Methodological Guidance Climate Change and Health Diagnostic A Country-Based Approach for Assessing Risks and Investing in Climate-Smart Health Systems Investing in Climate Change and Health Series Methodological Guidance: Climate Change and Health Diagnostic A Country-Based Approach for Assessing Risks and Investing in Climate-Smart Health Systems Investing in Climate Change and Health Series ©2018 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 WBG action on climate change and health. Other documents in this series include: • World Bank Approach and Action Plan for Climate Change and Health, 2017 • Geographic Hotspots for World Bank Action on Climate Change and Health, 2017 • Climate-Smart Healthcare: Low-Carbon and Resilience Strategies for the Health Sector, 2017 As this program evolves, diagnostics using the methodology outlined in this report will become available for individual countries. Acknowledgments This report is a joint production of the World Bank Group Climate Change Group and Health, Nutrition, and Population Global Practice. Timothy Bouley led the team comprising Kristie L. Ebi (University of Washington, primary author), Amelia Midgley, Joy Shumake- Guillemot (World Health Organization–World Meteorological Organization) and Christopher D. Golden (Harvard University). Key sup- port and advice was provided by Voahirana Rajoela, Jumana Qamruddin, Lisa Saldanha, Tazim Mawji, and Jakub Kakietek. The team thanks Catherine Lynch for her work on the City Strength Diagnostic, which was used as an early template of this project. The Nordic Development Fund (NDF) provided resources for the original climate change and health program, from which this report derives, and the team is indebted to the goodwill and support of the NDF team, particularly Pasi Hellman, Martina Jagerhorn, and Leena Klossner. Peer review was performed by Raul Alfaro-Pelico, John Balbus (US National Institutes of Health), Franck Berthe, Peter Berry (Health Canada), Dennis Bours (Global Environment Facility), Diarmid Campbell-Lendrum (World Health Organization), Catherine Machalaba (EcoHealth Alliance), Tamer Rabie, Kanta Rigaud, Elena Villalobos (World Health Organization), and Nick Watts (UCL). Important contributions were also made by Patricia Braxton, Paula Garcia, Gary Kleiman, Barbara Machado, Montserrat Meiro-Lorenzo, Hui Wang, and Susan Wilburn. Overall guidance within the World Bank was provided by John Roome, Timothy Grant Evans, James Close, Olusoji Adeyi, Fadia Saadah, and Stephen Hammer. Damian Milverton of GlobalEditor.org performed the final edit and review. Formatting and graphic development were undertaken by Shepherd Incorporated. iii M etho do l ogical G u id a n c e : C l i m at e C h a n ge a n d H ea lth D ia gn ostic How to use this document This guidebook is designed for use by task teams from the World Bank Group (WBG) and other development partners who are con- ducting climate change and health diagnostics in a client country or region. The methods are new and evolving, reflecting state-of- the-art approaches to increase resilience and promote low-carbon development. Guidance materials, including this guidebook, will be updated and revised with experience. This work also provides an introduction to health system resilience, offers guidance on initiating the diagnostic process and forming a strong implementation team, and describes the five main stages in detail. Each chapter includes step-by-step instruction and advice. Each implementation of the climate change and health diagnostic will be different; every country and health system has a unique set of attributes and development constraints. This guidebook offers a framework that can be used by specialists at the WBG and other development partners to guide their engagement with advice on matters specific to different stages. Each team’s experience will help to enrich the methods. It is therefore important for each team to share their ideas and lessons with the aim of improving the guidebook and the effectiveness of a climate and health diagnostic. Intended audience This document is primarily directed to development partners, including WBG staff working on health, nutrition, and population projects and programs. Much of the content also may be useful to those working on related issues in areas such as environment and natural resources, water, energy, transport, urban, and others. As a crosscutting discipline, climate change and health issues are germane to projects in many disciplines. Although some of the language in this document is specific to WBG policies and procedures (e.g., task team leaders, global practices, etc.), the document has value beyond this institution as other development banks, bilateral aid agencies, and communities are tackling common issues. Tools and approaches here can be applied in many of these contexts. Policymakers and managers likely will find this document useful as it provides a framework for assessing climate change impacts and opportunities within the health sector that may inform higher level dialogue and decision making. Operational teams should find value in the specific tools and approaches here that can be integrated within WBG lending programs. The examples should also provide useful context for all readers. iv Contents Acknowledgments iii How to use this document iv Intended audience iv Country-Level Climate Change and Health Diagnostic vii Benefits of Conducting a Diagnostic viii Connecting Health and Climate Change 1 Introduction 1 The Health Risks of Climate Variability and Change 3 What Is Resilience? 6 Resilience as a Priority for Health Systems 7 Qualities of Health System Resilience 7 What Is ‘Low-Carbon Development’? 7 Shocks and Stresses 9 Undertaking a Climate Change and Health Diagnostic 11 Steps in Conducting a Diagnostic 11 Getting Started 13 Form the Diagnostic Team 13 Stage 1: Conduct a Pre-Diagnostic Document and Data Review 15 A.  Review Existing Studies, Reports, Plans, and Interviews 15 B.  Map the Stakeholders 19 C.  Identify Priority Climate-Sensitive Health Impacts 20 D.  Prepare the Briefing Note 21 E.  Train the Task Team 21 Stage 2: Conduct a Workshop to Launch the Diagnostic 23 A.  Plan the Workshop 23 B. Conduct the Workshop 26 Stage 3: Conduct Interviews and Site Visits 29 A.  Conduct Interviews 29 B.  Visit Relevant Sites 29 v M etho do l ogical G u id a n c e : C l i m at e C h a n ge a n d H ea lth D ia gn ostic Stage 4: Develop Recommendations and Prepare a Summary Report 31 A.  Develop Recommendations for Investments 31 B.  Prepare a Summary Report 32 Stage 5: Present and Validate Report Findings and Recommendations 35 A.  Review Meeting and Second Stakeholder Consultation 35 B.  Finalize the Diagnostic Report 37 C.  Make the Findings Public 37 D.  Set the Path for Future Engagement 37 References 39 Annex A: Relevant WBG Tools and Resources 41 Climate Change and Health Website 41 Climate and Disaster Risk Screening Tools 41 Environmental Health Capacity Assessment Tool 41 Global Facility for Disaster Risk Reduction Resources 42 Operational Framework for Strengthening Public Health Systems at the Human-Animal-Environment Interface 42 Annex B: Connecting Climate Change and Health with “One Health,” “Planetary Health” and the Sustainable Development Goals 45 vi Country-Level Climate Change and Health Diagnostic The overall goal of conducting a climate change and health diagnostic is to link knowledge to investment. It aims to identify events and conditions where climate stresses and shocks undermine the effective- ness of health systems (at local or national scales), increasing morbidity and mortality. The diagnostic uses these insights to prioritize interventions toward establishing climate-smart health systems that both increase resilience and reduce climate forcing emissions. The diagnostic also identifies shocks and stresses in other sectors that could have negative consequences for public health in general or health systems in particular. Diagnostics are to be conducted within the context of an active lending portfolio so that recommendations can be directly integrated into investment. Figure 1: Mapping the diagnostic process, step by step. Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 2 1 3 Pre-Diagnostic Launch Field Visits & Prioritization Recommendations Review Workshop Interviews Session & Action Plan Collect and review Conduct workshop Conduct interviews Develop recommendations Present and validate existing documents and assess and and site visits to help and prepare a summary report findings and and data. Map key verify the information the technical team report with an overview of recommendations stakeholders and collected in Stage 1 better understand climate and health impacts with those who prepare a briefing with local partners, the challenges and and opportunities, while participated in the note for a diagnostic confirm initial opportunities also specifying links to launch workshop, as workshop. thinking and associated with WBG investment. well as decision directions, and climate-related makers and other identify additional shocks and stakeholders. resources and stresses. stakeholders. vii M etho do l ogical G u id a n c e : C l i m at e C h a n ge a n d H ea lth D ia gn ostic Benefits of Conducting a Diagnostic across departments and tiers of government, civil society, and the private sector. The process of diagnosing climate-sensitive risks and opportuni- • Learning. A diagnostic encourages a wider appreciation ties builds on information and knowledge across the local and by specialists in other sectors of the health risks of climate national levels. It considers options to increase the effectiveness change and ways that those risks could interact with their own and efficiency of policies and measures to manage those risks sectors. This learning applies to all of those involved in the and targets opportunities to facilitate low-carbon growth. The process: government technical staff, development partners, resulting Diagnostic goes directly to the question of how well and lending task teams, etc. health systems could manage extreme weather and climate events, • Development impact. Country-specific diagnostics generate better climate-sensitive disease outbreaks, and other possibilities outside advice and ultimately can enhance the impact of investment. the range of historic experience. Benefits of this approach include: • Business development. Climate change and health diagnostics • Client relationship. A comprehensive diagnostic facilitates a deliver a tangible output—a prioritized set of recommendations more internally coordinated approach by the WBG and other that enable task teams to develop proposals for ongoing support development partners in regards to communities and health to increase health system resilience and enhance low-carbon systems at local and national scales. It is an opportunity to interventions in the context of a changing climate. The propos- bring together a multi-sector team to support an integrated als could be supported by a range of environmental funders. approach to health system leadership, including expertise from other sectors, such as hydrometeorological and climate services. • Inclusion. Preparation of a climate change and health diag- nostic embraces multiple stakeholder perspectives, including viii Connecting Health and Climate Change Introduction Many World Bank Group (WBG) client countries—and especially their poor populations—are being disproportionately affected by the impacts of climate change on human health. According to new WBG analysis, 79 percent of countries supported by the International Development Association (IDA) are among the most at-risk countries for negative health outcomes associated with climate change (for either health impacts caused by climate change, health impacts associated with climate change-causing emissions, or both). Half are in Africa (World Bank 2017a). This significant majority underscores an absolute need for further engagement on the health and climate agenda and implicates a need for prioritization in future investment. Integrating climate and health considerations into current and upcoming investments presents a straightforward approach to helping development lending teams and countries meet overall climate com- mitments while aligning with country demands to address climate and environmental impacts on health. The WBG is committed to pursuing an end to extreme poverty and to building shared prosperity. This commitment includes improving health outcomes and achieving