developing cleaner and renewable resources. Pharmaceutical supply chains can benefit from more efficient and less polluting transport. And food and nutrition can be improved by the advances achieved through climate- smart agriculture. Climate change challenges are multi-sectoral and so too are the solutions. At the World Bank Group, we are tackling different dimensions of these environment and health threats in different ways. For example, the ‘Pollution Management and Environmental Health’ Trust Fund addresses air pollution, toxic land pol- lution, and marine litter. Work on Climate-Smart Agriculture aims to sustainably increase food productivity and human well-being in a changing climate. We are putting in place a new operational framework for strengthening human, animal, and environmental health systems in response to disease threats. And within the health sector, we have made Universal Health Coverage core and increasingly considerate of climate change and resilience. At the World Bank Group, we work with the broader development community to create solutions that can respond to and reduce these risks. Our work aligns with other global efforts aimed at improving envi- ronmental and human health, such as the work of the Climate and Clean Air Coalition, Global Alliance for Clean Cookstoves, One Health and Planetary Health communities, and broader efforts to achieve the Sustainable Development Goals. vii W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth This report outlines a World Bank Approach and Action Plan for climate change and health. It is intended to establish an institu- tional foundation from which country programming can be built. The document reflects a consultative process across the World Bank Group taken together with other experts to determine the most promising and feasible practices. And though the plan is specific to the World Bank Group, the approaches are intended to be generally applicable to any institution aiming to finance or implement climate change and health programs. The work presented here is expected to assist the development community in further mainstreaming climate change and health into development operations so that we may address the emerging needs of vulnerable communities, particularly women and children. We are committed to working with development practitioners around the world on climate change and health, capitalizing upon associ- ated opportunities and technologies, and contributing to the overall goals of ending extreme poverty and boosting shared prosperity. James Close Olusoji Adeyi Director Director Climate Change Group Health, Nutrition, and Population World Bank World Bank viii Acronyms AAP Ambient Air Pollution IFC International Finance Corporation CCSA Cross-Cutting Solutions Area IHME Institute for Health Metrics and CEETI  City Energy Efficiency Transformation Evaluation Initiative IPCC The Intergovernmental Panel on  CMU Country Management Unit Climate Change CoP Conferences of the Parties LLI Leadership Learning and Innovation CPFs Country Partnership Frameworks MDG Millennium Development Goals CC Climate Change MOOC Massive Open Online Course CSA Climate Smart Agriculture NAPA National Adaptation Programs of Action CURB  Climate Action for URBan Sustainability NDC Nationally-Determined Contributions tool NDF Nordic Development Fund DPOs Development Policy Operations OECD Organization for Economic  EDGE Excellence In Design For Greater Co-operation and Development Efficiencies PPCR Pilot Program for Climate Resilience ENR Environment and Natural Resources SCDs Systematic Country Diagnostics ESMAP Energy Sector Management Program SDG Sustainable Development Goals GFDRR  lobal Facility for Disaster Reduction G SLCP Short-Lived Climate Pollutants and Recovery TA Technical Assistance GHG Greenhouse Gas TTL Task Team Leader GP Global Practice UHC Universal Health Coverage HAP Household Air Pollution WHO World Health Organization HNP Health Nutrition and Population WMO World Meteorological Organization ix Introduction Climate change (CC) impacts on health outcomes—both direct and indirect—are sufficient to jeopardize achieving the World Bank Group’s visions and agendas in poverty reduction, population resilience, and health, nutrition and population (HNP). In the last 5 years, the number of voices calling for stronger international action on climate change and health has increased,1 as have the scale and depth of activi- ties. But current global efforts in climate and health are inadequately integrated. As a result, actions to address climate change—including World Bank Group (WBG) investment and lending—are missing opportunities to simultaneously promote better health outcomes and more resilient populations and health sectors. Accordingly, with the financial support of the Nordic Development Fund (NDF), the World Bank Group set out to develop an approach and a 4-year action plan—outlined in this paper—to integrate health-related climate considerations into selected WBG sector plans and investments.2 The approach and 4-year action plan is to integrate health-related climate considerations into selected WBG sector plans and investments. It does so using the prevailing health sector conceptual framework of Universal Health Coverage, which brings in the positive and negative impacts that investments in other sectors/areas of the economy have on health outcomes. A substantial share of the impacts that climate has on health are mediated through interventions in sectors other than health. Therefore, while reducing GHGs for climate change reasons will generally produce substantial short- and long-term benefits for health, that alone is unlikely to maximize the outcomes of health investments, and in the case of some investments in non-health sectors it may even negatively affect health outcomes.3 This paper proposes a two-pronged approach. One prong proposes to focus most of the World Bank’s efforts on improving the climate resilience of the health sector, both through purely adaptive solutions but also through improvements to the sector’s sustainable energy access and efficiency. The other prong proposes to look at selected investments in other sectors that affect climate-sensitive health outcomes, to maximize development impact while minimizing the possibility of maladaptation. As such, this paper sets out to inform key groups within the World Bank. It outlines a potential approach for the WBG in climate and health by considering the current health-climate change impera- tive, the evolution of the global policy environment and the picture today, and global initiatives and 1  Climate change has been called both the ‘biggest global health threat’ and the “greatest global health opportunity” of the 21st century (Costello, 2009; Watts, 2015). The Director General of the World Health Organization (WHO) has called climate change “the defining global health threat of the 21st century” (Chan, 2014), and the Executive Secretary of the United Nations Framework Convention on Climate Change has noted “a climate agreement is a global health agreement.” 2  In addition, NDF resources have also been allocated under a different Bank product to support Mozambique’s Ministry of Health in their efforts to strengthen the health sector’s resilience to climate change. 3  E.g.: Irrigation schemes, and reintroduction of mangroves as a coastal protection may help vector disease transmission if parallel measures are not considered. Fuel policy exclusively looking at pollution for health reasons may have substantial GHG impacts or vice versa, and climate resilient transport investments may worsen chronic flooding in certain areas or stimulate urban development in areas likely to become unhealthy because of flooding. 1 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth WBG roles now and in the future. It also describes strategic objec- the HNP GP is putting forward, emphasizes the importance of tives and potential operational steps and tools. The underlying other sectors to improving health outcomes. premise is that climate affects health today and has the potential There are two factors that argue in favor of UHC as the basis to significantly impact global health and poverty reduction in the for a new conceptual framework. First, it ensures the approach future, and that there exists a number of options for the WBG and plan can be understood and integrated within the context of and its partner countries to prevent an added burden of illness the existing priorities and activities of the WBG’s health, nutrition or death from a changing climate. and population community. Second, it serves to recognize the centrality of health to efforts in other sectors. Scope and Limitations In addition to the analytic work already carried out by the Climate Change Cross-Cutting Solutions Area (CCSA), this paper Reducing the impact of CC on health and increasing the resilience has benefited from and builds on the knowledge generated by of populations to the effects of climate on health requires policies, multiple initiatives and research across GPs, as well as the WBG technologies and interventions to increase adaptive capacity and Climate Action Plan and regional CC strategies. It also draws mitigate pollution and greenhouse gases across a number of sec- from documents prepared as part of the “Building an Approach tors and actors. The proposed approach recognizes this and takes to Climate Change and Health” knowledge product financed by into consideration ongoing efforts to counter climate change and NDF, including: its effects by various actors and their generally positive impacts • A geographical hotspots analysis using existing indicators on health. It focuses on leveraging those efforts and addressing to identify countries where climate change—or exposure to specific gaps. For instance, while reduction of greenhouse gas drivers of climate change (e.g., air pollution)—are expected (GHG) emissions (i.e., climate mitigation) is central to health in to most significantly alter the burden of disease. The analysis the short term (by addressing pollution) and in the long term (by guides the focus of this approach. slowing or stopping CC), the proposed approach places limited emphasis on this remedy given that such efforts are already under- • A report on “Climate Smart Healthcare” which aims to iden- way through other sectors. Instead, the proposed approach seeks tify low carbon and resilience strategies for the health sector. to address the most significant apparent weakness—the resilience • Two sector knowledge notes identifying issues and entry of the health sector, particularly its adaptive capacity. In those points to integrate health-related climate consideration into sectors outside health, nutrition and population, the emphasis is the agriculture and transport sector portfolios. on maladaptation, given its potential negative effects, as well as The CC and health work is anchored in the CCSA commit- opportunities to increase the impact of development activities by ment to deliver on corporate mandates, respond to client demand optimizing them for both climate change and climate sensitive by supporting efforts across GPs and country management units effects. Taking into account both the initiatives already underway (CMUs), and position the World Bank externally as the partner of and these two goals, this paper proposes a plan based around choice in global climate change risk identification, mitigation and universal health coverage (UHC) as the entry point for climate response. The participatory approach taken to develop this work engagement as it relates to health outcomes. Achieving UHC is has enhanced the cooperation between the CCSA and relevant the current core goal and strategic framework for the global health GPs on this topic. community and for the World Bank’s HNP Global Practice (GP). The strategic directions to support countries to achieve UHC that 2 Chapter 1 The Scope of the Climate Challenge to Health Development Climate impacts on health are likely to be greater in low- and middle-income countries. These are often most vulnerable to climate shifts and have the least capacity to take adaptation or mitigation measures given their weak health infrastructure and capacity. The threat posed by climate to health outcomes has been extensively discussed for some years and is seen to be growing. Climate change impacts could drag more than 100 million people back into extreme poverty by 2030 (Hallegate, 2016), with a significant part of this reversal attributable to negative impacts on health outcomes. There is clear and mounting evidence that health outcomes will—in large part—be negatively impacted by rising sea levels and temperatures and weather extremes due to climate change. Several of the emissions that drive climate change also affect health directly. These impacts will be greatest in the poorest countries and regions where the population is densest, most vulnerable, and least equipped to adapt (World Bank, 2012, 2013, and 2014; Smith et al., 2014). Given the complexity of social and environmental factors that influence disease and health outcomes, the precise extent of this impact is difficult to establish. The World Health Organization (WHO), for example, estimated in the early 2000s that climate change was already accounting for an additional 150,000 annual deaths (WHO, 2004). Forecasts suggest that by 2030 an additional 250,000 deaths per year will occur from heat exposure, undernutrition, malaria, and diarrheal disease due to climate change. These estimates are regarded as conservative and do not include all climate-sensitive health impacts, e.g., pollution, injuries, non-malaria infectious disease, and others for which projection data is lacking (WHO, 2014). Figure 1.1 shows the endpoints of climate-sensitive health impacts and correlates them to environmental variables, sensitive to a cycle of broader climatic change. This additional burden of disease comes with a significant economic global and local impact. One study (Ebi, 2008) estimates the global additional costs associated with climate change-related cases of just three sets of diseases—malaria, diarrheal diseases, and malnutrition—to be US$4–12 billion in 2030 under the business-as-usual scenario.4 A significant part of this burden is borne by poor countries where those three conditions are already persistent. Separate work suggests there are also significant costs associated with disaster-related health impacts. Although little research has been undertaken for the developing world, it was estimated that climate-related disasters have already caused US$14 billion in health-related costs over a 10-year period in the US alone (Knowlton, et al., 2011). Other research has estimated that impacts associated with labor productivity losses due to excess heat (correlating to health stress) may be as much as 11–20 percent in heat-prone regions such as Asia and the Caribbean by 2080 (Kjellstrom, 2009). If avoided, 4  This corresponds to a scenario that assumes that nothing additional would be done to control climate (e.g., reduce greenhouse gas emissions) beyond what would occur through increased efficiency, reductions in air pollution, etc. It corresponds to a CO2 concentration in the atmosphere of 750 parts per million. 3 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth Figure 1.1: Climate sensitive health impact endpoints. Impact of climate change on human health Asthma, Injuries, fatalities cardiovascular disease Severe Malaria, dengue, Heat stress, Air pollution weather encephalitis, hantavirus, cardiovascular failure Rift Valley fever U ERAT RES Vector-borne Heat EMP W diseases T G EA IN TH RIS ER EXTREME Water and Malnutrition, food Allergies Respiratory allergies, diarrhea, harmful supply poison ivy LS algal blooms VE S LE A RISING SE Waterborne Mental health diseases Environmental refugees Cholera, Anxiety, despair, cryptosporidiosis, depression, campylobacter, post-traumatic stress Forced migration, leptospirosis civil conflict Source: Adapted from J. Patz. National Oceanic and Atmospheric Administration. (https://toolkit.climate.gov/image/505). these aggregate health costs—along with other benefits of limiting millions more suffer from related diseases, including pneumonia warming to 2°C—can amount to economic savings that exceed the (particularly affecting children), lung cancer, cardiovascular disease, US$1.5–2 billion per year for health sector adaptation and start stroke, and chronic obstructive pulmonary diseases (WHO, 2015). to approach the estimated US$70–100 billion per year of overall As such, reducing emissions of greenhouse gases through better adaptation investment needed by 2050 (World Bank, 2009). transport, food and energy-use choices can result in improved Importantly, not all climate-related health impacts of concern health, especially through the reduction of air pollution. will occur in the future. Along with some direct impacts, the emis- The economic costs associated with the air pollution-related sions that drive climate change are largely co-emitted by the same burden of disease are also considerable. A study by the Organization sources that are responsible for air pollution. The 2013 Global for Economic Co-operation and Development (OECD, 2014) found Burden of Disease data suggest that ambient air pollution (AAP) that air pollution illnesses and mortalities correspond to US$1.7 tril- and, in the developing world, household air pollution (HAP) already lion of lost output annually in OECD countries, US$1.4 trillion in kill more than 5.5 million people annually (IHME, 2016). Tens of China, and US$500 billion in India. 