universal health coverage while also mitigating and adapting to climate change. The compounded effect of climate change on health will jeopardize these core WBG objectives and undermine the viability of investments, which rank among the largest of any development institution in the world. WBG recently established an “Approach and Action Plan for Climate Change and Health” describing institutional targets, geographies, and approaches to mainstreaming climate-smart healthcare (World Bank 2017a, 2017b, 2017c). One commitment within this Plan focuses on country-level engagement; in particular, it emphasizes conducting climate change and health diagnostics that assess overall health system and health outcome sensitivity to climate and other environmental changes, while identifying opportunities for investment and interventions to build climate-smart health systems. Regionally, climate and health work stands to add considerable value to development invest- ments, with minimal additional effort undertaken by country teams. International experts and partners have articulated and validated the case for WBG involvement, and the institution has identified key geographical areas of impact (along with methods of assessing subnational impact). The WBG has developed climate-smart health tools that can readily be built into investments, and also established an international community of climate and health experts that it can draw upon to perform country- and project-specific analyses. Addressing climate change and health spans multiple sectors. The WBG has a comparative advan- tage in aligning analytic and operational expertise across health, climate, economics, environmental management, and other core areas to address multidimensional development threats. Working at a system level, the WBG is especially well placed to help clients embed an integrated approach in their planning. Deep implementation expertise can then support countries in effectively executing programs and interventions, establishing a platform or standard upon which other development institutions can build. WBG research and economic analysis can also help countries establish financial baselines that 1 M etho do l ogical G u id a n c e : C l i m at e C h a n ge a n d H ea lth D ia gn ostic can be useful in government-wide planning beyond merely health adaptation, and capacity assessments (V&A assessment). V&A and environmental sectors. assessments are conducted at local to national scales to provide To promote understanding of potential future climate resilience, information on the health risks of climate variability and change the Climate Change and Health Diagnostic (hereafter referred to and on the options to increase resilience to those risks (WHO as the “Diagnostic”) was developed to help technical staff at the 2012). The results are communicated to health systems, other WBG and other development partners facilitate an action-focused stakeholders, and the public. These V&A assessments: dialogue among stakeholders about risks, resilience, and the per- • Improve evidence and understanding of the current associa- formance of sectors and systems. The Diagnostic identifies priority tions between weather/climate and health outcomes; actions and investments to enhance a health system’s (and other related systems’) resilience, reduce greenhouse gas emissions, and • Provide health officials, stakeholders, and the public with increase the climate-smart potential of planned or ongoing projects. information on the magnitude and pattern of current and The methods outlined in the Diagnostic aim to identify risks future health risks associated with climate variability and and measure the ability of health (or other) systems to manage change, including the populations and communities most potentially disruptive climate-related shocks and stresses. It helps vulnerable to these risks; identify those risks that would be difficult for communities and • Identify opportunities to incorporate climate change concerns health systems to manage while maintaining services to protect into existing policies and programs designed to manage health public health. This process takes into consideration socioeconomic risks associated with weather and climate, and to develop and political factors that can influence the vulnerability and capac- new programs where necessary to prevent and reduce the ity of populations and health systems. severity of future risks; The overall goal of conducting a climate change and health • Serve as a baseline analysis against which future changes in diagnostic is to link knowledge to investment. It aims to identify risks and in policies and programs can be monitored; and events and conditions where climate stresses and shocks undermine the effectiveness of health systems (at local or national scales), • Forge collaborations with sectors such as water and infra- increasing morbidity and mortality. The diagnostic uses these insights structure to further promote activities to improve population to prioritize interventions toward establishing climate-smart health health in a changing climate. systems that both increase resilience and reduce climate forcing The development of a country diagnostic is also a first step toward emissions. The diagnostic also identifies shocks and stresses in the actualization of climate-smart healthcare—a new approach to other sectors that could have negative consequences for public achieve low-carbon, resilient health systems that recognizes the sig- health in general or health systems in particular. This diagnostic has nificance of the climate and health relationship and prioritizes actions been conducted within the context of an active lending portfolio so to reduce the health sector carbon footprint and adapt systems to that recommendations can be directly integrated into investment. be resilient and responsive in the face of climate change (Figure 2). This diagnostic approach is an extension of analyses and infor- This work seeks to stimulate and support greater integration mation gathered during the process of conducting vulnerability, of health and climate considerations across the institution, within Figure 2: Climate smart healthcare. Box 1. Defining Components of a WBG Climate Change and Health Diagnostic • Identifies climate-related events and conditions that stress and shock health systems • Identifies climate-related events and conditions in non- Low-Carbon Climate-Smart Resilient health sectors that can negatively impact health or health Healthcare Healthcare Healthcare Interventions Interventions systems • Prioritizes interventions that address these shocks and stresses • Provides information useful in establishing climate-smart health-related interventions • Directly links to an active lending portfolio 2 C on n e ct i n g H ea lt h a n d C l i m ate C h ang e the Health, Nutrition, and Population (HNP) Global Practice, and in extreme weather and climate events, sea level rise, and ocean in other sectors. As part of corporate climate commitments, the acidification are expected to affect any health outcome that is WBG established a target of ensuring 28 percent of its portfolio sensitive to weather or climate. Impacts include the effects of generates climate co-benefits by 2020. Individual global practices heatwaves, floods, and storms. They lead to more suitable con- have their own targets that support this; for example, HNP aims ditions for the transmission of important infectious diseases and to ensure that 20 percent of new operations are climate consider- also harm the natural systems and socioeconomic sectors that ate by 2020. Doing so requires a much wider embrace of climate ultimately underpin human health (Smith et al. 2014; see also change issues within all departments but particularly HNP, where Figure 3). In summary, health impacts can arise from: there is at present little climate involvement. • Climate change-related alterations in the frequency, intensity, and duration of extreme weather and climate events (e.g., The Health Risks of Climate Variability heat waves, floods, droughts, and windstorms). Each year, and Change these events affect millions of people, damage critical public health infrastructure, and cause economic losses costing bil- Climate change will harm—and is harming—human health. lions of dollars. The frequency and intensity of some types of Increasing temperatures, changing precipitation patterns, increases extreme weather events are expected to continue to increase Figure 3: Health risks of a changing climate. Impact of Climate Change on Human Health Injuries, fatalities, Asthma, mental health impacts cardiovascular disease Severe Air Heat-related illness Weather Population Malaria, dengue, and deaths, encephalitis, hantavirus, cardiovascular failure Rift Valley fever, Lyme disease, chikungunya, West Nile virus ING RES MO R IS ATU W E Changes Extreme ER TEM R E in Vector EX HER Heat P AT TR Ecology EME SIN S EA VEL G LE Increasing L I RI Environmental 2 EV CO CR S NG ELS Allergens Degradation IN SEA Respiratory Forced migration, allergies, asthma civil conflict, Water and Food Water mental health impacts Supply Impacts Quality Impacts Cholera, Malnutrition, cryptosporidiosis, diarrheal disease campylobacter, leptospirosis, harmful algal blooms Source: Dr. George Luber, CDC. 3 M etho do l ogical G u id a n c e : C l i m at e C h a n ge a n d H ea lth D ia gn ostic over coming decades as a consequence of climate change detrimental, particularly in low- and low-middle-income countries (IPCC 2013), suggesting that the associated health impacts that experience higher burdens of climate-sensitive health outcomes could increase without additional prevention actions, includ- (Smith et al., 2014). Climate change may not be the most important ing impacts on mental health. driver of climate-sensitive health risks over the next few decades, but it could be significant beyond 2050. It is a stress multiplier • The effects of climate change on natural and physical systems putting pressure on vulnerable systems, populations, and regions. that in turn alter the number of people at risk of undernutrition, At the same time, considerable progress was made in recent the changes in geographic range and incidence of vector-borne, decades to reduce the burden of major climate-sensitive health zoonotic, and food- and waterborne diseases, and the prevalence outcomes, at least partly through efforts to achieve the Millen- of diseases associated with air pollutants and aeroallergens. nium Development Goals and other international development Additional climate change in coming decades is projected to goals (Smith et al., 2014). These trends are expected to continue significantly increase the number of people at risk of these major in coming decades (WHO 2014), depending on the development causes of ill health. pathways followed (Ebi 2014). • Climate-induced economic dislocation and environmental The post-2015 development agenda includes 17 proposed decline, as well as through development setbacks incurred by Sustainable Development Goals (SDGs; Figure 4). Goal 13 calls damage to critical public health infrastructure and livelihoods for urgent action to combat climate change and its impacts, while by extreme weather events. Goal 3 aims to encourage healthy lives and promote well-being. Efforts are only just beginning to detect changes in current Yet, virtually every other goal includes some dimension that health burdens associated with changing weather patterns and touches upon health and climate considerations, underscoring the ascertain the extent to which climate change is responsible (Ebi relevance of an integrated systems perspective across environmen- et al., 2017). Rising temperatures due to climate change are tal and health spheres. Fundamentally, all goals are linked such increasing the number of cases of heat-related illnesses, Lyme that progress in one can lead to collective achievement toward disease, and diseases associated with vibrios, in some regions. improved development and a more sustainable future. While climate change will likely benefit some health outcomes Climate variability and change present unique challenges to in certain locations in the short term, the overall balance will be health systems. Everyone is exposed to changing weather patterns, Figure 4: Sustainable Development Goals. 4 C on n e ct i n g H ea lt h a n d C l i m ate C h ang e although this exposure is not the same for all. Particular loca- The focus of health adaptation to date has been on strength- tions and population groups have higher levels of exposure to, ening health systems (e.g., public health and healthcare policies, for example, higher ambient temperatures (than the prevailing measures, and institutions) to better manage the changes that average for a region) or to greater risks for flooding. already are evident and to increase preparedness for projected risks. Climate change will increase for decades even after a reduction Incremental improvements are important first steps in a transition in emissions, as opposed to most environmental health hazards to systems-based approaches that can more effectively manage the where exposures can be reduced over time with improved con- multiple, simultaneous challenges that individuals, communities, trol (e.g., exposure to tobacco smoke or groundwater sources of and health systems will experience over coming decades. How- arsenic). Vulnerabilities will shift with changes in climate and ever, incremental changes are unlikely to be sufficient to manage due to changes in urban infrastructure, technology, access to surprises that exceed the capacity of health systems. Modifying safe water and improved sanitation, and factors associated with current programs to manage each climate-related hazard separately development choices. Additional evidence, new knowledge of may lead to inadequate preparation of health systems to manage trends, changing projections of climate and vulnerability, and multiple and synergistic exposures that are increasingly occurring emerging best practices in adaptation will affect options for man- in a particular location, such as a drought followed by flooding, aging the health risks of climate change. Together, these changes or multiple infectious disease outbreaks. More comprehensive, are likely to alter the effectiveness and success of health systems systems-oriented, and transformative approaches are warranted strategies and policies. In some cases, climate change could affect to manage multiple and synergistic exposures. the longer term sustainability and resilience of a program, such Key steps in modifying health systems include undertaking a as those designed to ensure access to safe water in coastal zones vulnerability and adaptation assessment and developing a national experiencing accelerating sea level rise and storm surges. health adaptation plan, within iterative cycles of learning timed The structure of health systems increases the challenges of to correlate with anticipated shifts in exposures, incoming data climate change given that, in general, different departments manage streams, and other information to inform management choices. individual health outcomes (e.g., malaria or undernutrition) with Systems-based approaches are more effective when they incorpo- often limited interactions across departments. The health risks of rate planning, implementation, evaluation processes, uncertainty, climate change span most departments in a ministry of health, and unpredictability into analyses of the magnitude and rate of requiring crosscutting approaches to adaptation. climate change. Other critical components include the capacity of Further, programs and activities often implicitly assume that systems to manage change, the effectiveness of interventions, and the same approach to managing a health risk is appropriate across learning. To be effective, adaptation should incorporate strategies spatial and temporal scales. This top-down approach worked well to manage the upstream drivers of adverse health risks. over the past 150 years to significantly increase public health Climate will continue to change for decades or longer and but is likely to be insufficient in coming decades as climate and modifications to health systems should aim to increase resilience to other global environmental changes make it more difficult to both current and future risks, creating—where possible—increased maintain and improve population health. Further, the magnitude flexibility to address future hazards as they arise. This can be of and pattern of future climate-related health risks will depend on particular concern for public health and healthcare infrastructure in the local context, requiring consideration of local vulnerabilities coastal regions where the integrity of and access to infrastructure and capacities in program planning. and access may be compromised with climate change impacts Given that the health risks of climate variability and change vary like sea level rise. over spatial and temporal scales, the extent to which a program or Climate change and its consequences can result in shocks intervention could be affected by a specific hazard at a particular and stresses that can affect public health and other aspects of time depends on local vulnerabilities and capacities. What is a development. Impacts are felt directly through the loss of lives, low risk in one situation could be a high risk in another, with livelihoods, and infrastructure, as well as indirectly through the those risks changing over time as, for example, diseases emerge diversion of funds from development to, for example, emergency in different times of the year or in new areas. relief and reconstruction (DFID 2005). To effectively protect public health, adaptation also should The impact of a shock depends not just on its magnitude but incorporate strategies to manage the upstream drivers of adverse also on the extent of exposure of human and natural systems, the health outcomes, restricted to not only issues such as access susceptibility of those systems to harm, and their ability to cope to safe water and improved sanitation but also factors such as with and recover from exposure (IPCC 2012; Steinbruner et al., travel and tourism, which are sources of emerging disease threats 2013). The extent to which health systems are prepared for and (Semenza et al., 2016). 5 M etho do l ogical G u id a n c e : C l i m at e C h a n ge a n d H ea lth D ia gn ostic have the capacity to manage changes in hazards, exposure, and health risks (i.e., adaptation). These modifications are critical to susceptibility will determine their resilience in coming decades. decrease vulnerability to climate variability but do not necessarily Therefore, climate resilience requires an evaluation of the increase resilience to future (and different) weather patterns. Health potential consequences of projected climate change within the system resilience recognizes that a wide range of hazardous and context of plausible future change in the extent of exposure to potentially disruptive events—stresses and shocks, both natural climate-related hazards, susceptibility to those exposures, and and human-induced—are increasingly likely to occur with climate the capacity of health systems to prepare for, manage, cope with, change. A climate-resilient approach to health systems aims to and recover from exposures. More climate-resilient health systems ensure the performance of a health system. have greater capacity and flexibility to prepare for and manage Additionally, resilience is not synonymous with sustainable changing risks. development. Resilience aims to achieve long-term sustainability Poverty is a key factor increasing vulnerability (Hallegatte et al., objectives—meeting the needs of the present without compro- 2016). In most countries, for example, poor urban households mising the ability of future generations to meet their own needs are more exposed to floods than the average urban population. (Brundtland Commission 1987). Resilience is about learning to live Without action, climate change could lead to higher agricultural with changing patterns of risks—expected and unexpected—that prices and threaten food security in poorer regions in Sub-Saharan will increasingly arise with climate change. Resilience recognizes Africa and South Asia. Without inclusive development, climate that complex interactions among people, the economy, and the change could force more than 100 million people into extreme environment will change over time. While sustainability aims to poverty by 2030. There are parallels in the experiences of nations put the world into balance, resilience looks for ways to manage under other kinds of duress. For example, countries that experi- in an imbalanced world (Zolli 2012). As such, resilience and enced major violence over the period 1981–2005 had an extreme sustainability are complementary approaches. poverty rate 21 percentage points higher than countries with no Resilience is more than the ability to recover from shocks; it violence (World Bank 2011). incorporates preparing for, coping with, and managing risks. Health To promote understanding of potential future climate resil- system resilience depends not just on the capacity of these systems, iency, the Climate Change and Health Diagnostic is designed to but also on the overall performance and capacity of other systems, help technical staff at the WBG and other development partners such as those concerned with ensuring water and food security and facilitate an action-oriented dialogue among stakeholders about safety. The World Development Report 2014: Risk and Opportunity: risks, resilience, and the performance of sectors and systems. The Managing Risk for Development argues that risk management is Diagnostic identifies priority actions and investments to enhance a powerful tool for development (WHO 2014). It contends “the a health system’s resilience (and that of other related systems), solution is not to reject change in order to avoid risk but to prepare reduce greenhouse gas emissions, and increase the resilience- for the opportunities and risks that change entails. Managing risks building potential of planned or ongoing projects. responsibly and effectively can save lives, avert economic damages, prevent development setbacks, and unleash opportunities. It has What Is Resilience? the potential to bring about security and a means of progress to people in developing countries and beyond.” Trade-offs and syner- Resilience is the capacity of individuals, communities, institutions, gies must be considered to identify ‘win-win’ situations that reduce and systems to cope with a hazardous event, trend, or disturbance, the possibility of loss and increase potential benefits. responding or reorganizing in ways that maintain their essential Building climate-resilient health systems is a cumulative pro- function, identity, and structure, while also maintaining the capac- cess that makes resilience a goal, in addition to protecting and ity for adaptation, learning, and transformation (IPCC 2014). A promoting public health, and being responsive and efficient in climate-resilient health system is one that is capable and has the providing social and financial protection (WHO 2015). This entails capacity to anticipate, respond to, cope with, recover from, and building capacity to: recognize, monitor, anticipate, communicate, adapt to climate-related shocks and stresses. A climate-resilient and prepare for health risks stemming from a changing climate; system delivers sustained improvements in population health in prevent, respond to, manage, and cope with uncertainty, adversity, an unstable and changing climate (WHO 2015). and stress; adapt operations to changing risk conditions; recover Resilience is not synonymous with climate change adapta- from crisis and setbacks with minimal outside support; and learn tion. Current public health strategies, policies, and measures from experience and improve system capacity for the future. are being modified to enhance management of climate-sensitive 6 C on n e ct i n g H ea lt h a n d C l i m ate C h ang e For a health system to increase its climate resilience, its inde- What Is ‘Low-Carbon Development’? pendent building blocks also need to become climate resilient (e.g., leadership and governance, the health workforce, health Low-carbon development is an approach for designing, building, information systems, essential medical products and technologies, operating, and investing in health systems and facilities that gen- service delivery, and financing). Coordination and collaboration erate minimal amounts of greenhouse gases (World Bank 2017a). also may need to be strengthened with other sectors, such as This approach puts health systems onto climate-smart development hydrometeorological services, agriculture, water, transport, and pathways. It also aligns health development and delivery with tourism, etc. Building climate resilience occurs through reducing global and national goals for reducing