4 T he Sc op e o f t he C li m at e C h alle n g e to He a lth D evel opme nt Figure 1.2: Exposure pathways by which climate change affects health. Mediating factors Environmental Social infrastructure Public health capability conditions and adaptation Direct exposures • Geography • Warning systems • Baseline weather • Flood damage • Socioeconomic • Soil/dust • Storm vulnerability status • Vegetation • Heat stress • Health and nutrition • Baseline air/water status quality • Primary healthcare CLIMATE CHANGE Indirect exposures HEALTH IMPACTS Mediated through natural • Precipitation systems: • Undernutrition • Heat • Allergens • Drowning • Floods • Disease vectors • Heart disease • Storms • Increased water/air • Malaria pollution Via economic and social disruption • Food production/ distribution • Mental stress Source: Smith et al., 2014. Climate Change Pathways 2. Ecosystem-Mediated Pathway This applies to illnesses and deaths due to events such as and Climate Drivers shifts in patterns of disease-carrying mosquitoes and ticks, The Intergovernmental Panel on Climate Change (IPCC) has iden- or increases in waterborne diseases caused by warmer condi- tified three ways in which climate change can influence health tions and increased precipitation and runoff. It also includes outcomes (Figure 1.2): 1) the direct pathway of climate change worsening air quality in general, and increased air pollution impact on health; 2) an ecosystem-mediated pathway for health in particular, due to temperature increases. impacts; and 3) a human institution-mediated pathway for health 3. Societal Systems/Human Institutions-Mediated Pathway impacts (Smith et al., 2014). Co-emitted air pollution is treated This includes death and sickness from altered systems cre- separately to better account for the health impacts associated ated by humans. These include agricultural production and with the drivers of climate change and is classified in terms of distribution, urban environments and food insecurity, stress sources that contribute to ambient air pollution versus those that and undernutrition and violent conflict caused by popula- contribute to household air pollution. tion displacement, economic losses due to widespread “heat 1. Direct Pathway to Health Impacts exhaustion” impacts on the workforce, or other environmental This pathway refers to direct illness and death due to exposure stressors. to extreme weather events in which climate change may play In Figure 1.2, the green box indicates the moderating influences a role. These include effects of high heat (including “heat of local environmental conditions on climate change exposure exhaustion” and heat waves), floods, storms, air quality, etc. pathways in a particular population. The gray box indicates the 5 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth extent to which factors such as background public health and Mitigation, in addition to delivering long-term health effects socioeconomic conditions and adaptation measures moderate by reducing the level of GHG emission, would also have an imme- the actual health burden produced by the three categories of diate impact on health outcomes due to lower pollution levels. exposure. The green arrows at the bottom indicate that there A significant proportion of potential deaths could be avoided may be feedback mechanisms—positive or negative—between with stringent climate mitigation, given air pollution’s role as societal infrastructure, public health, and adaptation measures a co-emitted byproduct of fossil-fuel combustion. However, the and climate change itself. remaining deaths are also avoidable through mitigation of black A significant percentage of the impacts of climate change carbon and methane, the so-called short-lived climate pollutants and its drivers is preventable through a range of proven health or SLCPs (Rogelj et al., 2014). and non-health interventions and adaptation measures that help Importantly, the present health status of a population may increase a population’s resilience. According to the IPCC, there be the single most important predictor of both the future health is substantial potential to reduce the climate impacts on health impacts of climate change and the costs of adaptation (Smith, across eight dimensions5 by shifting to higher levels of adaptation 2014). A population’s health status is a function of both access than those currently proposed. Whether in infectious disease, heat to health services and general development, the latter measured waves or natural disasters, history has shown that preparedness and through access to other basic goods and services such as food, response to threats can greatly limit the losses to health, human education, clean water and energy, clean air, and disaster pre- life and economies. For example, in 1970 a Category 3 hurricane paredness and protection. Currently, UHC is the ultimate goal of battered East Pakistan (present day Bangladesh) resulting in the health community as reflected in the new Sustainable Devel- 500,000 deaths. Similar storms hit Bangladesh again in 1991 and opment Goals (SDGs), national health policies, and strategies 2007, causing 140,000 and 3,400 deaths, respectively. Collabora- at development institutions. Achieving UHC—that is, ensuring tive adaptation over the intervening decades led to these dramatic that 100 percent of the population has access to equitable and improvements in lives lost (Smith et al., 2014) by increasing Ban- affordable basic health promotion, prevention, and treatment gladesh’s resilience to natural disasters. The country shifted to a and rehabilitation services—would significantly contribute to higher level of adaptation that included improving general disaster increases in a population’s resilience to both climate change education (greatly assisted by rising literacy rates, especially among impacts and the impacts of pollution. Further details on UHC women), deployment of early warning systems (which included are provided in Chapter 3. community mobilization), building a network of cyclone shelters, Despite evidence both of the problems and their potential relocation efforts, and increasing connectivity of health facilities solutions, there has been little effort in most low- and low-middle in high-risk areas. income countries to increase the levels of community resilience through interventions in health and other sectors to improve health 5  Those are: heat effects, vector-, food-, and waterborne diseases, mental and occu- outcomes. This historic trend is currently changing, and we may pational health, undernutrition, air quality, and extreme weather events. be at a “tipping point” for health and climate change. 6 Chapter 2 Evolution of the Climate-Health Imperative The past 24 years have brought advances in better understanding and quantifying the impacts of CC and pollution in health. However, it is only in the past 5 years (and notably in 2015) that a series of global changes and events have taken place, opening for the first time a real window of opportunity for intervention at significant scale. To seize this emerging opportunity, steps need to be taken globally and by the WBG to pursue well-targeted knowledge gathering and operational and capacity building efforts to correct some of the evident system failures. In this chapter is a brief summary of global and WBG efforts to date. The Global Perspective Growing Awareness and Research Attention on Impacts of Climate Change and Health Beginning with the Rio Earth Summit in 1992, a small group of health experts has advocated greater consideration of the impacts of climate change on human health. Subsequently, there has been a growing body of research addressing both singular and collective dimensions of climate change and health. Initially, public work in this area focused on raising awareness of the impacts of climate change: notably vector-borne diseases, waterborne diseases, and malnutrition. Over time, the focus on impacts expanded to encompass approaches to adaptation and by the early 2000s included heat stress, psy- chological impacts, respiratory impacts, and injuries from extreme weather. The onset of the European heat wave of 2003 served to heighten interest in the field. At the global level, this focus has gradually expanded to address the co-health benefits of mitigation (such as cardiorespiratory health), the recur- rence in recent years of climate-sensitive infectious diseases, the greater scientific understanding of the impacts of temperature changes on pollution, the quantification of the related burden of disease, and the growth of highly polluted megacities. In the meantime, specialized research institutions have been established, nongovernmental organiza- tions have dedicated themselves to the cause, the World Health Organization (WHO) and Pan-American Health Organization have created climate change and health divisions, and a number of private foun- dations have devoted specialized funding streams. WHO has led the effort in developing a catalogue of country engagement resources including training, assessments, and analytical pieces to be used in supporting national adaptation plans and country strategies. In collaboration with the World Meteoro- logical Organization (WMO), WHO has supported 17 major projects focusing on health adaptation to climate change in 14 countries across all WHO regions. It has also carried out assessments of health vulnerability to climate change in over 30 countries. WHO reviews country requirements and serves as a clearinghouse of current adaptation projects, while also providing guidance to pilot projects on green and safe health services. 7 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth International Bodies, Governments Placing New systems (health and others) that could prevent or respond Emphasis on Health Impacts of Climate Change to those epidemics has not been forthcoming until recently. • Financing for adaptation efforts became significant only after Politically, the topic of climate change and health became increas- the Tokyo protocol. Even today, it remains below financing ingly recognized in international resolutions and public statements efforts to mitigate GHG emissions. from governments and organizations, from the African Union to • There is a perception that the health sector has been, and the United Nations Security Council. The private sector has also continues to be, receiving more per capita resources than other taken notice, performing analysis and publishing detailed climate sectors. In reality, most funds have until recently been tightly change and health industry reports and business plans. The 2013 earmarked for diseases or issues and have not been conducive WHO conference on climate change and health attracted more than to increasing the health sector’s resilience. four dozen health ministers and hundreds of global delegates to explore solutions to climate and health challenges. • Finally, knowledge gaps in the health sector compound the Countries have been progressively emphasizing the health situation. First, climate data and model forecasting are complex impacts of climate change. In 2008, a total of 193 countries endorsed and difficult to interpret for those unfamiliar with these tools. a World Health Assembly resolution calling for action to protect To make things worse, the effects of similar climate situations health from climate change. In 2011, 39 out of 41 National Adapta- on health vary depending on geography and other factors, tion Programs of Action (NAPAs) from least-developed countries complicating forecasting and decision making. Second, there identified health as a priority sector affected by climate change, is limited experience in integrating climate considerations in and 30 included health interventions within adaptation needs. In health sectors and climate sensitive-health considerations in addition, substantial work has been done in sectors and topics other sectors. Third, there is insufficient knowledge within the that moderate the impacts of climate on health outcomes such health community of how to access climate adaptation funds, as agriculture, water pollution and other environmental services. as well as limited interest among donors in health adaptation. Yet, despite all these efforts, in 2011 only 1 percent of the financial resources for adaptation were devoted to the health sector. Shifts in Emphasis to Resilience, Health The reasons behind this limited attention in practice to increas- Systems Present Opportunity ing the health resilience of the health sector include: • The effects of climate on agriculture and water resources Recent years have brought a shift in attention and determination (e.g., droughts, floods) are much more readily understood by globally that presents a window of opportunity to bring past decision makers and the population, than climate effects on efforts to fruition. In the climate community, successive Confer- vector- or water-related diseases. ences of the Parties (CoPs) have expanded from their original almost exclusive focus on emissions reduction to placing equal • Until recently, the health community was focused on achieving emphasis on increasing resilience, which has opened the door for the Millennium Development Goals (MDGs), which did not interventions to improve health outcomes and financing adaptation make any connection between CC and health. measures. At the same time, the health community has evolved • The uncertainty of long-term climate effects on health and from its prior disease-centered focus to a health system focus, as the perceived distant time horizon in a sector that is dealing reflected both in the concept of UHC and the formulation of the with immediate life-threatening conditions make it difficult for SDGs. In the broader development sphere, the SDGs put climate professionals to focus on the issue. It is only recently that the change at the center of the development mandate and took a far emergence of new threats and the expansion of existing health more expansive view of interaction of health and climate change problems related to environmental disruption and climate (e.g., than the Millennium Development Goals. The body of experience meningitis, Ebola, Zika, and deaths caused by heat waves) as to how to increase the resilience of health systems is increas- are providing evidence for the global and national health ing, and WHO recently published an operational framework for community that climate change is already affecting health. building climate health systems (WHO, 2015). • Similarly, disasters that affect entire communities capture Partly as a consequence of these changes, low-income countries attention more readily, while the plight of a sick person is per- have increasingly included health impacts in their National Adap- ceived as an individual issue. Decision makers often turn their tation Plans of Action and Nationally-Determined Contributions attention and resources to illnesses only when these acquire (NDCs). To date, NDCs for 67 countries (of which 36 are eligible epidemic proportions. Financing for noncrisis efforts to build for IDA resources) out of 143 screened by the WBG include health 8 E vo lu ti on o f t he C li m at e - He alth Imperative as a focus area. Moreover, multilateral financing institutions and Knowledge Yet to Permeate WBG Operations several other donors and foundations have begun to show interest in investing in health sector resilience. To date, only two HNP projects (Nagaland and Moldova) include Both the SDGs and the Paris CoP accord offer a number of climate consideration in their design. Similarly, more could be entry points for increased World Bank activity, particularly as done to mention CC impacts on health in Systematic Country Diag- WBG client countries (and other partners) often lack planning nostics (SCDs) and Country Partnership Frameworks (CPFs) and and program capabilities in this area. to suggest low-cost/no-regret interventions to minimize impacts. Cross-sector adaptation programs such as the Pilot Program for The World Bank Perspective Climate Resilience and the Small Island States Resilience Initiative also could include health as one area of strategic focus. GFDRR A Growing Body of Research and Analysis does include health facilities in its disaster assessments and often it may leverage other resources for reconstruction after climate- World Bank work in health and climate change has followed a related disasters. GFDRR collaborated with WHO several years trajectory somewhat similar to that of the global community. ago on a safe hospitals guidance document and it could build on The WBG acknowledged the climate change/health connection this promising effort by establishing a global program for safer in 1994 and has progressively accelerated its analysis through to facilities, as it has through a similar initiative in education. the 2010 World Development Report (focusing on climate change In terms of translating knowledge into operational work, the and development) and the 2012 Turn Down the Heat report. More WBG’s experience has again largely mirrored that of the global recently, the 2015 Shockwaves report (Box 2.1), quantified the community, with the key difference that the strengthening of links between climate change and health outcomes, particularly health systems has been central to World Bank HNP work for for malnutrition and poverty. Climate change analyses from the over a decade. In addition, the World Bank has for many years Eastern Europe and Central Asia and the Middle East and North supported pollution abatement efforts across the world with the Africa regions have included chapters on impacts and potential intention of improving health outcomes, in addition to improving interventions in those areas. environmental results. Notwithstanding these exceptions, it is fair In addition, there are multiple analytical products that identify to characterize climate-related health work as a new opening for health as a co-benefit of interventions in other sectors. Examples the WBG, both in HNP and across other sectors, including the include work on short-lived climate pollutants (SLCP), the develop- Climate Change CCSA. ment of low-carbon cities, the phasing out of fossil fuel subsidies, as well as waste management, climate-smart agriculture, and disaster Recent Developments Open risk management. A comprehensive World Bank paper summariz- a Window for Improvement ing the work done on CC and health across sectors identified a range of analytical products that mentioned or discussed the CC The past 12 to 18 months have brought new opportunities within and health connection, but concluded that there has been little, the climate field to deliver on the promise of WBG knowledge on if any, translation from analytics to operations. health and climate in its operations: Accordingly, it is important to identify opportunities to empha- • The WBG Climate Change Action Plan (March, 2016) includes size the climate and health connection. For example, the 2013 health as a key tool for climate resilience while acknowledg- WBG Strategy and the CC Strategy both might have drawn the link ing the need to make the health sector itself climate resilient. between health and CC. Similarly, the 2007 HNP strategy might have made reference to climate change, as well as the 2013–2015 Global • The Climate and Disaster Risk Tool launched last fiscal year Facility for Disaster Reduction and Recovery (GFDRR) strategy. includes a module to screen health projects, although it could Similarly, while the WBG has made major strides in introducing benefit from the inclusion of questions focusing on the climate/ climate considerations throughout its operations and strategies in health angle while screening projects in other sectors. transport, energy, environment, agriculture, urban development • The corporate commitment to screen all International Devel- and disaster risk management, the link between those two issues opment Association (IDA) projects for climate risks, and to has not been, until very recently, recognized in documents, country increase climate financing to 28 percent of World Bank lending, dialogues, or operations. The exceptions have been Climate Smart sets an appropriate incentive structure across sectors. Agriculture (CSA) and the 2012 Environmental Strategy. 