greenhouse gas emissions overall vulnerability and strengthening specific system capacities. to reduce the magnitude and pattern of health risks that health systems will need to manage later in the century. Resilience as a Priority Low-carbon development saves money by reducing energy and for Health Systems resource costs, and it can improve the quality of care by increas- ing the resilience of healthcare facilities to extreme weather and Extreme weather and climate events, such as storms and droughts, climate events and other disasters. In low-resource, energy-poor are not the only risks health systems must face. Health systems settings, powering healthcare with low-carbon solutions can also are affected by disease epidemics, migration, economic enhance access to care, with particular benefits for the poor and downturns, and infrastructure failure. These shocks can cause most vulnerable. loss of life and asset damage, affecting the capacity of health Co-benefits of low-carbon development include improved systems to protect and promote population health. Acute shocks health through reduction in environmental pollution and climate and chronic stresses can also have a deep and lasting impact on change and more efficient, less costly health systems. Tailoring human development. Disaster losses are often linked with, or technology and models of care to the environment and to disease exacerbated by, poverty and vulnerability of the poor that stem burdens can slow the rising burden of health-related expenses, from socioeconomic and environmental imbalances. While the and can stimulate and strengthen local economies. origins and long-term impacts of shocks may differ dramatically, Key elements of low-carbon healthcare include: the necessity of health systems to absorb, adapt, and continue • Health system design and models of care based on low-carbon functioning in the short term remains constant. technologies, coordinated care, emphasis on local providers, and driven by public health needs Qualities of Health System Resilience • Building design and construction based on low-carbon approaches Health systems vary nationally and locally but all share common • Investment programs in renewable energy and energy efficiency “building blocks” that are needed to protect and promote popula- • Minimal waste and sustainable healthcare waste management tion health (WHO 2015). These building blocks include leadership and governance, the health workforce, health information systems, • Sustainable transport and water consumption policies essential medical products and technologies, service delivery, • Low-carbon procurement policies for pharmaceuticals, medical and financing. Collectively, they represent the starting point for devices, food, and other products enhancing climate resilience, as shown in Figure 5. • Resilience strategies to withstand extreme weather and cli- These components provide a comprehensive approach to mate events integrating climate resilience into health systems. Understanding the level of effort within these components will inform prioritiz- The Climate Change and Health Diagnostic is an opportunity ing the results of the climate and health diagnostic by providing to build low-carbon development into investments in health sys- insights into those areas where additional resources and activities tem strengthening, aligning efforts at adaptation and mitigation. could increase the capacity of health systems to prevent additional Table 2 shows selected low-carbon health sector interven- morbidity and mortality from climate-sensitive health outcomes. tions that could be considered (See Climate-Smart Healthcare: Qualities that make a health system resilient include those in Low-Carbon and Resilience Strategies for the Health Sector (World Table 1. Looking at health systems in relation to these qualities Bank 2017a) for more details). can reveal underlying weaknesses that may not be apparent when using more traditional risk assessment methods. 7 M etho do l ogical G u id a n c e : C l i m at e C h a n ge a n d H ea lth D ia gn ostic Figure 5: Building blocks of a climate-resilient health system. ATE RESILIENCE CLIM LEADERSHIP & GOVERNANCE E& G WO HEA AT NCIN RK LT IM A FO CL FIN H H RC LT E A Leadership & HE governance Health VU PACIT GEM SS CY Financing workforce T CA LN AD AS NE EN GEN ERA APT SE RED EMER SSM BILITY, ATIO ding bloc PREPA & MANA Y& uil ENT N ks Bof h C LIM A T E I N s D RI S K em Service ea Health P RO G RA lt h s y s t Y W IN G & IN G delivery information H E ALT ES systems MO RATE ARN R E A N IT O FOR MM H G TE ME RL IN Essential D medical M products & AN R EN ETE G technologies A EM CH & VI D OF O NM EN TH A R R M EN T OF AL SE H I H E RE EA NAN TAL C LIM E A T E R E S I LI E N T T LT H TS CL IMA & SU ST AIN ABLE TEC H N O L O GIE S A N D IN F R AS T RU CTU RE Source: WHO 2015 Table 1: Qualities of resilient health systems. Quality Description Robust Well-conceived, constructed, and managed physical assets that can withstand the impacts of shocks without significant damage or loss of function. Robust design anticipates potential failures, making provision to ensure failure is predictable, safe, and not disproportionate to the cause. Robust health systems do not depend on a single asset, avoiding cascading failures and design thresholds that might lead to catastrophic collapse. An important aspect of robustness is proper operations and maintenance to ensure that systems are functioning properly. Redundant A redundant network or system includes spare capacity or backup to accommodate disruption, extreme pressures, or surges in demand. Providing diverse ways of achieving a given need or fulfilling a particular function, such as surveillance, is a means to achieving a redundant system. If one service channel gets disrupted, another can be used. Reflective Resilient health systems examine, learn, and evolve based on their past experiences and new information, modifying standards or norms based on emerging evidence rather than seeking permanent solutions based on the status quo. As a result, people and institutions examine and systematically learn from their experiences and leverage this learning to inform future decision making. Coordinated Coordination between health systems organizations and agencies means that knowledge is shared, planning is collaborative and strategic, and decision making is based on investments that are mutually supportive toward a common outcome. Exchange of information between systems enables them to function collectively and respond rapidly. Inclusive Being inclusive recognizes that risk is perceived differently by different stakeholders and that shocks and stresses primarily affect the most vulnerable. An inclusive approach contributes to a sense of shared ownership or joint vision. This can be achieved through consultation and engagement with a wide range of stakeholders, including particularly vulnerable groups, to ensure that systems are more resilient by considering a wider range of vulnerabilities, risk management capacities, and localized information. Equity in access to infrastructure and services underpins social cohesion and opportunity. 8 C on n e ct i n g H ea lt h a n d C l i m ate C h ang e Table 2: Select low-carbon health sector interventions. landslides, or droughts. Severe economic volatility could be included because of its effect on the capacity of health systems Intervention Activities to manage other stresses. Energy efficiency • On-site renewable energy sources Stresses are longer term trends, whether environmen- and renewables tal, climatic, or other, that undermine the performance of a • Reduced energy devices (lighting, etc.) health system and increase the vulnerability of actors within • Passive cooling, heating, and ventilation it. These can include natural resource degradation, loss of • Service delivery and low-carbon models agricultural production, demographic changes (e.g., aging of care and depopulation), climate change, political instability, or • Cold water detergents economic decline (DFID 2011). Stresses can be cumulative, compounding gradually until a tipping point is reached, and Waste management • Waste minimization transformed into a shock. • Waste segregation and recycling Managing risks from specific shocks and increasing overall • Clean waste disposal resilience are different and complementary practices. The first • On-site disposals requires knowledge of shocks that health systems will likely face; • Wastewater pretreatment and sanitation some of these will be predictable (e.g., increases in the frequency improvements and intensity of heat waves, or increased flooding intensity) and • Choice of cleaning products others will be surprises (like sudden changes in the geographic range of a vector-borne disease, such as malaria). Building resil- Water supply • Water conservation, including rainwater ience increases the ability of health systems to avoid shocks and harvesting where appropriate and use of to manage risks when faced with uncertainty, including increased low flow devices risk tolerance, flexibility, and adaptability (de Bruijne, Boin, and Transport and travel • Tele-solutions where technology allows van Eeten 2010). Resilience focuses on enhancing the performance of a system in the face of multiple shocks and stresses, rather Supply chain • Food and pharmaceuticals than preventing or mitigating the morbidity and mortality due to management • Use of local materials where appropriate a specific event (Arup International 2014). Considering a broader spectrum of risks is an opportunity to take a strategic view across Low-carbon service • Alignment with public transport networks different types of risks, including the underlying drivers of risk delivery or the development of such, as well as and the systems they impact, and thereby better prioritize risk reliance of population on walking and mitigation interventions. cycling Including low-carbon considerations in health systems reduces risk in other dimensions. Although lower- and middle-income country health systems generate only a small proportion of the national, cumulative greenhouse gas (GHG) emissions, they still Shocks and Stresses contribute to the country’s GHG footprint. By building greener health systems, countries help reduce overall emissions, increase A shock is a single unpredictable event and a stress is an ongoing the chances of greater environmental sustainability, and reduce hardship that can affect population health: pollution; these have more proximal benefits for human health. Shocks are sudden events, whether environmental, cli- Environmentally friendly health systems have benefits for the matic, or other, that impact the performance of systems. Many environment and the people who live in them, while also culti- different types of climate-related shocks can strike at differ- vating a standard of excellence that others can and should seek ent levels, including disease outbreaks, floods, high winds, to replicate. 9 Undertaking a Climate Change and Health Diagnostic Steps in Conducting a Diagnostic Development of any new climate-smart strategy begins with the creation of baselines and the iden- tification of suitable opportunities. For climate and health considerations, this means conducting a health and climate assessment (suitable for use by an institution or government) that describes risks, capacities, and opportunities. Established approaches for carrying out such climate change and health assessments were developed by the World Health Organization (WHO) and partner governments. These assessments are broadly relevant to the development community and have been used to help countries formulate climate change and health action plans to address unique geographic and system needs. Country-specific climate and health diagnostics using the WBG approach (World Bank 2017a) expand upon these assessments to increase their relevance for development operations and to inform investment. Methods developed here may be useful for other development institutions and investors endeavoring to undertake similar analyses. A climate change and health diagnostic consists of five stages (explained in greater detail in sub- sequent sections), with leadership commitment for low carbon and resilience interventions on the front end and a longer term engagement with development partners through financing or technical assistance at the back end (Figure 6). Stage 1: Conduct a pre-diagnostic document and data review. This stage focuses on collecting information and leveraging existing efforts, particularly health V&A assessments and adaptation plan- ning documents within the health sector, as well as information regarding investments and adaptation projects that are relevant for health. Stocktaking identifies all relevant studies, reports, or plans developed by the ministry of health, the national climate change team, the WBG, WHO, or other organizations and development partners. If the national adaptation plan already contains a health component, then the stocktaking involved in that process would provide a basis for this stage. Documents and reports should be sought that provide details on recent climate-related shocks and stresses and the effective- ness of health systems in preventing associated morbidity and mortality. This first stage should map the key stakeholders to include in the diagnostic. It also should result in a briefing note that can be used for a diagnostic workshop and for technical specialists at the WBG and other relevant development partners. Information gathered during the stocktaking exercise might need to be complemented by specific background studies or data collection initiatives. The first stage also includes training of the climate change and health diagnostic task team and the preparation of other workshop materials. Stage 2: Conduct a workshop to launch the Diagnostic. The purpose here is to assess and verify information collected during Stage 1 with in-country partners, confirm initial thinking and directions, and identify additional resources and stakeholders that should be part of the overall assessment. This includes a workshop in which participants discuss the collected data, evaluating the extent to which communities 11 M etho do l ogical G u id a n c e : C l i m at e C h a n ge a n d H ea lth D ia gn ostic Figure 6: The diagnostic process by stage. Stage 1: Pre-diagnostic Stage 2: Workshop to Stage 3: Interviews Stage 4: Stage 5: Validating date and document launch the climate and site visits Recommendations and report findings and review change and health initiating summary recommendations diagnostic report Review existing studies, Host review meeting Plan for Conduct Develop reports, and plans, and 2nd stakeholders the workshop interviews recommendations and interviews consultation Conduct the Prepare a Finalize Map the stakeholders Visit sites workshop summary report the report Identify priority climate- Make the findings sensitive health impacts public Set the path for Prepare the briefing note future engagement Train the task team and health systems could manage the shocks and stresses. They increase the capacity of communities and health systems to prepare would also identify additional resources, tools, and policies that, if for and manage climate-related shocks and stresses. This document available, could prevent adverse population health consequences also should evaluate the extent to which priority actions and invest- today and under a changed climate. ments could increase low-carbon growth, identifying options that Stage 3. Conduct interviews and site visits. These activities could achieve adaptation and mitigation goals. will help the technical team better understand the challenges and Such an overview ensures due consideration of a country’s opportunities that climate-related shocks and stresses could present resilience to the health risks of climate change, including: critical for specific populations, communities, and health systems. They gaps or areas of weakness in health systems; the dependencies and also allow for a qualitative assessment of the extent to which cur- interdependencies among health and other sectors that can lead rent policies and programs could manage the risks. The interviews to cascading disruptions or failures or compound existing vulner- and site visits also will identify opportunities for promoting low- abilities; and opportunities to align WBG-recommended actions and carbon development while increasing adaptive capacity. investments with local goals and objectives. Prioritization can be Stage 4: Develop recommendations and prepare a summary based on cost-benefit analyses, cost-effectiveness analyses, multi- report. This stage produces an overview of climate and health impacts criteria analyses, risk-based prioritization, or other approaches. and opportunities in the target country in the format of a five-part Stage 5: Present and validate report findings and recommenda- report (with annexes). The report should be a comprehensive account tions. This stage brings together participants in the launch workshop of the latest in climate and health information in the client country, (Stage 2) with decision makers and other stakeholders to present the detailing impacts, opportunities, a systems assessment, and recom- findings of the diagnostic and discuss priority recommendations. It mendations for actions and investments (or line items in projects). It is critical for this report to have clear value for WBG lending teams, should incorporate factors such as the likelihood and timing of the as well as government and other international partners. Ideally, this threat, competing demands, windows of opportunity based on current meeting will result in agreed priorities and next steps to increasing and planned projects and investments, and stakeholder concerns resilience and low-carbon growth in the context of the capacity of and preferences. It should also prioritize policies and measures to health systems and barriers and constraints to investments. 12 U n d erta k i n g a C l i mate C ha n ge a n d Hea lt h D iag no s tic Getting Started over several days, plus a few days for interviews and possible field trips. Developing recommendations and writing up the report would The fundamental steps for initiating the climate and health diag- be expected to take a final 2–3 months, depending on the extent nostic include: of review and coordination of institutional timelines. • Contact the WBG Climate Change Group, Climate Analytics and Advisory Services Team, or build a team familiar with Form the Diagnostic Team climate change, health, and development lending in the context Conducting a climate change and health diagnostic is an opportunity of the country of interest. to task a multi-sector team of technical experts and specialists to • Identify the key local and national stakeholders who will par- deliver recommendations that cut across disciplines and traditional ticipate in and contribute to the climate and health diagnostic. silos to protect population health in a changing climate. • Form a team of technical specialists that includes technical The team leader will coordinate all activities and be the central staff from the WBG or other development partners who will contact point with the client. In some cases, the team leader will support developing and implementing the diagnostic. be part of the country team and actively engaged in the coun- try. In others, it will be an expert in climate change and health • Prepare a schedule that identifies the time periods for each familiar with the relevant institutions and lending practices. It is stage, including research, country missions, and synthesis. important that the team leader has a solid understanding of the It will be important to ensure the participation and engage- country context and history of engagement with the WBG and ment of health system leaders and management from the WBG other development partners. and other development partners from the start of the process of To support the team leader, the team should consist of technical conducting a climate change and health diagnostic. This should specialists in the areas of projected climate change for the country include direct correspondence between the initiating team, the or region, the health risks of climate change, and development expert team, and country stakeholders, including development plans for the country, including low-carbon development. It is partners and government officials. Identification of a local govern- also recommended that the team include a member with strong ment focal point is also critical for the arrangement of activities. facilitation skills for the workshop and prioritization session. There will need to be an agreed timeline for the diagnostic. A translator may also be required depending on the country of Stages 1 and 2 (pre-diagnostic data review and workshop/­ meetings) engagement. (Full team composition provided in Table 3). can be expected to last 1–2 months. The workshop will be held Table 3: Diagnostic team composition. Team member Expertise/Activity Team leader Coordinate all activities and liaises with the client. Administrative support Provide logistical support for planning and conducting the launch workshop, including issuing invitations, selecting the venue, providing support during conducting the workshop (including taking notes of discussions). Technical specialist(s) in climate Provide information on the magnitude and pattern of climate change at temporal and spatial scales of change projections for the country interest, and of investments and country adaptation projects relevant for health. Technical specialist(s) in climate Conduct a desk review of reports and studies, providing summary information for the launch workshop and change and health for the climate and health diagnostic. These experts can be WBG staff and consultants. Development specialist(s) Provide information on the country context with respect to development priorities, including low-carbon development. Facilitator Facilitate the launch and final workshops. Translator(s) As necessary. Editor Edit the final report. Design expert Lay out and format the final report. 13 M etho do l ogical G u id a n c e : C l i m at e C h a n ge a n d H ea lth D ia gn ostic In addition to the technical specialists, important team members The team members also should have a direct link to a WBG working behind the scenes should include, for example, staff and Country Management Unit (CMU) or a lending program, or the consultants conducting the desk review of available reports and equivalent for other development partners. studies, administrative and logistical support for event planning, and a designer and editor for the final report. 14 stage 1 Conduct a Pre-Diagnostic Document and Data Review Stage 1 is primarily desk-based. The task team leader, working with select members of the team will undertake five primary tasks. A. Reviewing existing studies, reports, plans, and interviews B. Mapping the stakeholders C. Identifying priority climate-sensitive health impacts D. Preparing the briefing note E. Training the task team Representatives from local and/or national health systems and other sectors are introduced to the objectives and implementation steps of the climate and health diagnostic. Knowing what to expect allows leadership at the ministry or department of health to prepare relevant data for the review, and to articulate expectations for their staff. Being sensitized to the goals and objectives of the climate and health diagnostic will enhance the engagement of health systems and other sectors in the process. Stage 1 is typically conducted by a smaller group within the task team, including the leader and one or two technical specialists. The key outputs from this stage include a briefing note that captures the main findings of the desk review, a preliminary list of shocks and stresses for national or local health systems, a detailed stakeholder list, a list of relevant WBG investments and in-country adapta- tion projects, and a briefing note and materials for the launch workshop. A.  