9 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth Box 2.1: The 2015 Shockwaves Report Climate change (CC) threatens the objective of sustainably eradicating Figure 2.1: By 2050, socioeconomic development should poverty. The Shock Waves report identifies health as one of the main reduce malaria incidence, even with climate change channels through which CC will threaten poor and vulnerable people, (Shockwaves, p. 119). including children. The precise impacts of CC on health threats remain uncertain in what is still an emerging research field. Progress in medical a. Climate change only treatments offers hope that some of these issues could be solved over the long term thanks to new drugs and better health infrastructure. But short-term impacts could still be significant. Health shocks are important for poverty dynamics and the impact of CC for three main reasons. First, the diseases that most affect poor people are diseases expected to expand with CC (such as malaria and diarrhea). In Africa, for instance, malaria could increase by 5–7 percent b. Development only among populations at risk in higher altitudes, leading to a potential increase in the number of cases of up to 28 percent. Similarly, climate impacts could increase the burden of diarrhea by up to 10 percent by 2030 in some regions. Second, health expenditures are regressive, with poor households largely uninsured (such outlays push an estimated 100 million people per year into poverty) and the loss of income for the sick or the caregiver can have a large impact on family prospects. Third, children are most vulnerable to these shocks and can suffer from c. Combined effects irreversible impacts that affect their lifetime earnings and lead to the intergenerational transmission of poverty. Partly because of its impacts on agriculture, CC will increase undernutrition and could sharply increase severe stunting. By 2030, an additional 7.5 million children may be stunted. Climate Change may even lead to an absolute increase in the number of stunted children in some parts of Africa, with the negative effect of climate change outweighing the positive effect of economic Expansion Contraction No change Absent growth. Recent evidence suggests that the nutritional quality of food (e.g., its content in terms of micronutrients such as iron, iodine, vitamin A, folate, and zinc) could also be affected by CC, even though little is known about potential impacts. Development—notably better access to health care and to services such as water and sanitation infrastructure—has the potential to reduce but not eliminate the risks climate change poses for health (see for instance, figure on malaria incidence). Universal health coverage would contribute greatly to climate change adaptation—and moni- toring and surveillance systems (both in the health and environmental sectors) will be critical to deal with emerging health issues.6 (Extract from Hallegatte, et al. 2016. Shock Waves: Managing the Impacts of Climate Change on Poverty, Climate Change and Development; Washington, DC: World Bank.) • Increasing demand from countries for support with the health • The creation of a Climate Change Cross-Cutting Solution Area impacts of climate through the NDCs and NAPAs. (CCSA) that oversees all World Bank climate change efforts and that has considerable technical capacity. • The launching of the Pollution Management and Environment Health Program (PMEH), managed by the Environment GP, con- • Resources from the Nordic Development Fund have allowed siders GHG in its discussion of pollution and its health impacts. the development of this approach and action plan paper, and technical assistance for Mozambique’s Ministry of Health 6  Source: Based on Béguin et al., 2011. to develop its health sector climate change action plan and Note: Map of projected areas of malaria presence for 2050. Areas where the malaria disaster preparedness and response. status changes between the baseline and the scenario period are shown in color. Grey areas represent those regions in which the model predicts no malaria transmission There are also recent efforts to link CC and health in the context by 2050 under any scenario. of other sector goals. The Energy Efficient Cities initiative in the 10 E vo lu ti on o f t he C li m at e - He alth Imperative Energy Sector Management Program (ESMAP) includes hospitals HNP has made its mission “to support countries accelerating and health facilities, and the Clean Heating and Cooking initiative, their progress towards UHC,” which is in itself a key means to led by ESMAP in collaboration with HNP and the CCSA works to increase population resilience to climate sensitive conditions and reduce indoor air pollution. The CityStrength tool, a collaboration disasters. Moreover, one of the three HNP strategic activities to between the Urban Development Team and GFDRR, allows for the realize this mission includes “harnessing the potential of other inclusion of health while focusing on increased city resilience to sectors to strengthen climate-sensitive HNP results and generate climate change and disasters in general. public goods.” This emphasis, which is exclusive to the World The Climate Smart Agriculture Strategy places emphasis on Bank, is an entry point to capitalize on efforts in other sectors the effects of climate on undernutrition (particularly stunting) to increase health sector and community resilience to climate through its impact in the agricultural value chain. Additionally, sensitive health effects. the One Health initiative, led by the Agriculture GP in collabora- To crystalize the existing opportunities and address the weak- tion with HNP, links animal and health to climate and to human nesses identified, the proposed WBG approach and action plan health. Finally, efforts to add a clean air and health module to outlined in Chapter 4 and detailed in Annex C recognize both the existing Climate Action for URBan Sustainability tool (CURB) the importance of a resilient health sector as well as the need to will make the links between efforts to reduce GHG emissions and embrace cross-sector solutions. It proposes to begin the dialogue health outcomes, via air pollution, directly quantifiable. not from the basis of climate, as has been the case, but from the On the health side, HNP is currently updating its strategy prevailing health community policy framework (i.e., UHC). Such through a strategic directions paper. This presents an opportunity an innovative approach could help facilitate dialogue both with to include climate considerations at the core of HNP operations. the health sector and other sectors. 11 Chapter 3 The Conceptual Framework: Making UHC Climate Smart for World Bank’s Clients’ Population The single most significant predictor of future health impacts of climate change and health-related adaptation costs in a country may be the population’s current health status. It has also been noted that effective resilience hinges upon a country’s progress toward UHC, the degree of public access to basic goods and services beyond the health sector, and preparedness and response to disasters (whether climate-related or otherwise). These all serve to reduce impacts in terms of health and the costs of climate adaptation to the minimum. The 2010 World Health Report defined UHC as ensuring that everyone receives the health services they need—including initiatives designed to promote better health, prevent illness, and to provide treat- ment, rehabilitation, and palliative care of sufficient quality to be effective—while at the same time ensuring that the use of these services does not expose the user to financial hardship (WHO, 2010). In practice, these health services can encompass policies that discourage smoking, vaccination programs, and end-of-life care. UHC’s three dimensions—health services, finance, and population—are represented in what has come to be known as the “Coverage Cube” (Boerma T. et al., 2014; Figure 3.1). As illustrated in Figure 3.1, attaining universal health coverage requires growing the smaller blue cube to fill the larger cube. The larger cube represents the ideal world and the dotted arrows the gap between the situation today and the goal to be achieved. The X axis reflects the goal of ensuring health coverage of 100 percent of the population. At the same time, UHC requires increasing the number and types of services to which all the population has access from whatever is included today in the basic package of services to reach those determined to be defined policy aims (Y axis). For instance, a policy goal may be to make dental care available to all regardless of whether they can afford it. Finally, the Z axis corresponds to the percentage of the costs of health care that are financed by so called out- of-pocket payments. Under UHC, everyone is covered by one form or another of financial pooling mechanisms (e.g., insurance). This is to guarantee that no one is impoverished because of the need to pay for health care costs. The same way that “good” development is a necessary but not sufficient condition to increase the population’s resilience to climate change (World Bank, 2009), accelerating progress toward UHC is absolutely necessary to protect individuals and communities from the health effects of climate change but will be insufficient if pursued in a “business as usual” manner. Moreover, full implementation of UHC cannot eliminate all climate risks. Even wealthy countries with high adaptive capacity have pockets of poverty and groups of people who tend to be more vulnerable to climate variability and change, as demonstrated by the European heat wave in 2003, the Chicago heatwave in 1995 (Scheraga and Grambsch, 1998; NOAA, 1995), and Hurricane Sandy in 2012 (EHP, 2013; JAMA, 2014). 13 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth Figure 3.1: How climate change impedes achievement of UHC. y Direct: strain in other two axes increases stress in third Incidental effects: Direct costs: ability to pay ‡ increasing Reduce proportion share of population that needs cost sharing Include of the costs subsidized health insurance and fees other covered and other subsidies services Extend to non-covered Current pooled funds x Services: which services z Population: who is covered? are covered? Increased burden & new disease & disease patterns ‡ increased demand Disasters reduce access to health & other goods & services Broader effects: e.g., temperature reduced agricultural yields ‡ undernutrition Changes to rain fall ‡ increase vector and water transmitted diseases Source: Authors, adapted from Boerma T., et al. (2014) Monitoring Progress towards Universal Health Coverage at Country and Global Levels. PLoS Med 11(9): e1001731. doi:10.1371/journal.pmed.1001731 Generally, efforts to achieve UHC will strengthen health systems facilities unreachable and/or inoperable. Discrete chronic stress and address many climate-sensitive health impacts (Box 3.2). How- can also affect the sector; for example, rising temperatures ever, it is important to explicitly consider climate variability and increase energy demand (especially in those buildings that change in health sector’s strategy especially in certain geographies are not prepared for it), producing brown-outs and otherwise where disease risk is likely to be climate sensitive or change with disrupting service provision. Even moderate drought can affect coming decades. Forward planning to ensure the correct facilities the reliability of hydropower utilities. are in place, e.g., diagnostic labs, and public health campaigns, • Climate change can jeopardize the expansion of financial e.g., for heat stress or infectious disease are essential to realize coverage for health services. Increased pressure in the other best outcomes. two axes automatically reduces the availability of resources to Climate change can affect the ability of countries to achieve increase the level of financial coverage. Moreover, by increasing UHC by putting stress on progress along all three axes of Figure 3.1 poverty—through disasters or hardships—climate affects the (blue arrows): ability of individuals and families to contribute financially to • By increasing the burden and modifying the pattern of risk-pooling systems. disease, climate change impedes the expansion of service As such, UHC efforts must be “climate smart” if they are to coverage, as well as the package of services. As illustrated promote the increased resilience of populations to the health in Boxes 2.1 and 3.1, climate change increases the burden of impacts of climate change. disease by facilitating the transmission of existing diseases, contributing to the resurgence of old diseases, and/or intro- The World Bank Climate Change ducing new ones. It also modifies the pattern by, for instance, facilitating transmission in a different month of the year, tak- and Health Conceptual Framework: ing health facilities by surprise. Box 2.1 also illustrates the Climate-Smart UHC effects of climate in nutritional status through its influence over agricultural production. In addition, climate can affect the Currently, the December 2015 draft of the Update to the Strategic functioning of the health system. Disaster can render health Directions for Health, Nutrition and Population Global Practice 14 Th e Con ce pt u a l F ra me wo r k : Ma k i n g UHC C li m at e Sm a r t for Wor ld Ban k ’s Cli e nts’ Popu lat ion Box 3.1: Shifting Disease Patterns, Box 3.2: How Health and Climate Natural Disasters, and 100-Year Heat Considerations Can Be Addressed Waves as “The New Normal” for by Efforts to Achieve UHC Health. What Can Be Done? In the short term . . . A recent and significant increase in the frequency of floods and • Diminished disease burdens in populations sensitive to climate cyclones in Mozambique places enormous demands on the impacts through greater efforts in prevention, education, and resources of that country’s Ministry of Health, reducing the avail- community health influence ability of resources for basic programs. Often health facilities • Earlier identification of health threats worsened by climate change are reconstructed without necessarily taking into consideration and reduction of associated morbidities, e.g., respiratory and expanding flood plains or storm surges, making those facilities very cardiovascular disease vulnerable to another hazard in the near term. Carrying out a health • More effective and immediate treatment of morbidity associated facility and network vulnerability assessment, and revising construc- with heat stress or extreme weather impacts tion standards are some of the interventions to be considered while • Better access to antibiotics, antiparasitic and antiviral drugs that designing a project to help support the government achieve UHC. can be used in acute outbreaks of vector-borne or waterborne In Africa’s “meningitis belt,” changes in the timing of the dry and diseases worsened by climate change wet seasons and higher temperatures have brought unexpected • Decreased morbidity from undernutrition or nutrient-deficiency meningitis outbreaks. Incorporating climate data and weather associated diseases forecasts in meningitis surveillance can help identify heightened transmission risks, and thus help manage the meningitis threat. In the long term . . . In the Netherlands, two of the three most lethal natural disasters • Reduced overall climate vulnerability by improving access to and of the last 100 years occurred in this century, and neither was a quality of healthcare flood. The 2003 heat wave caused approximately 1,500 deaths. • Diminished climate-sensitive disease burdens through cumulative Unfortunately, this was viewed as an exceptional event and insuf- protection measures against certain transmissible diseases ficient measures to avoid deaths were put in place. When a second • Diminished impact of mental health issues that could be wors- heat wave hit just three years later in 2006, the Netherlands was one ened by climate impacts, including displacement of the few European countries that registered a substantial number • Improved labor productivity and better financial returns that of extra deaths, totaling 1,000 people. Developing a response plan would otherwise be lost from climate-sensitive health impacts and an early warning system helped reduce mortality across the rest • Improved childhood development and social outcomes from bet- of Europe. ter nutrition and avoidance of stunting and impaired neurological development identifies HNP’s mission as assisting countries in accelerating their progress toward UHC. To this end, HNP has identified the This paper suggests that by including climate consideration in three following strategic directions: 1) establishing systems for its HNP Strategic Directions and its HNP portfolio, and including fair, efficient, and sustainable financing of health nutrition and climate and health consideration in selected operations in selected population outcomes; 2) ensuring equitable access to affordable, non-HNP sectors, the World Bank will maximize the impact of quality health, nutrition and population services; and 3) harness- its efforts to increase population resilience to climate-sensitive ing the potential of other sectors to strengthen HNP results and effects. The purpose of introducing climate considerations in generate public goods. This last point stresses the need for policies an HNP operation is to improve the operation’s effectiveness, and interventions in non-health sectors in order to achieve UHC, resilience and sustainability, not its objectives or strategy. In non- because the effects of climate change in those sectors also affect HNP operations, introducing climate and health considerations as health status and thus the prospects for achieving UHC. Examples relevant can increase their efficiency. include food safety and security, transport access and safety, pol- In practice making UHC climate smart means: 1) Establishing lution abatement, energy access, water availability and quality, systems for fair, efficient, and sustainable financing of health nutri- disaster preparedness and infrastructure safety. Therefore, the tion and population outcomes that are also adaptive (i.e., flexible proposed framework, while focusing on health one, links reduc- and scalable); 2) Ensuring equitable access to affordable, quality ing climate change impact in health outcomes to actions across health nutrition and population services that are also resilient; several key sectors. and 3) Leverage climate-smart interventions in other sectors to strengthen HNP results and generate public goods. 15 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth Establishing Systems for Fair, Efficient, • Investments plans take into consideration weather and climate and Sustainable Financing of Health, Nutrition changes and trends using, when relevant, risk analysis and and Population Outcomes That Are Also robust decision-making tools for investment planning. Adaptive (i.e., flexible and scalable) • Health staff is knowledgeable on the effects of climate and air pollution in health and on how to interpret tailored weather Currently, national health services financing mechanisms are gen- warnings and climate data to inform the population. erally not designed to respond to sudden increases in the number • Health facilities are climate appropriate and resilient to local of patients, or changes in the types of services to be covered, for current and expected disasters. instance the case of an epidemic or disaster. Sudden increases on demand are not exclusively or directly related to climate. • Health facilities have access to sufficient, reliable clean power, However, climate-smart UHC would require financing systems and are energy efficient. and mechanisms that can be easily scaled to provide expanded • Leverage climate-smart interventions in other sectors to financial protection and to fund additional services that may be strengthen HNP results and generate public goods. Solutions required after a disaster or an outbreak due to a climate-sensitive to climate impacts on health embrace all the affected sectors. disease. These financing systems and instruments also should Most mitigation and adaptation efforts in transport, energy, use climate data to forecast potential increased financial needs urban development, water and sanitation, agriculture, etc., will in a given geographic area or over a specified period of floods or reduce the health impact of climate change. But if the focus of storms). They may include contingency (risk) financing mecha- solutions is too narrow (i.e., limited to the resilience of a project nisms to complement existing pooling mechanisms, and should or investment or to increasing the adaptation capacity of a be regularly updated through vulnerability assessments to ensure geographic area) there can be missed opportunities to achieve that they are identifying the most vulnerable groups. the full potential, positive health impacts. The social return on these investments could therefore be raised by incorporating Ensuring Equitable Access to Affordable, health benefits into analysis and planning. Table 3.1 offers Quality Health Nutrition and Population Services examples of interventions in non-HNP sectors that have an That Are Also Resilient impact in climate-sensitive health outcomes. Existing WBG tools and initiatives that already begin to incorporate climate WHO defines a climate-resilient health system as able to “anticipate, and health consideration or can easily do so include EDGE, respond to, cope with, recover from, and adapt to climate-related CityStrength, and the City Energy Efficiency Transformation shocks and stress . . .” (WHO, 2015). It identifies six independent Initiative,7 among others. building blocks (i.e., leadership and governance, health workforce, health information systems, essential medical products technolo- Unfortunately, there is limited experience in developing coun- gies and infrastructures, service delivery and financing) necessary tries with adaptive financing systems, resilient and responsive to attain UHC and improved health outcomes (Figure 3.2). These health services, and with leveraging others sectors’ knowledge blocks must themselves be climate resilient. and platforms to increase the resilience of the health sector and The goal is to ensure health infrastructure and systems that the population to climate impacts. Currently, the WBG’s Social are climate appropriate, adequately powered, energy efficient, Protection GP is advancing an initiative to work with adaptive highly connected and resistant to disasters, and that can create financing for social protection systems. However, in this and other or tap additional capacity during natural disasters or outbreaks. initiatives it is too early to identify substantive lessons learned; In most low and several middle income countries that is not the close attention to these efforts could help define HNP’s modalities. case. Therefore new HNP investments would finance intervention to ensure that: • Surveillance systems are able to use climate data to forecast 7  EDGE is an IFC initiative that helps design green buildings in 125 countries by providing a relatively straightforward process culminating in certification. The health risks from climate sensitive diseases (rather than wait hospital track is somewhat underdeveloped at this point. CityStrength is a rapid until the outbreak or disaster strikes), take necessary mea- diagnostic tool that aims to help cities enhance their resilience to a variety of shocks. sures to reduce the risk and warn the population in advance The qualitative diagnostic takes a holistic and integrated approach (that includes the health sector), and encourages collaboration between sectors to more efficiently of events. Such systems promote protecting behaviors in the tackle issues and unlock opportunities within the city. The City Energy Efficiency population and can use climate data to plan preventive mea- Transformation Initiative is a technical assistance program led by the World Bank’s sures and responses. Energy Sector Management Assistance Program (ESMAP) that provides support in identifying, developing, and mobilizing finance for transformational investment • Disaster risk mitigation plans for service provision apply flex- programs in urban energy efficiency. Its activities include financial and technical ible and alternative methods (e.g., “tele medicine”). support, capacity building and e-learning, knowledge creation and exchange. 16 Th e Con ce pt u a l F ra me wo r k : Ma k i n g UHC C li m at e Sm a r t for Wor ld Ban k ’s Cli e nts’ Popu lat ion Figure 3.2: WHO operational framework for building climate resilient health systems. TE RESILIE I MA NC C L Leadership & E Governance & g W He a te ncin or alt kf h lim in a or C hF ce lt a He Leadership & governance Health Vul acity & Financing ss ment Cap tation Prepa ency workforce Ada smen ner Ass redne abil nage es g p Emer i n g bl o c ity, ld ui & Ma k t B s s Health of Service em Clim th Pro information Ear itoring k Hea ea Mon ted Ris lth s y st delivery & h ng systems ate l arni -info rams gra ly W g rme Inte Essential d medical products & M technologies a En nag h De iro eme v h & arc p nm n e alt ese of ar tm en t of H R He e tal ate alt nts Climate Resilient lim h C & Sustainable Technologies and Infrastructure Source: WHO 2015. Additionally, major infrastructure projects have treated positive Bangladesh, substantial mortality reduction was achieved chiefly health outcomes as secondary benefits and often these aspects through early warning systems that utilized climate data, through have been omitted from project or economic analyses. Recently, improved women’s literacy, and a reliance on local disaster work- experience with the CityStrength diagnostic tool in Vietnam has ers who cycled to different communities to warn them of cyclones shown that an integrated resilience diagnostic review can sub- and explain protection measures, evacuation routes and shelter stantially modify project design. This suggests that the integration locations. Naturally, political will is central to these actions and of aspects such as health during project design can inspire very their success. different types of investments. The next chapter outlines the operational steps for the WBG Most experience in increasing community resilience has to help countries move toward making UHC climate smart, recog- been related to disasters and increasing the resilience of health nizing that the solutions will require planning and coordination infrastructure (but not necessarily health systems). The example across key sectors that can strengthen and sustain climate-adjusted of Mirebalais (Box 3.3) speaks to increasing energy resilience. In health improvements. 17 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth Table 3.1: Examples of interventions in non-HNP sectors that affect climate-sensitive health outcomes. Non-health Sector Examples Climate sensitive health effects Education: Weather and climate appropriate, with electricity, energy Resilient schools, higher population education levels, especially among efficient electrified and safe school buildings. Improved access to education, women, instrumental in disaster preparedness & response, reduction of awareness raising & integration into education. vector & water transmitted diseases. Energy: Clean renewable energy generation & resilient distribution, universal Reduces climate-sensitive health impacts, through reduction in indoor & access to clean energy, renewable energy, incentives for energy efficiency. outdoor air pollution which negatively affects health outcomes. Urban development: Urban planning & upgrading programs; air quality Reduces climate-sensitive impacts, through reduction in outdoor air standards, building standards (resilience & energy efficiency), active pollution & health island effect. Drainage reduces vector transmitted transport, heat reflecting surfaces, maintaining wetlands & urban green diseases. Wetlands in urban and peri-urban areas are likely to increase vector spaces; infrastructure & services; managing development in flood prone and transmitted diseases. Depending on the model, waste management can other high risk areas; land zoning laws; easement areas, storm and drain increase or decrease (or at least maintain) vector transmitted diseases at clearance, waste management. times in different areas of a city. Agriculture: Income, asset & livelihood diversification; improved Increasing yields while reducing stagnant water, food security & safety infrastructure; access to technology and decision-making forums; increased interventions improve climate-sensitive health outcomes. Water storage, to decision-making power; changed cropping & livestock practices; reliance on reduce impact of drought in crops can increase water stagnation & vector social networks, extension services sharing indigenous, traditional and local transmitted diseases. Effects of climate, especially heat stress in agriculture knowledge; seed banks; crop insurance. workers needs to be taken into consideration. Disaster Management: Sea walls, flood levees & coastal protection; early- Reduction of direct disaster impacts in health, and vector and water warning & response systems; hazard & vulnerability mapping; floods and transmitted diseases. cyclones shelter; building codes/practices; climate services; participatory scenario development; integrated disaster assessments. Environment: Air quality standards; reduction stressors on ecosystems Improved AQM, and environmental services will generally reduce the impacts and habitat fragmentation; maintenance of genetic biodiversity, restoring of climate-sensitive diseases. Maintenance of wetlands in urban and peri- wetlands; ecological restoration; soil conservation; afforestation & urban zones is likely to increase vector-transmitted diseases. Environment reforestation including mangroves; assisted species migration and green authorities often lead national adaptation plans and determined contributions, infrastructure; control overfishing; aquaculture practices; payments for close coordination with other authorities is at the center of successful ecosystem services; national & subnational adaptation plans. adaptation efforts. Water: Watershed & reservoir management; climate resilient water safety Mostly reduce climate-sensitive disease; water capture and storage may plans; diversifying water resources municipal services (water & sanitation); increase vector transmitted diseases. water and fecal waste effluent quality control; pricing water to encourage universal provision and careful use. Transport: Transport and road infrastructure improvements, clean rapid Mostly reduces impacts through increased connectivity and production of transport systems, transport corridors, waterways, ports. pollution. Can guide population to climate disaster areas. Meteorological/Hydromet Services: Data generation and sharing; If weather, climate data are used for decision making across different sectors, systematic monitoring and remote sensing; development of climate services it can reduce climate-sensitive diseases. targeted to different sectors and the population; early warning systems. Social Protection and labor: Social safety nets & social protection; insurance; migration. 18 Th e Con ce pt u a l F ra me wo r k : Ma k i n g UHC C li m at e Sm a r t for Wor ld Ban k ’s Cli e nts’ Popu lat ion Box 3.3: Curbing the CO2 Footprint of the Health Sector. Examples of Mitigation Interventions The health sector’s GHG/CO2 footprint is smaller than some other sectors, such as energy, transport, and agriculture. It is however, energy-intensive, and often pays inadequate regard to energy efficiency. In low- and some middle-income countries, energy payments represent a substantial per- centage of operating costs at health facilities (WHO and World Bank, 2014). A lack of forward thinking traps the health sector on a high carbon path that will be expensive to reverse later. At the same time, in many of those same countries, health facilities have very limited access to the minimum power they need to offer basic services, posing a barrier to achieving UHC. Affordable, adequate, reliable and sustainable access to energy for health facilities is central to achieving UHC. Studies show that, in general, focusing on energy efficiency and clean power in the health sector results in essential savings that can be applied to clinics and hospitals (WHO and World Bank, 2014). Health facilities with electricity help attract skilled health workers, enable potentially more sustainable health care models, and introduce lifesaving technologies. In the private sector, pharmaceutical and medical device companies may lose competitiveness if dependent upon high fossil fuel needs in their technology investments. Finally, reducing GHG gases in any sector is a public good. The 2010 World Development Report pointed to the fact that “affordability hinges on mitigation being (achieved) cost-effectively.” Partners in Health (PIH) work in Mirebalais University Hospital, is an example of such a clean-energy, cost-saving approach taken by one hospi- tal operator in Haiti. Since 2007, PIH has installed small-scale solar energy systems at five clinics in rural Rwanda, as well as in Malawi, Lesotho, and Haiti. After the devastating Haitian earthquake in 2010, PIH chose to use solar power as a cost-effective, reliable, and environmentally responsible means to help power the University Hospital at Mirebalais and avoid the disruption posed by Haiti’s frequent blackouts. On most sunny days, the system’s 1,800 solar panels will generate more electricity than the hospital consumes, allowing the surplus energy to feed back into the electrical grid. In addition, the hospital minimizes energy needs through high-efficiency fluorescent light fixtures, motion sensors for lights that save up to 60 percent in energy usage, and natural ventilation that reduces both the spread of infection and the need for air conditioning. On the roof, reflective white coating keeps the building cooler and makes the solar panels up to 15 percent more efficient. Other successful interventions across the world include the use of micro-dams to power hospitals, improved temperature controls, improved insulation, and staff behavior change such as turning off equipment when not in use. For further expansion, please see the 2017 World Bank report, “Climate-smart healthcare: low carbon and resilience strategies for the health sector.” Source: http://www.pih.org/blog/mirebalais-hospital-construction 19 Chapter 4 Operational Framework for WBG Approach to Health and Climate This Approach and Climate and Health Action Plan build upon the World Bank Group Climate Change Action Plan (CCAP) approved by the WBG Board in April 2016. The CCAP affirms the institution’s commitment to strengthen action on climate and health, to increase its capacity to respond to coun- tries eligible for World Bank support that have included health in their NDCs, and to integrate climate considerations within its support for UHC. It states that, subject to available resources: 1) by the end of FY2020, the WBG will have supported two countries in developing plans to reduce GHG emissions in the health sector; 2) by the end of FY2017, the WBG will have supported two countries to carry out vulnerability assessments; and 3) by the end of FY2018, the WBG will have supported two countries to develop climate smart surveillance and early warning systems. In addition, by the end of FY2019, 75 percent of HNP task team leaders will be trained in climate change and health; and by the end of FY2020, 20 percent of new HNP projects will consider climate in their design. Those goals are seen as enough to show proof of concept (or “low scenario”) for the climate change and health work. The proposed plan of action detailed in Annex C sets even more ambitious targets (see also Table 5.1), including defining and structuring, jointly with partners, the use of climate data for health planning, surveillance and early warning, the enhancement of existing urban energy efficiency planning tools to include impacts of clean air in health, and covering knowledge gaps in the economics of climate change and health. To deliver on its commitment to support countries in their resilience path as regards to health and climate, the WBG needs to facilitate the expansion of climate-smart UHC. This implies mainstreaming climate considerations in HNP operations and ensuring that critical aspects of health and climate are integrated into climate-smart WBG activities in other sectors. It also would require significant efforts to increase its internal capacity. The operational framework described in Figure 4.1 proposes two stra- tegic objectives, three activity pillars addressing the key systemic failures previously identified, and two transversal support areas. These pillars are of course interrelated. The knowledge being gathered and generated will increase World Bank staff’s capacity as well as that of our clients, and both will result in improved investments and operations. The details of the activities envisaged under these pillars and cross-cutting areas are presented below, after discussing the strategic objectives. The theory of change on which the approach and plan of action are based, as well as the operating model and different sectors comparative advan- tages to implement the plan of action, are summarized in Chapter 5. 