Review Existing Studies, Reports, Plans, and Interviews A review is conducted of the state of understanding of the national health risks of climate variability and change, of the populations and regions particularly vulnerable to these risks, and of the ministry of health capacities to manage these risks. This understanding can be gleaned from policies, reports, and plans from the ministry of health, universities, donor agencies, other development partners, and research publications. In some cases, it may be difficult to obtain copies of all the desired reference materials: they might not be accessible on the Internet or may be unpublished. In addition, some docu- ments may be in the local language, requiring time and resources for translation. The types of studies, reports, and plans of interest would include: ministry of health plans; projec- tions of the magnitude and pattern of climate change; health vulnerability and adaptation assessments; national adaptation plans; National Adaptation Programmes of Action (NAPAs); poverty assessments; disaster management plans; capital investment plans; and WBG and development partner initiatives. This review will assist in developing an initial list of shock and stress profiles and of capacities and barriers to increasing resilience to the health risks of climate change. (A list of some resources are provided in Annex A.) 15 M etho do l ogical G u id a n c e : C l i m at e C h a n ge a n d H ea lth D ia gn ostic In tandem with the development of these Diagnostsic meth- Of all climate-sensitive health impacts, undernutrition ods, a pilot was conducted in Madagascar. Throughout the report, stands out, as it is already a critical issue in Madagascar, and examples from this applied country case are cited for purposes of new climate stresses will worsen the situation. Increases in clarity and illustration. extreme weather can disrupt food and health system supply Some questions to identify where impacts may occur today or chains. Protein and nutrient content of some cereal crops are in the future are outlined in Table 4. Obviously, other questions may declining with rising atmospheric concentrations of carbon also be important, depending on the local and development contexts. dioxide (CO2) (Myers et al., 2014). Poor households reliant on An example from the Madagascar climate change and health subsistence food production systems can be easily disrupted diagnostic is of the potential risks climate change presents for by climate-related exposures, such as flooding or extreme undernutrition (World Bank 2018). heat. As these systems are not integrated into markets, there Table 4: Suggested questions to assist in information gathering. Current burden of climate-sensitive health What are the priority climate-sensitive health outcomes in the country? What is the recent burden of outcomes in the country these outcomes? Has the burden changed over time? Are temperature and precipitation associated with the health outcome(s) or with the transmission cycle(s) of interest in the country? How important are the associations to the current burdens of climate-sensitive health outcome? Is there evidence that infectious diseases, such as malaria, dengue, or diarrheal diseases, are changing their geographic range or seasonality of transmission? Does the number of cases of the health outcome increase (or decrease) during heat waves, floods, droughts, and/or storm surges, or have these events affected the transmission cycle? How important is the increase or decrease? Are there trends for the hazards, suggesting how climate change could affect the burden of climate- sensitive health outcomes over the shorter term, such as the health consequences of flooding? Which populations and regions are particularly vulnerable? How effective is the health system in What policies and programs are in place to manage climate-sensitive health outcomes? How effective managing the burden of climate-sensitive are these? health outcomes? What is the status of surveillance and monitoring systems to track the number of injuries, illnesses, and deaths from climate-sensitive health outcomes? Are there plans to alter the policies and programs over the next few years? Future burden of climate-sensitive health How much might increasing temperatures and changing precipitation patterns affect the magnitude risks in the country: and pattern of burdens of priority health outcome(s)? How important could this change be over the next • Availability of safe water (quality and few decades? quantity) Could changing weather patterns alter food security? Over what time period? • Food safety and security Could climate change alter the geographic range, seasonality, or intensity of transmission of malaria, • Health outcomes associated with dengue, and other infectious and re-emerging diseases? Over what time period? extreme weather and climate events How could changes in the patterns of extreme events (heat waves, droughts, floods, extreme storms) • Vector-borne and other infectious affect the burden of climate-sensitive health outcomes? Over what time period? diseases Based on projections, are health outcomes likely to become more/less important over time? Could • Health outcomes associated with poor climate change facilitate the emergence of health outcomes that may need more attention? How could air quality hotspots of health outcomes change with climate change? • Population displacement (continued) 16 C on duc t a Pr e-D i a gn o s tic D o cu men t a n d Data R ev i ew Table 4: Continued. Environmental factors that could affect To what extent do temperature, precipitation, other weather variables, and sea level rise affect access population health in the country, including: to ecosystem services? How important is the association? • Wildfires How could water supply and sanitation systems be affected by changes in precipitation or salinization? • Coastal erosion How could wildfires and coastal erosion, for example, affect access to environmental services? • Saltwater intrusion To what extent could changes in these environmental factors affect population vulnerability to the risks associated with climate change? Social and economic context in the To what extent do temperature, precipitation, other weather variables, and sea level rise affect social country, including: and economic factors? How important is the association? • Community services How could climate change affect the future availability and level of these services? Over what time • Livelihoods, period? • Social capital To what extent could changes in these socioeconomic factors affect population vulnerability to the other risks associated with climate change? Over what time period? • Economic resources What are the ongoing and planned investments and adaptation projects of relevance for health? • Infrastructure Health systems in the country, including To what extent do temperature, precipitation, other weather variables, and sea level rise affect the factors such as: ability of health systems to deliver services? • Ability to deliver services Have extreme weather and climate events affected access to health care systems? How important was • Access to health care facilities the disruption? • Supply chains, particularly during Have extreme weather and climate events affected supply chains? How important was the disruption? extreme weather and climate events Geography and climate of the country Which regions of the country could be affected by the climate-related hazard? Over what time period? Where are the most vulnerable populations for the health outcome(s) of interest located? Which ecosystems and other services are of importance? Over what time period? Are there other factors of concern? is no trade to smooth shocks and stresses, leaving populations professionals to the population served indicates there is very highly vulnerable. little capacity to treat new patients. Such systems might not be able to respond effectively when climate shocks result in a large The information gathered should identify vulnerable populations number of cases. Additionally, the urban concertation of health and regions. For example, some regions may be more vulnerable facilities relative to those available in rural areas, coupled with to floods and droughts, while other regions may be more vulner- often inadequate transportation infrastructure to reach clinics, able to high ambient temperatures and heat waves. Communities indicates that climate change will likely impact poor people living with high rates of poverty, limited access to healthcare, low levels in rural areas disproportionately. Scaling up in rural areas can be of literacy, high prevalence of climate-sensitive health outcomes difficult because of the high cost of such activities. (such as undernutrition or diarrheal diseases), and other factors can This first stage should gather information regarding the structure increase sensitivity to the hazards created by a changing climate. of the health system, which is essential for the design and imple- Table 5 shows examples of populations vulnerable to the health mentation of interventions. Different departments usually focus risks of climate change (adapted from WHO 2013). on individual health outcomes (e.g., malaria or undernutrition) Constrained access to healthcare is a particular cause for with only limited interactions between them, exacerbating the concern with regard to the ability of health systems to manage challenges. The health risks of climate change cut across most of climate-related stresses, such as increases in patient numbers the departments in a ministry of health, requiring multidimensional during extreme weather and climate events, when large numbers approaches to adaptation. Within a country, there can be large of patients may require medical support. A low ratio of medical 17 M etho do l ogical G u id a n c e : C l i m at e C h a n ge a n d H ea lth D ia gn ostic Table 5: Populations vulnerable to the health risks of climate change. Category Vulnerability Demographic factors Age (proportion of young and old) Gender (proportion of women) Population density Biological/health factors Populations with seasonal or chronic undernutrition Populations with high burdens of infectious or chronic diseases Immunocompromised and HIV/AIDS-affected populations Individuals who are mentally or physically challenged Behavioral factors Poor food preparation habits Poor hygiene habits and knowledge Unsafe defecation practices Socioeconomic factors Poverty Low education and illiteracy Inadequate access to or use of healthcare Inadequate safe water and sanitation access and use Inadequate access to communications and information Displaced and migrant populations Marginalized populations, such as ethnic minorities and nomadic and seminomadic peoples Environmental or geographic factors Exposure to environmental pollutants, livestock, or agricultural wastewater Fragile ecosystems, such as drylands, coastal areas, floodplains, mountains, or degraded ecosystems Populations living in crowded, poor, and/or unplanned urban and peri-urban settlements, worker settlements Sociopolitical factors Political instability Occurrences of complex emergencies and conflict Limited freedom of speech and information Infringements of civil rights variations in supervision across urban and rural and geographic well as the increase in climate-related injuries and illnesses (and, regions, with the former often better supervised. Without adequate therefore, patients). The potential disruption of services attributed supervision, it is likely that the health sector will be unable to to climate-induced destruction will lead to health challenges. adequately respond to climate shocks and stresses as the climate Limited spending in rural communities could also represent a signal strengthens over time. potential threat, given their increased vulnerability. Exploration of health system spending can provide insight into There may be estimates of the costs of climate-related shocks what the system values and prioritizes. What was valued in the to health systems. For example, in the Madagascar Climate Change past is not always what will or should be valued in the future. and Health Diagnostic, it was estimated that Madagascar experi- Priorities and circumstances change and it is critical to adapt ences approximately US$100 million in economic losses annu- spending to prepare for and respond to new threats. Perhaps none ally from cyclones, earthquakes, and floods (World Bank 2016). is of more immediate threat than climate change. There will need While data are limited on the cost of such events on the health to be larger budgets allocated to maintenance, rehabilitation, and system, an assessment of 2008 events gives an indication of their expansion of the sector given the damage that climate is expected magnitude. These should be viewed as conservative figures given to inflict on the health sector and its associated infrastructure, as the subsequent observed development in the Malagasy economy. 