21 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth Figure 4.1: Institutional operational framework. GOAL Support increased resilience of populations to health impacts of climate change by assisting countries to achieve climate-smart UHC STRATEGIC OBJECTIVES Mainstream climate in HNP operations Integrate climate-sensitive dimensions in non-HNP operations PILLARS Knowledge generation Improve staff capacity Country support Tool development Training Technical assistance and financing Sector-specific analytics Clinics Cost-benefit analyses of interventions Information sessions Leverage UHC joint learning Network Mobilize resources Increase access to existing climate finance. Leveraging operational budget and IDA resources. Leverage partnerships Internal partnerships: support existing GP platforms and initiatives. External partnerships: knowledge and financial. Strategic Objectives: Integrating • Ensure adequacy of infrastructure and technology to current and trending climate variability and to climate shocks. This Climate and Health Considerations could embrace health facility access to clean and renewable in WBG Operations energy and water, as well as alternative service delivery solu- tions, (i.e., telemedicine, satellite communications, etc.). Mainstreaming Climate in HNP Operations • Promote creation and deployment of disaster preparedness, The purpose of this strategic objective is to increase the resilience response and recovery plans and implementation protocols, of the health systems in client countries. In addition to increasing as well as coordination with relevant authorities. knowledge and awareness of HNP staff on climate and health • Upgrade surveillance, early warning and information systems, issues, key entry points would be operational reviews, project and encourage the use of climate data for decision making in climate and disaster risk screening, and access to climate funds. different programs and at different levels. According to local conditions, countries and teams would prioritize • Encourage development of flexible and scalable financing one or a combination of the following actions: systems to cover unexpected population needs in case of • Creation of a baseline of climate-sensitive existing conditions disaster or disease outbreak. and potential emerging threats in different geographic/ecosys- • Ensure mechanisms for coordination across sectors and advo- tems, poverty levels, population characteristics, etc. cacy from the health sector. • Improve staff capacity to detect and respond to climate stress. Utilize weather forecasts to redeploy personnel prior to any emergency. 22 O p e r at i ona l F r a me wo r k f or WB G A pp r oa ch to H ea lth and Climate Integrating Climate-Sensitive Dimensions NAPAS. The CCSA, jointly with HNP, has recently finalized a in Non-HNP Operations hotspot analysis to identify countries where climate change, or exposure to drivers of climate change (i.e., kinds of air pollution), The purpose of this second strategic objective would be to maximize are expected to most significantly alter the burden of disease and the potential of interventions in other sectors to reduce climate expose vulnerabilities in existing health systems. We propose to change risks and increase resilience while minimizing the potential use the results of this analysis, in conjunction with the lists of negative health impacts of these activities (i.e., avoid maladapta- countries that have included health as a focus area in their NDCs, tion). As Table 3.1 shows, successful development investments in to guide WBG priorities for interventions. While we recognize non-health sectors also have positive impacts—or co-benefits—in that the hotspots analysis has some shortcomings, it is based on health. Climate sensitive health co-benefits may not be central to internationally recognized data and indexes, allowing for a good the original purpose of the project but their inclusion during project first approximation of the issues. Likewise, NDCs and NAPAS are economic analysis or design may, at a minimum, make a project not necessarily completed or the issues and interventions may more desirable or assist in choosing between two technologies not be clearly defined. However, they represent the best proxy or interventions. Occasionally, such consideration of health co- of country commitment and, as such, a first measure of political benefits might substantially change the design of the intervention willingness necessary to achieve progress. Likewise, they are a tool (see Box 3.3 in previous chapter). to generate donor support. Once a country is identified, further Such changes in approach might be achieved through WBG in-depth analysis will be needed to identify specific risks, vulner- processes such as SCDs/CPFs and project reviews, and would abilities and interventions, as well as the costs of implementing build on existing opportunities and programs in other sectors. proposed interventions. Such an approach would ensure cooperation across sectors to In terms of health systems strengthening, the proposed areas address relevant knowledge gaps that might reduce their ability of focus (in collaboration with HNP) would be climate and health to incorporate climate and health considerations. vulnerability analysis, climate smart early warning and surveillance As discussed, climate effects on health outcomes are often systems, costing of interventions to achieve NDC commitments, mediated through natural and human systems (other than the and energy access and efficiency for health facilities. The specific health system), therefore activities to reduce those impacts and activities would be shaped by the two operational guidance notes increase population resilience will need to be channeled through for HNP operations currently under preparation (see the follow- interventions in other sectors. Priority sectors that would assist ing section on knowledge generation). For dialogue with sectors in deepening the impact of climate-sensitive health measures other than HNP, we will continue to prepare a series of sector are water and sanitation, urban development, energy, transport, notes to assess entry points, opportunities, existing tools, and agriculture, and environment. Most of these sectors have defined knowledge gaps. what the likely impact of climate in their investments is and, The remainder of this chapter discusses in more detail each of since many of those have a substantive CO2 footprint, they have the three operational pillars and two transversal support areas that also assessed what impact those investments will have on GHG can drive WBG efforts to achieve the overarching goal of helping emissions and defined their strategies to incorporate climate in populations become more resilient to the health impacts of climate their operations. Communication around these interventions and change by making health systems climate smart. coordination between those sectors and the health system is likely to increase the developmental impact of World Bank investments. Operational Pillars Prioritizing Activities Knowledge Generation and Management Under the approach outlined here, country support and other Preparation of this approach and action plan has identified knowl- activities would be prioritized on the bases of risk and country edge gaps and barriers to access existing knowledge. There is also demand. On the basis of risk, we propose to focus intervention a need for tools to help teams operationalize the climate-health on specific countries or “hotspots” where World Bank operations angle, both in HNP and other sectors. Some of the products of can maximize positive health outcomes in the face of climate this work will have an internal focus, while others will benefit the change and its drivers. Within a country, support would also be World Bank’s work but also have a global good aspect. prioritized on the basis of vulnerability and exposure. Another As such, the emphasis would be on the continued synthesis and consideration is country demand, as reflected in NDCs and dissemination of knowledge for WBG purposes and the development 23 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth of appropriate tools for country clients. Indeed, such activities are (IFC) have also helped identify energy efficiency in hospitals already in motion, and tool development is being phased according as an area ripe for joint work. We expect to prepare three more to available financing. In terms of global goods, we will aim at notes in the coming fiscal years with the Urban Development leveraging existing public knowledge platforms to include health team, Energy and Water GPs. We are also identifying jointly and CC. Including health tools in the Climate Smart Planning with academia and other external partners, opportunities for Platform will entail only minor additional cost and introducing economic analysis related to health and CC in order to develop a climate and health chapter in the UHC Joint Learning Network a potential global research agenda on this topic. will similarly require some additional funding; we are evaluating the possibilities with HNP. Additionally, resources will be needed Improve Staff Capacity to support the development of guidance for the climate services for health work, and for the economic analysis in health and CC. There is an opportunity to customize interventions to optimize Additional details on these activities follow. World Bank investments for climate-sensitive impacts—both in • Synthesize knowledge for World Bank purposes: This HNP and other sector operations—by more explicitly recognizing largely addresses global risk identification and the packaging the nature of climate-sensitive diseases. Over the next four fiscal and “translation” of existing operational knowledge for WBG years the goal is to increase HNP staff awareness of CC impacts in teams. As noted above, the CCSA—with HNP support—has health and the potential for vulnerability assessments, interven- identified climate and climate driver hotspots for health out- tions, and the use of climate data for early warning, surveillance comes. An additional report on “climate-smart healthcare” and planning. The target is that by FY2020 at least 80 percent of has been published in this series. Other knowledge notes are HNP staff would be conversant across these issues. Similarly, there under preparation jointly with WBG teams from transport will be efforts made to increase the awareness of staff in other and agriculture to launch the dialogue with those sectors sectors of the issues linked to climate and health in their areas and identify knowledge gaps. Additional notes will be jointly of expertise. Some of this work will be performed by using WB drafted on climate change and health with various GPs and processes as entry points to initiate a dialogue with GPs and CMUs. teams across the Bank group. This approach aims to focus on those countries identified as high risk and/or high demand, as outlined in the prioritization chapter. • Tool development: The aim is to help operationalize the To increase WBG staff capacity in integrating climate sensitive climate-health dimension in HNP and other sectors. The CCSA considerations across operations, the action plan proposes three is working with HNP and the urban team to enhance the types of activities: existing Climate Action for URBan Sustainability tool (CURB) to include air pollution and its effects on health outcomes • Information sessions: These would aim to increase WBG staff (CURB+) and possibly add indoor air pollution. This tool awareness of CC and health issues and interventions. Most targets both internal and external audiences, and development activities would be targeted to HNP staff but certain products is being phased according to funding availability. also should target other sectors and CMUs. Content would include impacts of CC in health outcomes, applications of • Inclusion of climate change and health in relevant public climate services and health, and health sector interventions knowledge platforms: These include the Climate-Smart Plan- to reduce health impact. Such sessions would also serve to ning Platform, the UHC learning network, etc. review and share experiences from the CCSA (specifically the • New knowledge generation: The Bank will work with WHO, Pilot Program for Climate Resilience, or PPCR, and disaster WMO and potentially other partners to develop tools (e.g., case risk management) and Environment and Natural Resources GP studies, guidance, etc.) to meet the current gap on guidance (ENR), as well as knowledge generated jointly with other sec- for and implementation of climate services in the health sec- tors, especially tools that can be used to make the link between tor. In addition, with our Agriculture and Transport colleagues GHG, health, and air pollution. Information sessions would we have identified two such entry points, respectively: 1) the also present knowledge from external partners, such as WHO impact of climate variability in the health of agricultural labor/ and WMO. Finally, these sessions would disseminate the joint farmers; and 2) guidance on the impact of fuel emissions on work of HNP and the CCSA, including the hotspots analysis pollution and health in the context of climate change. Discus- and the operational guidance notes, to increase adaptation sion with ESMAP and the International Finance Corporation capacity and reduce the CO2 footprint in the health sector. 24 O p e r at i ona l F r a me wo r k f or WB G A pp r oa ch to H ea lth and Climate • Formal training: We propose to work with the HNP and • Increasing country knowledge around climate and health, CCSA knowledge teams, as well as ENR, to develop a course with a focus on climate services for health. Jointly with on health and CC, which could be conducted online followed our external partners (chiefly WHO and WMO) we propose by some in-person sessions. synthesizing and crystalizing the concept of climate services for health through knowledge pieces and a “massive open • Clinics/problem solving: We will work with the CCSA Knowl- online course” (MOOC) on climate services for the health edge and Partnerships Team to develop HNP-specific project sector. In addition, we will explore the interest of UHC Joint screening clinics as well as clinics on preparing proposals to Learning Network partners in developing a climate and health access climate funds for climate and health adaptation and technical stream. mitigation interventions. • Supplementing World Bank investments and DPOs (espe- Country Assistance cially IDA operations) with trust fund and or climate fund resources8 to support activities in 10 countries over the next Country support is central to mainstreaming climate and health four fiscal years. We estimate that between US$1–2 million considerations in World Bank operations. There are substantial per country could catalyze adaptation and mitigation actions knowledge gaps that hamper resilience to the health impacts of in low-income countries, principally in health but also across climate change at the country and subnational levels. Accordingly, other sectors. These resources could finance technical assistance countries will require technical assistance and financial support for new projects for, among other things, country vulnerability to design and implement policies and interventions across several diagnostics, intervention design (including the development of sectors to assess the population’s vulnerability to climate sensitive climate-smart early warning and surveillance systems), as well health conditions in specific geographic areas. This assistance as limited goods and services for implementation, especially also will be essential as they subsequently progress to introducing in low-income countries. This could supplement lending for climate-smart interventions, such as early warning and surveil- project preparation or investment projects in HNP, ENR, and lance systems and the inclusion of climate considerations in their other sectors. It could also supplement DPOs (especially ‘green planning processes. growth’ DPOs that include climate) to finance TA or investments The approach outlined in this note proposes a concerted effort to fulfill a health and CC target (e.g., Mozambique Box 4.1). to create incentives for World Bank teams to engage and help In the health sector, key opportunities for support include meet client demand for assistance. The approach suggested here technical assistance and financing for: 1) assessing vulnerabilities also recognizes the important role World Bank staff can play in at both the national and subnational levels as well as developing encouraging demand, internally through systematic project and plans and implementing interventions; 2) implementing climate- SCD/CPFs reviews, followed by knowledge sharing and offers of informed surveillance and early warning systems; 3) costing the technical assistance in areas such as climate services. The World interventions to increase resilience; and 4) determining the costs Bank also should seek to augment its investments and Develop- of inaction. ment Policy Operations (DPOs) with trust fund resources. In other sectors, the emphasis will be on support for integrated As we have seen in other initiatives, financial incentives linked approaches to project resilience that maximizes development to operations, especially IDA, are likely to catalyze the embrace outcomes. It may be possible to pilot such an approach in two or of a new concept, helping create a critical mass of countries and three projects. Alternatively, we might seek to increase the overall experience that can be tapped to create a movement. resilience in one geographic area through concentrated efforts by To this end, we propose activities to be financed under this multiple sectors under a common plan. We will explore alterna- pillar be divided into three groups: tives during FY2017. • Review of Operations, SCDs and CPFs. The goal would be to utilize these World Bank processes to introduce data on country health vulnerabilities to climate impacts. Climate and disaster risk assessment processes and tools offer good entry points. In high-risk countries or those with strong demand, the CCSA could offer formal presentations to the CMUs and 8  Climate funding includes among others, the Global Environmental Facility (GEF), relevant GP teams on this topic. the Green Climate Fund (GCF), climate investments funds, etc. 25 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth Box 4.1: Climate Change and Box 4.2: Can Tho Urban Development Health Knowledge in Operations: and Resilience Project Mozambique Example Can Tho City, Vietnam’s fourth-largest city, is susceptible to flooding The explosion of new knowledge and information on the linkages because of its location in the Mekong delta. Seasonal flooding typi- between climate change and health only has relevance to our clients cally impacts 30 percent of the city area but has recently increased on the ground when we put that knowledge into practice. The to 50 percent. A recent study of the economic losses of urban recent Technical Assistance (TA) project in Mozambique is a good flooding shows that the largest share of economic loss is in the form example of this. of indirect costs, such as missed work, lost revenue, and additional Since 2011, the World Bank has been working with the Gov- health costs (Vo T. Danh, 2014). ernment of Mozambique to design and deliver a comprehensive Transport infrastructure in Can Tho depends on roads that are program of support on climate change. This includes a program- vulnerable to disruptions caused by seasonal flooding. While the matic Climate Change Development Policy Operation (DPO) series. city has proactively assessed transport investments based on flood Piloting extreme weather protocols for the Ministry of Health in at risks, the link between transport and urban land-use planning is not least 10 districts across the country is one of the finance triggers. fully considered. Road investments in Can Tho have tended to focus A collaboration between the Environment and Natural on providing improved access to existing communities or provid- Resources and the Health, Nutrition and Population (HNP) Global ing access to large-scale economic development sites. The scale Practices is enabling the Ministry of Health in Mozambique to and nature of land use along the roadways has not been sufficiently develop, adopt and operationalize those disaster preparedness, monitored or planned, and the result has been sprawling growth into response, and recovery protocols to address the increasingly fre- low-lying areas. quent extreme weather events occurring there. Transport can play a major role in inducing and guiding urban- At the same time—through a Health Service Delivery project— ization and transport investments. A World Bank study revealed the World Bank is helping the Ministry of Health (MOH) to improve that pursuing road upgrades outside the city center, as originally service delivery through expansion of health facilities, ensuring envisaged, would attract new settlement to flood plains, increas- access to facilities—whether conditions are extreme or not—and ing the vulnerability of the population. Instead the city chose to taking steps to improve malaria control. strengthen the city center, which is also the highest elevation in An NDF-supported TA grant leverages these two ongoing the area, guiding growth to low-risk areas near the heart of the city programs in that it has helped establish a participatory process, while improving connectivity. A combined system of an elevated engaging MOH staff to help them to develop the mentioned proto- road, embankments, and tidal gates/valves along the line will be a cols, to ensure health care access in support of the MOH and the “ring embankment” to protect the core urban area from flooding. In World Bank supported HNP health delivery goals while also meeting addition to benefiting the urban population in general by improving the climate DPO targets. its health and sanitation conditions, the project may benefit urban Building on these protocols, the TA will also establish an Action businesses and commuting grocers from neighboring districts by Plan for piloting and rolling out these protocols at the provincial and reducing risk of economic loss and prolonged travel-work time district level. The work will also help identify and prioritize which caused by flooding. districts are most vulnerable to climate-sensitive health risks. Adapted from: Transport & ICT. 2015. Moving Toward Climate-Resilient Trans- By working together, these three efforts are delivering more than port. The World Bank’s Experience from Building Adaptation into Programs. the sum of their parts. They are ensuring that the linkages between Washington DC. World Bank. climate and health are recognized and prioritized in regions that are most vulnerable, that solutions are deployed as quickly as possible, and that the Government of Mozambique takes ownership of the results. These accomplishments that are being seen in Mozambique Transversal Support Areas right now, serve as a model for replication in other countries. A relatively small financial leverage for ongoing operations—­ Resource Mobilization targeted at those linkages between climate change and health—will ensure that the full complement of environmental health issues a Many of the proposed activities such as knowledge generation country faces are addressed in the context of a changing climate. in health and climate change, and tool development, are new to the WBG and, given current operational budget constraints, Source: Sanjay Srivastava, task team leader (TTL), Mozambique Technical Assistance Health and Climate Change. Personal communication. additional external financial resources will be needed to carry them out. This also holds true to support country operations. 26 O p e r at i ona l F r a me wo r k f or WB G A pp r oa ch to H ea lth and Climate Some of the countries that are at higher risk for climate impacts products, operational support and lending, and corporate work, on health are among the poorest in the world. They will need to including donor relations and reporting. assess their vulnerability and to build their capacity to add climate • External partnerships: We are proposing activities to expand to their national health plans. In these countries IDA will be the and deepen strategic partnerships to further this agenda. There major source of financing to implement climate-smart/sustainable are both current/near-term collaborations as well as longer programs to achieve UHC. However, experience suggests that a term collaborations on the horizon. WHO, WMO and univer- modest amount of catalytic grant resources is needed to stimulate sities have been gathering knowledge around climate change the uptake of “green field” activities, and interventions to scale in and health for years. We believe we can amplify the impact of the early years.9 Accordingly, we propose a two pronged approach this work by bringing it to new audiences while also adding to mobilize non-IDA resources. On the one hand, as indicated in operational and economic perspectives. One particular area the knowledge generation and management pillar, the CCSA will with immediate potential is climate services for health, where organize information sessions on the types and characteristics we have recently teamed with Columbia University, WMO, and of existing climate funds—with a focus on health examples—to WHO to host a symposium on the topic—bringing together increase the capacity of World Bank staff, especially in HNP. The front-line field staff with academics and policy makers. We CCSA will also provide technical support to World Bank teams to are also working with WHO on the development of climate prepare financing proposals for said funds. In addition, it will work change and health country profiles, which can be used to with GPs to tap into existing financing initiatives to support opera- guide our clients in the understanding and implementation tions and research; examples include ESMAP and PMEH. Finally, it of climate and health programming. In addition, the Bank will explore with donors the possibility of creating a trust fund to has relationships with other institutions working on climate address health and climate change. It is as yet too early to specify change such as the United Nations Framework Convention on the operating structures and funding amounts. Possible structures Climate Change (UNFCCC), the Climate and Clean Air Coalition include: a health and climate change window in existing climate (CCAC), and various other academic, policy, and civil society funds; a multi-agency multi-donor facility; and a more modest organizations where collaborations can both contribute to our WBG-managed multi-donor trust fund to launch activities at the needs and drive global action. In the future, it is likely we will country level and to finance proof-of-concept activities. work more closely with the WHO and/or LSHTM on global- level economic studies, ClimateWorks Foundation on climate Expanding Strategic Partnerships and health tool development, and various other development agencies and MDBs on enabling and activating climate change There are two types of partnerships for this work: and health finance. We will also work to support the inclu- • Internal partnerships: We will prioritize the leveraging of sion of climate and health considerations in key global events existing initiatives, programs and tools across GPs and the such as Conferences of the Parties of the UNFCCC, and (as CCSA. This is envisioned to include collaboration on knowledge we have already done with the World Health Assembly), in WHO conferences on health and climate. We will co-sponsor knowledge sharing events to consolidate this partnership. 9  Examples include the Multi-Country AIDS Program (MAP) resources early in the WBG will also cooperate with other multilateral agencies to process of mainstreaming AIDS control in Bank projects, both in HNP and across other sectors, and the ongoing safe school initiative to strengthen school resilience share lessons learned from implementation and to harmonize to disasters. approaches when appropriate. 27 Chapter 5 The Climate Change and Health Plan of Action FY2017–2020 While we are confident that most of the targets stated in the WBG overall Climate Action Plan can be achieved within existing World Bank budgets, the proposed scope of this Climate and Health Plan of Action requires substantial additional financing. Accordingly, the plan of action presents scenarios consistent with the level of available financing. This chapter summarizes proposed activities in support of the Climate Change and Health Plan of Action for the next four fiscal years, including a road map with financing needs, and general metrics and targets. The Theory of Change What is being proposed here ultimately implies integrating climate in both HNP and non-HNP opera- tions. Successful experience mainstreaming other concepts and actions across WBG operations and policy dialogues suggests the need for an authorizing environment, such as corporate commitments and strategies. Mainstreaming mechanisms include people, processes and programs, and financial resources, as these serve to catalyze changes in the policy discussions and investments. Figure 5.1 describes the proposed elements that need to be in place to facilitate the successful main- streaming of climate change considerations in HNP, and of climate and health consideration in selected operations in the rest of the World Bank portfolio. Experience suggests that a conducive authorizing environment greatly facilitates integrating new concepts or ideas into World Bank operations. Using existing corporate processes also helps. However, to be sustainable, such top-down support needs to be complemented by bottom-up buy-in, which is generally best achieved through increased awareness of staff, especially “champions” who are already leading innovative products. Working with staff across sectors who are leading such initiatives, and finding ways to leverage existing tools and resources, adds value to such platforms to reduce the burden on teams. For instance, in the case of climate change and health, we propose to leverage ESMAP’s knowledge and technical resources from the Efficient and Sustainable Buildings initiative, and IFC’s Excellence in Designs for Greater Efficiency tool, to increase the energy access and efficiency of health facilities in the public and private sectors, respectively. This is more efficient and much more likely to be successful than having the CCSA or HNP develop energy efficiency standards for health facilities. As indicated, this Climate and Health Plan of Action builds upon the World Bank Group CCAP. In its low scenario it proposes activities to fulfil the CCAP targets.10 In addition the proposed plan of action, detailed in Annex C, proposes two medium and high resource scenarios that set even more ambitious 10  In a nutshell before 2020 the WBG would have supported at least six countries to develop plans to reduce GHG emissions in the health sector, or carry out vulnerability assessments or develop climate smart surveillance and early warning systems. It would have trained 75 percent of HNP task team leaders in climate change and health and 20 percent of new HNP projects will consider climate in their design. 29 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth Figure 5.1: Integrating CC and health in WBG operations. Theory of change (examples). Concept to Authorizing Mainstreaming Impact integrate environment mechanisms People • Bank’s staff trained/aware of principles & accessing diagnostic tools & interventions Process Policy changes Corporate commitments in the ground • SCDs/CPFs Resilient health • Climate financing target systems • Operational reviews • IDA 17–18 • Project Risk Screening Leverage additional Climate smart Corporate strategies IDA/IBRD funds agriculture or Programs • Climate Action Plan drought resilience • CityStrength measures that • Universal health • Efficient & sustainable buildings reduce vector coverage • Excellence in Design of Greater Changes in breeding • Climate smart Efficiencies (EDGE) project design agriculture strategy • DPOs/DPLs • Energy for all • Pilot Programs for Climate Resilience (PPCR) • Pollution Management & Environmental Health (PMEH) • One health Financial Resources • Global financing facility • Climate funds • PMEH • Global Facility for Disaster Reduction & Recovery targets (see also Table 5.1), requiring substantial additional financ- increase the developmental impact of existing interventions. In ing. Accordingly, the plan of action presents scenarios consistent the two examples listed above, this would require the inclusion of with the level of available financing. climate considerations in ongoing interventions to achieve UHC, It is important to note that the plan of action builds on ongoing or placing SLCPs more centrally in pollution control efforts, as no-regret actions by focusing on additional activities. For instance, well as including GHG reduction in the cost scenarios for pollu- we do not mention HNP ongoing efforts to achieve UHC (without tion abatement. taking into consideration climate), or ENR efforts to reduce air pollution and improve air quality. Although both are at the core of Implementation Roles increasing a population’s resilience to CC and reduce GHG emis- and Arrangements sions, respectively, they are at the core of HNP and ENR activities, with or without climate change, and no additional resources are Implementation arrangements for the proposed Climate Change required to sustain these initiatives. The plan of action focuses and Health Approach and its associated plan of action take into on new efforts, often requiring additional resources, which would consideration the different institutional and topical comparative 30 T he C li m at e Ch an g e and He a lth Plan of  Action FY2017–2020 Table 5.1: Climate and health plan of action: targets/indicators FY2017–2020. Pillars/ Crosscutting Areas Targets/Indicators Knowledge generation • By June 30, 2017 Sector notes on Energy, Urban and Water elaborated and knowledge gaps and opportunities for collaboration identified Scenario 1 • By June 30, 2017 CURB+ developed Improve staff capacity • By June 30, 2017, 50 percent of HNP projects in last FY have benefited from training or a clinic on climate and disaster risk management • By June 30, 2020: • 75 percent of HNP TTLs have received training • 20 percent of HNP projects consider climate in their design Country support • By June 30, 2020, 80 percent of new SCDs and CPFs in high-risk countries identified in the hotspots analysis and those in which NDCs identify health as an area of focus, include discussion of CC and health • By June 30, 2020, all HNP teams in PMEH countries are engaged in its implementation • By June 30, 2018, notes on the health of farmers and fuel policies completed and results applied in project design Scenario 1 • By June 30, 2020: (Low-resource scenario + additional • Two countries have carried out a climate and health vulnerability diagnostic and work plan activities) • Two countries have developed and implemented a climate smart early warning system and surveillance systems • Two countries have developed action plans to reduce GHG emissions in the health sector • By June 30 2018, CURB+ applied in at least 10 cities • By June 30 2020, CURB++ applied in at least 20 cities Scenario 2 • By June 30, 2018, a MOOC on climate services for health has been developed jointly with partners (Low-resources + Scenario 1 + additional • By June 30, 2020, technical staff from ministries of health, meteorological agencies and other relevant activities) institutions from 20 countries have taken the MOOC Resource mobilization • By June 30, 2020, at least 10 health and CC proposals have been submitted to climate investment funds for (Relevant to all scenarios) financing Expand strategic partnerships • Joint products and programs with some potential partners