18 C on duc t a Pr e-D i a gn o s tic D o cu men t a n d Data R ev i ew The total cost to the economy was US$330 million, and the cost water retention. Looming droughts that would otherwise lead to to health infrastructure totaled US$10.3 million. Overall, 70 per- freshwater scarcity and increases in waterborne diseases can be cent of the costs were associated with physical assets; 30 percent minimized, ensuring water for human consumption and agriculture. were associated with equipment and furniture, medicines and After the initial review of plans, studies, and interviews, the supplies, and losses of revenues to health facilities. Damage to team will meet with relevant departments in the ministry of health health infrastructure and to roads connecting communities with and the climate change team to review the list of documents for health facilities led to the closure of a number of these health relevance and applicability to current and planned activities. The centers. This disrupted the country’s health services, particularly team determines the documents that are actually informing and the treatment of common diseases and diseases covered by con- guiding the ministry of health’s efforts on climate change and pro- trol and prevention programs (especially with regard to maternal duces a briefing note that summarizes the purpose and conditions and child health), in the face of increased need for such services. under which each document was produced (authors, collaborators, Information also should be collected on government goals and funders) and real-life application (which department used the and objectives as reflected in National Adaptation Programmes document, when, and for what purpose). of Action, National Adaptation Plans, the country’s Nationally A decision could be made at this point to commission specific Determined Contributions (NDCs), poverty reduction strategies, background studies or data collection initiatives depending on the and other similar papers and plans. The task team may conduct context and availability of information. This is particularly relevant informal interviews with key figures from the ministry or depart- for health systems with very limited baseline data. The climate and ment of health, the national climate change team, and other health diagnostic could also serve to identify specific knowledge stakeholders to capture knowledge and experiences not recorded gaps as one of its outcomes. Given that the climate change and in documents and plans. These interviews can supplement the health diagnostic identifies a range of players and actions, there review with more detailed information on, for example, effective- may be an opportunity to work with other development partners ness of public health programs. and academia to provide inputs into the process. In the Madagascar Climate Change and Health Diagnostic, In addition to identifying climate-sensitive health risks of the WBG held discussions with an interagency working group concern in the country, the document review should: on climate change and health to identify the climate and weather • Identify climate and shocks that may impact the successful information and service needs of the health sector, including gaps implementation of the project and integrate into project plan- in current data, information, and service delivery. Another goal ning; and was to assist the Madagascar Meteorological Service in meeting the specific needs of the health sector. It also aimed to help the • Identify climate change and health risks and opportunities health sector use climate data and information efficiently for the within project documents to establish awareness amongst prevention of epidemics and for guiding response activities for funders and policymakers. climate-sensitive diseases in the country. The working group has This information can be used to engage other institutions been a catalyst for resource mobilization and climate and health and departments working on related climate change and health engagement across the government. However, it should not be work, and to apply for additional climate-related finance for expected that every country will have such a resource. health activities. The document review and interviews should identify potential entry points in other sectors to ensure a multi-sector approach. B.  Map the Stakeholders The review may identify interventions that would simultaneously optimize climate, environmental, economic, and health benefits. During the diagnostic, it is essential to identify and organize These include climate-smart initiatives but are not limited to climate meetings with key officials at all relevant levels of government in scope. Many forms of environmental interventions and ecosys- as well as other stakeholders such as nongovernmental organiza- tem management can be fine-tuned to deliver economic gain and tions (NGOs), private sector associations, and universities, etc. maximize health benefits. For example, reforestation can promote Inclusiveness is a key characteristic of resilience and the climate access to dietary diversity and a wide range of ecosystem services, and health diagnostic is an opportunity to strengthen connec- contribute to creating global carbon sinks, enable agroforestry, tions. Moreover, these stakeholders may play an important role in provide traditional medicines, and lead to cooler microclimates. developing resilience-building strategies and their implementation, Another example is that minimizing freshwater waste can yield a particularly for upstream drivers of population health. variety of benefits through developing climate-smart urban water To identify the key stakeholders, the task team must understand systems, and by increasing forest and watershed protection to enhance the political and institutional reality in the nation or region. This may 19 M etho do l ogical G u id a n c e : C l i m at e C h a n ge a n d H ea lth D ia gn ostic Table 6: Template for mapping stakeholders and activities. Relevant Agency Type of Current Documents Planned activity Team Name Entity Expertise 1 Contact Activities and Data Activities collaborators member National Government Projections of Contact Modeling Projections of Study on Hydrometeorological Relationship climate agency climate change name regional the magnitude historic levels services manager change climate and pattern of of flooding team change climate change include regional and national stakeholders, as the upstream drivers • Schools, universities, and research institutes of climate-sensitive health outcomes are often the responsibility of • Other multilateral and international organizations with ongo- other ministries and because policies and actions taken by other ing activities in the country ministries may have health consequences. Moreover, developing policies and programs to manage the shocks and stresses explored In addition to identifying relevant participants, the pre-diag- in the climate and health diagnostic may include modifications nostic review should include key information about stakeholders’ to strategies and policies in multiple ministries and departments, ongoing and planned activities, including relevant documents and within and outside the ministry of health. Finally, to capture and data. Table 6 offers a template for capturing stakeholder information. build on ongoing activities and to learn from recent projects, it is important to consult with development organizations, NGOs, C.  Identify Priority Climate-Sensitive and experts engaged locally. Health Impacts The health and climate team should work in partnership with the country and lending teams to summarize the political The task team will identify a preliminary list of climate-sensitive and institutional context for managing the health risks of climate health outcomes from the desk-based review to consider in the change, including the responsibilities of local, national, and regional climate and health diagnostic. Climate-sensitive health outcomes governments and institutions, as well as donor agencies, research of potential interest include those: institutes, and civil society groups. • With current high burdens; It is important to identify a focal point—one familiar with local • That are likely to increase over coming decades with additional partners and fluent in local politics and language—to facilitate the climate change, including outcomes associated with increases task team’s activities. A comprehensive mapping of actors ensures in the frequency, intensity, and duration of extreme weather that a technically suitable and diversified group of stakeholders is and climate events; and included in the climate and health diagnostic. Target stakeholders could include: • Where an outbreak could affect the ability of health systems to manage. • Technical staff at the ministry or department of health Informal interviews with representatives of the ministry of • Representatives of large healthcare facilities health, the national climate change team, researchers, and other • Representatives of regional resilience collaborations and/or experts may identify other climate-sensitive health outcomes of central government initiatives potential interest. • Local institutions (public utilities/service providers, plan- The magnitude and pattern of the potential risks that make ning agencies, public-private agencies providing household the preliminary list of climate-sensitive health outcomes should services, etc.) be considered from the perspectives of potential changes in the individual components of risk: hazards, exposure, susceptibility, • Private sector (chambers of commerce, industry groups, etc.) and capacity: • Civil society (local and international NGOs) and community • Climate-related hazards will change with additional climate groups change—such as increases in some extreme weather and 20 C on duc t a Pr e-D i a gn o s tic D o cu men t a n d Data R ev i ew climate events—or trends in temperature or precipitation that • Key findings of relevant studies and plans, highlighting the could affect the distribution of a range of infectious diseases. use of these documents to inform policy and projects • Development choices mean that population exposure to, for • A preliminary list of priority climate-sensitive health outcomes, example, sea level rise and storm surges, will change with including the rationale for their selection urbanization plans. • A listing of government goals and objectives • Individual and community susceptibility to climate-related • A preliminary list of investments and how they align with the hazards will change as, for example, populations age. priority climate-sensitive health outcomes • The capacity to manage the health risks of climate change also • An overview of all relevant stakeholders, ongoing activities, will change with investments in health systems, population and future plans aging, socioeconomic development, and other factors. The briefing note and library of documents are shared with High-priority climate-sensitive health impacts are those that the full team as early as possible in the process. It is assumed that pose proven or potential risk with changes in exposure, hazard, the briefing note alone is not sufficient to fully prepare technical susceptibility, or capacity and that align with ongoing or pipeline specialists who are not familiar with the country or region; rather investments. For example, when there is a large planned nutrition it is intended to serve as a guide so that the specialists are aware investment in the country, it would make sense to focus the assess- of the full library of resources available for further, more detailed ment on nutrition-related threats within the larger context of other review. It is the individual specialist’s responsibility to ensure that key risks (such as infectious disease, heat stress, and malnutrition), he or she is adequately prepared to participate in the climate and as these interventions will have the greatest potential impact. health diagnostic. These higher priority climate-sensitive health outcomes will In addition to the briefing note, any relevant maps or be used to populate the landscape of targeted interventions for georeferenced data that could enable the task team to better investment. The launch workshop is an opportunity for a broader understand spatial issues should be collected. Examples include set of stakeholders to comment on and confirm the set of climate- projected changes in population densities and economic activity; sensitive health outcomes of interest and their potential health projected changes in the location of vulnerable populations; consequences with changes in hazards, exposures, and vulnerability. and projected changes in the intensity, frequency, and location of hazards. D.  Prepare the Briefing Note E.  