developed (Relevant to all scenarios) advantages of the CCSA and the relevant GPs, while recognizing interested in the pollution agenda, and the CCSA would facilitate these are constantly evolving. For example, at the country level the dialogue with WMO, climate agencies, and traditional Part 1 HNP would lead the dialogue with health ministries while ENR climate donors and foundations. The arrangements proposed here would take the lead on engaging ministries of environment. have been discussed and agreed upon at a technical level. The CCSA is often best placed to engage the hydrological and meteorological agencies. In addition, one of the key goals is to Climate Change CCSA—Would Lead increase GP capacity, with the ultimate aim of having them take the Global Dialogue and Facilitate Dialogue on most activities. on This Topic across GPs Resource mobilization (internal and external), and maintain- The plan of action proposed the CCSA’s engagement in: ing or deepening strategic engagements with external partners 1) awareness-raising across the institution, including country man- in support of the plan of action, will be conducted jointly and agement units; 2) knowledge generation and synthesis; 3) capacity led by the appropriate GP or the CCSA. For instance, HNP would building and TA for operational teams; 4) convening capacity across lead the dialogue with Part 1 countries who are most interested multiple GPs; 5) resource mobilization among traditional climate in supporting the health agenda, and with health agencies, such donors, including foundations for operations; and 6) facilitating as the WHO, while ENR would take the lead with Part 1 countries the achievement of corporate mandates through reviewing and 31 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth providing comments and information during SCD/CPF processes ENR—Would Lead the Pollution Management and project preparation. The CCSA would also use existing plat- and Its Associated Health Impacts Portfolio forms as entry points to include health in the policy dialogue as and Related Budget Support Instruments it relates to hydrological/meteorological agencies or services. The Through this work, ENR would coordinate efforts to reduce the CCSA could also facilitate links with partners in climate change and impact of SLCPs in health while also ensuring that, whenever disaster management fields, such as the UNFCCC, CCAC, WMO, possible, countries consider including GHG reduction in the cost climate financing institutions such as GEF, GCF and other climate scenarios for pollution abatement. In the context of the pollution, funds, as well as any multilateral bank teams working on climate. management and environmental health program, ENR and HNP The relationship with the UNFCCC is particularly important as have agreed to coordinate efforts at the country level. ENR already it convenes the Conferences of Parties (CoPs) that are the main leads the majority of the Green Growth agenda and DPOs. In this mechanisms that define the global agenda on climate and (after context, ENR would explore including CC and health disburse- the Paris accord) country public commitments though the NDCs. ment triggers in those operations, as well as work with HNP and This role would be carried out in close collaboration with the cor- the CCSA to mobilize parallel investment financing that may be responding GPs, with attention to phasing out technical assistance, needed to fulfill those triggers. training and awareness-raising activities as climate and health activities are successfully mainstreamed across the World Bank. Other GPs in Key Roles The Urban Development team will be leading the work on CURB, HNP—Would Lead the Health, Nutrition and—jointly with the Global Facility for Disaster Reduction and and Population Policy Dialogue Recovery (GFDRR)—any potential collaboration efforts around with Our Clients and Relevant Partners CityStrength. The Agriculture and Transport GPs would work As such, HNP’s central role is creating the opportunity for coun- jointly with the CCSA in developing respective knowledge notes try policy dialogue for this agenda and supporting government on the health of farmers and on fuel policy. All those joint prod- efforts to implement it. Specifically, HNP would play a pivotal ucts would be reviewed by HNP and ENR. The specific role of role in convening health authorities, identifying country-specific other GPs such as Water, Energy and others will be examined in needs, coordinating activities with local partners in the sector, and the coming fiscal year. assisting in raising resources for country efforts. Based on country demand, it would lead the work on identifying and responding to Road Map country operational and Advisory Services and Analytics requests, with the CCSA providing support as deemed necessary. Equally Figure 5.2 below presents a roadmap for the implementation important, HNP would guide the CCSA’s awareness-raising efforts of activities included in the plan of action (Annex C). The low in the health sector and with CMUs. HNP would ensure that resources scenario assumes some World Bank funding and increased projects are screened for climate and disaster risks and follow resources from successful applications to existing climate invest- through with any remedial measures, identify projects or clients ment funds. Figure 5.3 presents activities requiring substantial that want to include climate considerations in their national plans additional resources that will allow for full mainstreaming of and strategies and modernize their early warning systems. Further, climate in HNP operations, as well as increased dialogue and and in close collaboration with the CCSA, HNP would co-organize inclusion of climate and health considerations in other sectors. trainings for HNP staff (particularly task team leaders) on climate and health issues and programing. 32 Figure 5.2: Climate change and health action plan FY2017–2020. Road map (low-resource scenario). Activities Year 1 Year 2 Year 3 Year 4 Specific Objectives Three sector knowledge notes (water, Carry out sector KPs Finalize KPs urban and energy) Cover jointly identified knowledge gaps on effects of CC in health mediated Five joint knowledge products (transport, Carry out sector KPs Finalize KPs through agriculture, transport, water, agriculture, water, urban and energy) urban and energy Develop internal course on CC and health Develop the course Training Training Training Increase bank HNP staff awareness of adaptation and mitigation and train staff the effects of CC in health and their Train HNP teams on climate and Clinics Clinics Clinics Clinics knowledge to incorporate climate disaster screening operations, SCDs and CPFs Train HNP teams on access to Increase transport, agriculture, water, climate funds urban and energy staff awareness of Organize information sessions for WB effects of CC in health mediated through staff on effects in CC in health mediated their sectors through different sectors Support 7 HNP teams (1–2/year) to Increase number of HNP projects include CC considerations in including climate considerations operational design Integrate HNP teams in PPCR, and PMEH teams Support agriculture, transport, water, Increase number of agriculture, urban and energy teams to introduce CC transport, water urban and energy and health considerations in operations projects that take into consideration the effects of CC in health as mediated through their sectors Comment on SCD/CPFs and Increase number of SCD/CPFs that engage with SCD/CPF teams in include CC and health considerations hotspot countries Prepare funding proposals and Create MDTF to support the inclusion engage donors of CC and health consideration in WB operations Engage partners and participate in Increase banks presence in global key events area on the subject to keep abreast of new knowledge, tools and opportunities Total $125,000 $200,000 $110,000 $200,000 Note: Resource requirements reflected in this table refer exclusively to variable costs. Detail costs including staff time needs/fixed costs are reflected in the more detailed Plan of Action (Annex C). 33 T he C li m at e Ch an g e and He a lth Plan of  Action FY2017–2020 34 Figure 5.3: Climate change and health action plan FY2017–2020. Road map (additional resources scenario). Activities Year 1 Year 2 Year 3 Year 4 Specific Objectives Total Develop clean ambient air and health module of CURB and implement it in multiple cities Increase the number of cities in (CURB+) client countries that take steps Develop CURB+ CURB++ in Deploy CURB++ Deploy CURB++ $3.5 Develop clean air and health to reduce the health impact of 20 cities cities in more cities million module of CURB incorporating pollution and reduce GHG the ambient air pollution fraction emissions (in the planning?) Develop CURB++ due to household combustion and implement it in multiple cities (CURB++) Climate services for health materials developed with WHO Start End and WMO Start Launch Maintain $275,000 Develop a MOCC on climate services for health outcomes Leverage IDA and IBRD resources to have at least 1–2 operations/year that integrate Increase number of clients CC and health through: 1–2 countries/year 1–2 countries/year 1–2 countries/year implementing measures to • CC & H vulnerability increase the population’s $1 million/ diagnostic & action plan resilience to the effects of CC country • Climate smart early in health warning & surveillance • Health sector greening plan W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth Launch UHC JLN technical Start Deploy Maintain Maintain UC JLN CC platform maintained stream on CC & H (scenario 3) $1 million (scenario 3) Economic analysis Start End Increase global knowledge $500,000 Note: Resource requirements reflected in this table refer exclusively to variable costs. Activities reflected in this table are additional to those in Figure 5.2. Detail costs including staff time needs/fixed costs are reflected in the more detailed Plan of Action (Annex C). These additional activities will be carried out according to resource availability. Conclusion and Next Steps The health impacts of climate change demand an immediate response, and there are many opportunities to confront these new health-related climate realities across the numerous dimensions of World Bank work. The CCSA and the HNP, and ENR GPs are central to this effort but so too are other sectors and GPs, including Agriculture, Transport, Urban Development, Energy and Water, among others, as each has a stake in considering the health impacts and opportunities of climate change. If we recognize and act upon this challenge, we will be prepared for a substantially altered burden of health conditions; the impacts of extreme weather events will be anticipated and managed, and low-carbon cities will provide mobility while addressing pollution and related noncommunicable diseases. Recognition of health costs will reinforce the economic case for shifting to low-carbon growth. Regions and countries also need to address these near-term and long-term impacts, drawing upon the tools of many of the involved sectors. Through a strengthened coalition of international actors, the potential for health impacts to undermine the international community’s goals for the post-2015 development agenda will be recognized and addressed. International actors bring different mandates and resources to this issue and the World Bank can play a role in line with its comparative advantages that includes its convening power, knowledge resources, and finance. As a convener, the World Bank can help mobilize coalitions for action from a broad sector base, such as those in public health, environment, and—importantly—finance. As a knowledge bank, it can use analytical resources to strengthen the evidence base for action. As a financing institution, it can respond to growing demand to deliver responses at scale. Success requires that investment and lending operations be informed by sector strategies that rec- ognize the climate exposure pathways that lead to health impacts, and integrate responses (both for adaptation and mitigation) that lessen the burden of disease over time, particularly in the areas that are currently being—and will be—most affected. Despite substantial efforts over the last 25 years, both by the World Bank and others in the inter- national community, the health sector is yet to embrace the need to increase its resilience to climate change to improve health outcomes. Given that achieving UHC is the core goal and strategic framework for the global health community, this paper has selected UHC as the entry point for climate engagement as it relates to health outcomes. It illustrates the ways in which climate can hamper progress to this objective as well as pointing to ways the health sector can counter those effects. For the WBG, viewing climate change through the lens of this framework also highlights the central role of other sectors in increasing community resilience to climate-related health effects. The imperative for the World Bank climate change and health plan of action, summarized above and detailed in Annex C, is to upgrade and expand its own capacity and define new priorities to place health and climate change prominently within its own programs; not only in health, nutrition and population but also in other areas of activity, such as environment, agriculture, energy, and 35 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth infrastructure. In addition to close internal coordination, the for health guidance documentation, and the massive open online WBG will also need to collaborate with outside partners to tap course on climate services for health. In parallel, the team will the knowledge and financial resources available and leverage continue building internal partnerships to identify opportunities these to gain the greatest impact in safeguarding health outcomes for collaboration and joint work, and will identify opportunities from climate impacts. for cooperation and for influencing investments under preparation. If approved, this action plan and approach will be presented to We will also work with the CCSA communications and knowledge partners and donors at a meeting to evolve funding. Priority will teams to develop a learning series on CC and health, as well as a be given to country assistance, development of climate services course on CC and health. 36 annex A References Boerma T., et al., 2014. Monitoring Progress towards Universal Health Coverage at Country and Global Levels. PLoS Med 11(9): e1001731. doi:10.1371/journal.pmed.1001731 Costello, Anthony, Mustafa Abbas, Adriana Allen, Sarah Ball, Sarah Bell, Richard Bellamy, Sharon Friel, Nora Groce, Anne Johnson, Maria Kett, Maria Lee, Caren Levy, Mark Maslin, David McCoy, Bill McGuire, Hugh Montgomery, David Napier, Christina Pagel, Jinesh Patel, Jose Antonio Puppim de Oliveira, Nanneke Redclift, Hannah Rees, Daniel Rogger, Joanne Scott, Judith Stephenson, John Twigg, Jonathan Wolff, Craig Patterson, 2009. “Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission.” The Lancet, Vol. 373, No. 9676. Ebi, K., 2008. Adaptation costs for climate change-related cases of diarrhoeal disease, malnutrition, and malaria in 2030, Globalization and Health, Vol. 4, 2008. EHP, 2013. Environ Health Perspective 121:A152–A159 (2013). http://dx.doi.org/10.1289/ehp.121-a152 [online 01 May 2013] Hallegatte, Stephane et al., 2016. Shock waves managing the impacts of climate change on poverty. Climate Change and Development Series. Washington, DC: World Bank. IHME, 2016. Institute for Health Metrics and Evaluation, University of Washington, Seattle. http://www.healthdata .org/news-release/poor-air-quality-kills-55-million-worldwide-annually International Institute for Environment and Development (IIED). Annual Report 2014. Building bridges for sustain- able development. London, United Kingdom. JAMA, 2014. http://jama.jamanetwork.com/article.aspx?articleID=1392489 Kjellstrom, T., et al., 2009. “The direct impact of climate change on regional labor productivity.” Archives of Envi- ronmental & Occupational Health 64.4 (2009): 217–227. Knowlton, K. et al., 2011. “Six Climate Change-Related Events in the United States Accounted for about $14 Billion in Lost Lives and Health Costs,” doi: 10.1377/hlthaff.2011.0229, Health Aff., November 2011 vol. 30 no. 11 2167–2176. http://content.healthaffairs.org/content/30/11/2167.full National Oceanic and Atmospheric Administration (NOAA), 1995. Natural Disaster Survey Report on July 1995 Heat Wave. Silver Spring, Maryland. OECD, 2014. The Cost of Air Pollution: Health Impacts of Road Transport, Organization for Economic Cooperation and Development, Geneva, Switzerland. DOI: 10.1787/9789264210448-en Rogelj, J. et al., 2014. “Disentangling the effects of CO2 and short-lived climate forced mitigation,” PNAS, www.pnas .org/cgi/doi/10.1073/pnas.1415631111 Scheraga, Joel D., and Anne E. Grambsch. “Risks, opportunities and adaptation to climate change.” Climate research 11.1 (1998): 85–95. Smith, K. R., A. Woodward, D. Campbell-Lendrum, D. D. Chadee, Y. Honda, Q. Liu, J. M. Olwoch, B. Revich, and R. Sauerborn, 2014: Human health: impacts, adaptation, and co-benefits. In: Climate Change 2014: Impacts, Adaptation, and Vulnerability. Part A: Global and Sectoral Aspects. Contribution of Working Group II to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change [Field, C. B., V. R. Barros, D. J. Dokken, K. J. Mach, M. D. Mastrandrea, T. E. Bilir, M. Chatterjee, K. L. Ebi, Y. O. Estrada, R. C. Genova, B. Girma, E. S. Kissel, A. N. Levy, S. MacCracken, P. R. Mastrandrea, and L. L. White (eds.)]. Cambridge University Press, Cambridge, United Kingdom and New York, NY, USA, pp. 709–754. Vo T. Danh, 2014. Household economic losses of urban flooding: Case study of Can Tho City, Vietnam. Asian Cities Climate Resilience. Human Settlements Working Paper Series 12: 2014. International Institute for Environment and Development (IIED), 2014. Watts, Nick, W. Neil Adger, Paolo Agnolucci, Jason Blackstock, Peter Byass, Wenjia Cai, Sarah Chaytor, Tim Colbourn, Mat Collins, Adam Cooper, Peter M. Cox, Joanna Depledge, Paul Drummond, Paul Ekins, Victor Galaz, Delia Grace, Hilary Graham, Michael Grubb, Andy Haines, Ian Hamilton, Alasdair Hunter, Xujia Jiang, Moxuan Li, Ilan Kelman, Lu Liang, Melissa Lott, Robert Lowe, Yong Luo, Georgina Mace, Mark Maslin, Maria 37 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth Nilsson, Tadj Oreszczyn, Steve Pye, Tara Quinn, My Svensdotter, Wilson, R. Nicholls, S. Hales, F. Tanser, D. Le Sueur, M. Schlesinger Sergey Venevsky, Koko Warner, Bing Xu, Jun Yang, Yongyuan Yin, and N. Andronova (2004). In Comparative Quantification of Health Chaoqing Yu, Qiang Zhang, Peng Gong, Hugh Montgomery, Anthony Risks, Global and Regional Burden of Disease Attributable to Selected Costello, 2015. “Health and climate change: policy responses to protect Major Risk Factors: Ezzati M., A. D. Lopez, A. Roders and C. J. L. public health.” The Lancet, Vol. 386, No. 10006. Murray (eds.), World Health Organization, Geneva, Switzerland. World Bank, 2009. World Development Report 2010: Development and WHO, 2010. The World Health Report. Health Systems Financing: The Path Climate Change. Washington D.C.: World Bank. to Universal Coverage. World Health Organization, Geneva, Switzerland World Bank, 2012. Turn Down the Heat: Why a 4°C Warmer World Must (http://www.who.int/whr/2010/en/, accessed 10 February 2016). Be Avoided. A report for the World Bank by the Potsdam Institute for WHO, 2014. Quantitative risk assessment of the effects of climate change Climate Impact and Climate Analytics. Washington, DC: World Bank. on selected causes of death, 2030s and 2050s. World Health Organiza- ———. 2013. Turn Down the Heat: Climate Extremes Regional Impacts, and tion, Geneva, Switzerland. the Case for Resilience. A report for the World Bank by the Potsdam WHO, 2015. Operational framework for building climate resilient health Institute for Climate Impact and Climate Analytics. Washington, DC: systems. World Health Organization, Geneva, Switzerland. World Bank. WHO-World Bank, 2014. Access to modern energy services for health facili- ———. 2014. Turn Down the Heat: Confronting the New Climate Normal. A ties in resource-constrained settings: a review of status, significance, report for the World Bank by the Potsdam Institute for Climate Impact challenges and measurement. World Health Organization, Geneva, and Climate Analytics. Washington, DC: World Bank. Switzerland. World Bank. WHO, 2004. “Global Climate Change,” (pp. 1543–1650), by McMichael, A., D. Campbell-Lendrum, S. Kovats, S. Edwards, P. Wilkinson, T. 38 annex B Health Sector Interventions in Response to Climate Change For full details, please see “Climate-smart healthcare: low carbon and resilience strategies for the health sector, 2017.” Table B.1: Mitigation strategies applicable to the health care sector. Mitigation strategy Actions GHG impact Health co-benefits Improve energy Fuel switching; Reduced transmission Immediate energy savings supply and distribution Energy recovery; Distributed losses; Reduced and operational resilience/ efficiency generation; emissions from energy reliability Combined heat & power use, fuel production and Reduced air pollution transport exposures Improved access to reliable health care On-site renewable Solar photovoltaics Reduced emissions Improved operational energy sources Thermal solar energy Other from energy use, fuel resilience/reliability renewable energies production and transport Long-term energy savings Reduced ambient air emissions Reduced-energy Non-electric medical devices Reduced emissions Energy and operations devices Direct-current devices from energy use, fuel savings and energy security Energy efficient appliances production and transport Improved functionality at night and device reliability Improved diagnosis of tuberculosis with low-energy LED microscopes Increased access to health care and energy security Passive cooling, Natural ventilation in health Reduced direct emissions Energy and operations heating and ventilation care settings from on-site energy savings and energy security strategies Evaporative cooling production; reduced Improved indoor air quality Desiccant dehumidification emissions from energy Decreased transmission of Underground earth-pipe use, fuel production and airborne infections cooling transport Improved social welfare, productivity and patient health (continued) 39 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth Table B.1: Continued Mitigation strategy Actions GHG impact Health co-benefits Facility wastewater Advanced autoclaving Reduced energy Savings in waste/water and solid waste of infectious health care waste emissions for waste and disposal fees management On-site wastewater pre- water treatment Reduced waste volumes treatment and sanitation Reduced greenhouse Improved compliance with improvements gas (GHG) footprint local air quality regulations/ High-heat incineration from waste treatment guidelines of pharmaceuticals with processes in some Improved hygiene around pollution scrubbers settings facility Reduced aquifer and Reduced methane and other ecosystem damage emissions Reduced risks of exposure to infectious agents, and to diarrhea and other water- borne diseases Reduced GHG Waste anaesthetic gas Reduced direct emissions Anaesthesia cost savings with emissions from recapture and scavenging from anaesthesia gas reuse anaesthesia gas use waste Reduced health risks for and disposal health workers exposed to gas Improved health worker productivity Reduced procurement Better-managed procurement Reduced energy Resource savings on unused/ carbon footprint of pharmaceuticals, medical footprint in production wasted products, Reduced devices, business products and transport of unused risks from use of outdated/ and services, food/catering pharmaceuticals and expired products and other facility inputs products Telehealth/ Home patient telemonitoring Reduced emissions from More cost-effective health telemedicine and guidance health care-related travel care Emergency response Reduced risk of travel-related Health worker advice injuries, collaboration via mobile phones Improved management of chronic conditions, such as diabetes and heart disease, as well as emergency response Better access to health care advice in poorly-resourced remote locations 40 H ea lth Se c tor Int e r v e nti ons i n Re spons e to C li mat e Ch ange Mitigation strategy Actions GHG impact Health co-benefits Health facilities in Public transport options Reduced transport- Reduced traffic injury risk for proximity to public mapped during planning of related emissions from health workers and hospital/ transport and safe buildings to locate new facilities health worker and hospital clinic visitors travelling to walking/cycling nearby visitor travel health facilities Employee incentives for public Potential for active transport active transport use and by health care workers to facilities reduce risks of hypertension, cardiac disease and diabetes Improved facility access for health workers and visitors who do not have cars Conserve and maintain Water-efficient fixtures, leakage Reduced energy use for Improved performance due to water resources management, water safety water extraction from better access to safe water Onsite water treatment and surface/aquifer sources Savings in water fees safe water storage in health Reduced truck transit of Reduced water contamination facilities water resources from health facility activities Rainwater harvesting, gray Reduced aquifer and Reduced disease water recapture/ recycling ecosystem damage from transmission from unsafe water extraction water and drinking water Improved access to safe, potable water in poorly resourced health facilities Source: Adapted from the World Health Organization. 41 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth Table B.2: Health sector interventions for adapting to and building resilience to climate-sensitive health impacts. Respiratory and Vector-borne Water-borne cardiovascular disease disease Undernutrition Heat stress health Mental health Cross-cutting medical and public health measures Medical personnel training and capacity buildings Public health awareness campaigns for climate-sensitive health impacts Climate awareness in-built to Universal Health Coverage Mapping of hospitals and clinics in relation to climate-sensitive geographies Preventative Preventative Education of pregnant Medical guidance to Implementation of Increased mental-health interventions: interventions: women, mothers and vulnerable workers— early-warning systems workforce vaccinations, bednets, vaccinations, water supply of PNVs. e.g., outdoor laborers associated with poor insecticides purification and factory workers air quality associated with climate pollutants or other biologic aero-allergens Implementation of Implementation of Supply of nutritional Implementation of Improved diagnostics Improved storage and early-warning systems early-warning systems supplements ahead of early-warning systems for allergic reactions access to mental health associated with associated with flooding extreme weather associated with treatments disease-correlated events or drought extreme heat weather events, such as high temperature or precipitation Improved laboratory Improved laboratory Improved pediatric Stockpiling and     and on-site diagnostic and on-site diagnostic facilities in climate- distribution of facilities facilities sensitive areas emergency oral rehydration solution Trainings for medical Trainings for medical         staff to recognize staff to recognize symptoms symptoms Stockpiles of antiviral Stockpiles of antivirals,         and antiparasitic antiparasitics, and medications antibiotics 42 annex C Mainstreaming/Integrating Climate-Health Dimensions across World Bank Operations Table C.1: CC and health action plan FY2017. Objectives/targets Activities Staff weeks Low scen. Scen. 1 Scen. 2 Pillar 1. Objective: • Develop Water, CCSA: 15 $30 k $30 k $30 k Knowledge generation Urban and Energy HNP: 4 • Water, Urban and Energy knowledge notes knowledge gaps and to identify gaps and opportunities identified opportunities • KPs in agriculture and • KP on Impact of CC transport launched in agricultural labor • Expand Reducing Air Pollution from Urban Transport report with health, pollution & CC • CURB+ developed • Hire consultant to HNP, URBAN, $250 k $250 k develop clean air CCSA, ENR: 10 and health module Pillar 2. Objective: Improve • Clinics for HNP CCSA FP: 3 $55 k $55 k $55 k WB staff capacity teams on CC CCSA KMT: 4 • 25% of teams preparing and disasters HNP: 6 new HNP projects in last project screening ENR: 4 FY have benefited from CCSA’s KM CCSA: 20 training on climate and • Organize a CC and disaster risk screening health series (BBL) • 6 training events on CC • Develop jointly and health delivered with (CCSA, HNP, • Develop internal course ENR) KM, an online internal course for World Bank staff on impacts and actions on CC and health (continued) 43 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth Table C.1: Continued. Objectives/targets Activities Staff weeks Low scen. Scen. 1 Scen. 2 Pillar 3. Objectives: • TA from CCSA to CCSA: 10 $20 k $20 k $20 k Increase number of HNP teams HNP: 1 + 50 k upcoming SCDs/CPFs • Engage country and HNP operations partners, ministries incorporating CC & H of environment, • A percentage of HNP disaster authorities, operations include CC & meteorological H activities, e.g.: CC & H authorities, WMO/ vulnerability assessment & WHO. work plan, climate • SCD/CSA review smart early warning & and engaging with surveillance, reduction teams of GHG emission in the health sector • All new SCDs/CPFs in high risk countries include CC &H • 20% of HNP new projects consider CC in their design • MOOC on climate • Develop MOOC on CCSA: 15 $250 k $250 k services for health climate services LLI: 20 launched for health jointly with WHO, WMO, USAID • UHC JLN technical • Proposal, web CCSA: 6 $1 m/ stream on CC & H development, HNP: 8 3 years launched 2 learning events Crosscutting area 1. • Training and TA CCSA: 3 SW $20 k $20 k Objective: Leverage WB to HNP teams to HNP: 3 SW resources prepare proposals • # of HNP operations for GEF and CIFs accessing climate funds • Prepare funding • Explore external funding proposals opportunities Crosscutting area 2. • Participate CCSA: 6 $25 k $25 k $25 k Objective: Influence co-sponsor investments internally & international events influence global dialogue Total $100 k $650 k $1.7 m 44 Ma i nst r e a mi n g/ Int e gr at i n g C li m at e - He alth Di me ns i ons a cross Wo r ld Bank O perations Table C.2: CC and health action plan FY2018. Objectives/targets Activities Staff weeks Low scen. Scen. 1 Scen. 2 Pillar 1. Objective: Knowledge generation • KP on issues identified by water, urban & CCSA: 3 Urban $100 k $130 k $210 k • Water, Urban and Energy KPs launched energy ENR: 3 Urban: 15 • CURB++ developed • Consultant to develop household HNP/URBAN, $250 k $250 k pollution contribution to outdoor air CCSA/ENR: 10 pollution & health module Pillar 2. Objective: Improve WB staff • Clinics for HNP teams on CC and CCSA FP: 3 $10 k $10 k $10 k capacity disasters project screening CCSA’s KM CCSA KMT: 4 • 50% of HNP new projects in last FY • Organize a CC and health series (BBL) HNP: 2 benefited from training/clinic on CC & (HNP/CCSA/ENR) ENR: 2 disaster risk screening • Course maintenance AG: 1 • 10% of HNP new projects consider CC Transport: 1 • 40% of staff trained on CC impact on HNP Pillar 3. Objectives: Increase number • TA from CCSA to HNP teams CCSA: 6 $20 k $60 k $80 k of upcoming SCDs/CPFs and HNP • Engage country partners, ministries HNP: 4 operations incorporating CC & H of environment, disaster authorities, Transport:2 • At least one Transport operation and one meteorological authorities, WMO/WHO Agriculture: 2 Agriculture operation incorporate the Energy, Urban, results of respective KPs Water: 12 • All new SCDs/CPFs in high risk countries include CC and health considerations • UHC JLN CC platform maintained • TA from CCSA to HNP teams CCSA: 22 $20 k • One or two additional HNP operations • Support countries to hire TA HNP: 10 $1 m $2 m include CC & H activities • MOOC on climate services for health • Develop MOOC on climate services for CCSA: 15 $100 k $100 k implemented health jointly with WHO, WMO, USAID LLI: 20 • CURB+ applied to 10 cities • Support country teams to apply CURB HNP/URBAN, $1 m CCSA/ENR: 10 Crosscutting area 1. Objective: Leverage • Training and TA to HNP teams to prepare CCSA: 12 SW $30 k $30 k $30 k WB resources proposals for GEF and CIFs HNP: 10 SW • # of HNP operations accessing climate • Engage donors and foundations and funds World Bank’s financial team • Explore MDTF or similar funding architecture for CC & H work Crosscutting area 2. Objective: Influence • Participate cosponsor international events CCSA: 3 SW $20 k $20 k $20 k investments internally & influence global HNP: 3 SW dialogue Total $200 k $1.6 m $3.7 m 45 W o r l d B a nk A pproa ch a nd A ct i on P l a n fo r C li mate C hang e and H e alth Table C.3: CC and health action plan FY2019. Objectives/targets Activities Staff weeks Low scen. Scen. 1 Scen. 2 Pillar 1. Objective: Knowledge generation • Define TORs and contract CCSA: 8 $200 k $200 k • Launch CC & health economic analysis HNP: 8 Pillar 2. Objective: Improve WB staff • Clinics to HNP teams on CC and CCSA FP: 3 $10 k $10 k $10 k capacity disasters project screening CCSA’s KM CCSA KMT: 4 • 65% of HNP new projects in last FY • Organize a CC and health series (BBL) HNP: 2 benefited from training/clinic on CC & (HNP/CCSA/ENR) ENR: 2 disaster risk screening • Course maintenance AG, Transport, • 15% of HNP new projects consider CC Water, Urban, • 60% of staff trained on CC impact on Energy: 5 HNP Pillar 3. Objectives: Increase number • TA from CCSA to HNP teams CCSA: 8 $20 k $30 k $80 k of upcoming SCDs/CPFs and HNP • Engage country partners, ministries HNP: 8 operations incorporating CC & H of environment, disaster authorities, Transport, AG, At least five non-HNP operations incorporate meteorological authorities, WMO/WHO Energy, Urban, CC and H angle, the results of respective KPs Water: 20 All new SCDs/CPFs in high risk countries include CC and health considerations • UHC JLN CC platform maintained • One or two additional HNP or other • TA from CCSA to HNP teams CCSA: 20 $20 k $1 m $2 m sector operations include CC & H • Support countries to hire TA HNP: 2 activities • CURB++ applied to 10 cities • Support country teams to apply CCSA: 3 $1 m CURB++ ENR: 3 Urban: 15 Crosscutting area 1. Objective: Leverage • Negotiate with donors a MDTF for CCSA: 15 SW $30 k $30 k $30 k WB resources health & CC HNP: 8 SW • # of HNP operations accessing climate • Prepare funding proposals funds • Architecture for MTF set Crosscutting area 2. Objective: Influence • Participate cosponsor international events CCSA: 3 SW $30 k $30 k $30 k investments internally & influence global • Publish work HNP: 3 SW dialogue Total $110 k $1.3 m $3.3 m 46 Ma i nst r e a mi n g/ Int e gr at i n g C li m at e - He alth Di me ns i ons a cross Wo r ld Bank O perations Table C.4: CC and health action plan FY2020. Objectives/targets Activities Staff weeks Low scen. Scen. 1 Scen. 2 Pillar 1. Objective: Knowledge generation • Contract evaluation $100 k $100 k $100 k • Evaluation of the Plan of Action Pillar 2. Objective: Improve WB staff • Clinics to HNP teams on CC and CCSA FP: 3 $10 k $10 k $10 k capacity disasters project screening CCSA’s KM CCSA KMT: 4 • 80% of HNP new projects in last FY • Organize a CC and health series (BBL) HNP: 2 benefited from training/clinic on CC & (HNP/CCSA/ENR) ENR: 2 disaster risk screening • Course maintenance AG, Transport, • 20% of HNP new projects consider CC Water, Urban, • 75% of HNP staff trained on CC impact Energy: 5 on HNP Pillar 3. Objectives: Increase number • TA from CCSA to HNP teams CCSA: 8 $20 k $50 k $80 k of upcoming SCDs/CPFs and HNP • Engage country partners, ministries HNP: 8 operations incorporating CC & H of environment, disaster authorities, Transport, AG, At least five non-HNP operations incorporate meteorological authorities, WMO/WHO Energy, Urban, CC and H angle/ the results of respective KPs Water: 20 All new SCDs/CPFs high risk countries include CC and health considerations • UHC JLN CC platform maintained • One or two more HNP or other sectors • TA from CCSA to HNP teams CCSA: 20 $20 k $1 m $2 m operations include CC & H activities • Support countries to hire TA HNP: 2 • CURB++ applied to 10 new cities • Support country teams to apply CURB++ CCSA: 3 $1 m ENR: 3 Urban: 15 Crosscutting area 1. Objective: Leverage • Training and TA to HNP teams to prepare CCSA: 3 SW $30 k $30 k $30 k WB resources proposals for GEF and CIFs HNP: 3 SW • # of HNP operations accessing climate • Prepare funding proposals funds • Functioning MDTF Crosscutting area 2. Objective: Influence • Participate cosponsor international events CCSA: 3 SW $30 k $30 k $30 k investments internally & influence global • Publish work HNP: 3 SW dialogue Total $200 k $1.22 m $3.25 m 47 WORLD BANK REPORT NUMBER 113573-GLB