Train the Task Team The briefing note fulfills several functions: it synthesizes informa- tion regarding the climate-sensitive health risks that could arise In addition to reviewing the guidebook, team members may require with climate change; describes those systems that might need to training on climate change and health, the concepts underpinning manage these impacts; and provides the task team with a solid climate-smart healthcare, or knowledge of diagnostic country prior understanding of the current situation. The briefing note will serve to engaging with stakeholders. This can be done through a combi- as a reference for the team throughout the climate and health nation of group meetings, presentations, and one-on-one briefings. diagnostic. The briefing note needs to strike a balance between The learning process among the team may require multiple modes comprehensiveness and brevity. The challenge lies in selecting of knowledge transfer. It may be challenging to conduct trainings those pieces of information deemed essential for the team mem- with the full team and, therefore, necessary to conduct multiple ber knowledge while also providing a coherent overview. At a trainings or meetings with smaller groups. minimum, the briefing note should contain: Organizing a brown bag lunch or other session in the country • A listing of available documents that are included in the review office is also an opportunity to train the specialists participating • Demographic and service delivery snapshots and trends in the climate change and health diagnostic while informing oth- ers and achieving broader institutional buy-in for the initiative. • Institutional structure of the national or local governments 21 stage 2 Conduct a Workshop to Launch the Diagnostic Stage 2 launches the diagnostic process, confirming the initial data and knowledge generated from the stocktaking in Stage 1. This stage also seeks to uncover new knowledge, assess the extent to which partici- pants think health systems could manage the health risks of climate change, and familiarize participants with each other and with the climate change and health diagnostic team. The workshop will engage a broad range of stakeholders, including government, civil society, and experts in international development. Stage 2 comprises two main parts: A. Planning the workshop B. Conducting the workshop The exact approach to be taken in the launch workshop will depend on work already conducted by government and country stakeholders. Some countries will have identified priority climate-sensitive health risks; others may just be starting those discussions. The extent of knowledge of the health risks of climate change uncovered in the data and document review can be used to modify the plans for the launch workshop to ensure it is as informative and useful as possible. Regardless of the approach, it is critical to be sensitive to the political arrangements of the country and to respect ongoing channels of engagement and relationships with other development partners. It also is crucial to understand the cultural context of the country and region while designing the work- shop agenda, including facilitation of discussions, timing of workshop sessions (i.e., start time in the morning, lunch break, etc.), and finding the right balance between plenary presentations and breakout group activities. In all cases, ample time should be provided for discussion between presentations so as to promote the participation of all stakeholders. In some cases, particularly where language may be an issue, it may be helpful to provide printed copies of reports and other documents. Information should be collected on key points of the deliberations and conclusions with respect to the feasibility of the results of Stage 1, including the likely extent to which the country’s health system could manage changes in the burden of climate-sensitive health risks with current resources and insti- tutional arrangements: what could be managed with additional resources; what might be beyond the capability and capacity of the health system; and what might be the possible consequences. It can be helpful to have designated individuals to take notes during the presentations and discussions. A.  Plan the Workshop The workshop should take an inclusive approach to identifying workshop participants to facilitate mutual information sharing. It will be important to work closely with the Ministry of Health and other government partners to identify and invite relevant stakeholders to the workshop. It is also crucial to receive support in disseminating the invitations. The Ministry of Health or national climate change team also could support the logistical arrangements and preparations for the workshop and advise on cultural and political customs. The facility selected for the workshop should be large enough to 23 M etho do l ogical G u id a n c e : C l i m at e C h a n ge a n d H ea lth D ia gn ostic accommodate up to 75 participants, with tables configured for Participation by knowledgeable technical staff is essential dialogue and discussion. to the success of the climate and health diagnostic. If important The following stakeholders could be potentially relevant stakeholders are not able to attend, the task team should make attendees, depending on the local context and existing coopera- a strong effort to meet with them at another time. All task team tion between different stakeholder groups: members should be prepared to provide a short overview of the climate and health diagnostic process during one-on-one meetings. • Technical staff, such as department directors in the ministries All task team members should attend the climate change and of health, environment, and agriculture; national climate health diagnostic workshop. In addition, if possible, a representa- change team; emergency and disaster risk management team; tive from the WBG County Management Unit (or a comparable hydrometeorological agencies; and others, as well as the heads representative from other development partners) should open the of vector-borne disease and other control programs; workshop alongside a leader from the local government. • Civil society (community representatives, NGOs); Preparation for the diagnostic workshop is largely performed • Academia/researchers; in parallel with the pre-diagnostic review. Specifically, the briefing note is the key input to the presentations, the draft list of invitees, • International agencies such as WHO and UN Development the preliminary list of climate-sensitive health risks, and goals for Programme (UNDP), at headquarters and country levels; group activities. Table 7 outlines the basic sections of the workshop • Other tiers of government (regional and national); and and can serve as a guide for the necessary materials. Any standard • Development organizations and donors active in protecting presentations should be customized to the local context with case population health, or in adapting to climate change. studies that may better resonate with participants. Table 7: Climate change and health workshop #1 agenda template. Module Component Presenter(s) Objectives Welcome and introduction Welcome Country Director/program • Explain the broader context of the leader and senior official workshop Overview of workshop Task team leader and • Clarify the objectives of the Ministry of Health focal workshop point • Demonstrate the commitment of ministry of health and the national climate change team leadership Ministry of Health Overview of ministry of health plans and Ministry of Health official • Share relevant plans and projects achievements, plans, and development goals • Discuss and confirm the ministry goals of health’s long-term goals and objectives with the context of national strategies Background information Overview of the climate, environmental, Official from the national • Describe national and regional relevant to the health risks and other drivers of climate-sensitive health hydrometeorological trends in weather and climate of climate change outcomes services, and members of • Summarize the health risks of the task team climate variability and change • Describe the importance of ecosystems and other drivers in the magnitude and pattern of climate-sensitive health risks 24 C on duc t a W or k sh op to L au nch th e  D iag no s t ic Table 7: Continued. Module Component Presenter(s) Objectives Review of national and Overview of national vulnerability and Senior official from the • Describe the status of national vulnerability, adaptation, adaptation assessments, and national national climate change vulnerability and adaptation and mitigation efforts adaptation and mitigation plans team assessments and adaptation and relevant to health systems mitigation plans Introduce the Climate Overview of health systems resilience Task team leader or ministry • Explain the concept of resilience Change and Health of health coordinator • Explain the climate and health Diagnostic diagnostic process and outcomes Introduction to the Diagnostic Task team leader or ministry • Highlight the benefits of of health coordinator enhancing resilience for protection and promoting health in a changing climate • Discuss low-carbon options for decreasing greenhouse gas emissions from health facilities Confirm the findings of Overview of the findings from Stage 1 Task team member • Share and discuss the main Stage 1 findings from existing studies, plans, and interviews with ministry of health departments • Share the preliminary list of priority climate-sensitive health risks identified during Stage 1 Explore how climate change Facilitated breakout group discussions Task team • Reach consensus on priority could alter the burden of on how climate-sensitive health risks climate-sensitive health risks climate-sensitive health could change over coming decades with risks additional climate change Explore the capacity of the Facilitated group discussions on the extent Task team • Describe the current and likely health system to manage to which the country health system could future capacity of the country changes in climate-sensitive manage changes in the geographic range, health system to manage climate- health risks seasonality, or intensity of transmission of sensitive health risks climate-sensitive health risks with additional climate change. The use of climate scenarios could prove useful in such an exercise. Next steps Conclusions and planning Task team leader and • Explain the next steps, including ministry of health focal point field visits and interviews • Clarify the role of stakeholders throughout the process 25 M etho do l ogical G u id a n c e : C l i m at e C h a n ge a n d H ea lth D ia gn ostic B. Conduct the Workshop medical personnel, and training), distribution chains, and disaster preparedness, etc.? Does strategic planning consider The Diagnostic workshop is a one- or two-day event designed to climate change-related risks and their potential consequences? engage representatives from the ministry of health, other stakehold- • Are memorandums of understanding in place with other min- ers, and technical specialists from the WBG and other development istries and departments, such as hydrometeorological services, partners in a process to identify and prioritize climate-sensitive to facilitate timely access to data and information? health risks (if not previously performed) and assess the extent • Has there been an evaluation of climate-related risks to healthcare to which the ministry of health could manage climate-related infrastructure and of any challenges to maintaining services shocks and stresses. in cases of epidemics or extreme weather and climate events? Group exercises are recommended on the topics of climate- sensitive health risks and how their burden could change over • Are there educational and training programs that could easily coming decades with additional climate change, and of what be modified to include the health risks of climate variability would be needed for the country health system to manage these and change? changes within the context of development plans. The objective • Are there national and/or international research programs is to obtain further information on what additional resources, focused on issues such as: policies, and other supports would be needed for the country • Understanding the associations between weather variables health system to be adequately prepared. This is an opportunity and health outcomes with poorly understood causes? for diverse stakeholders to exchange views on risks that could • Identifying hotspots of health impacts under climate change constrain the health systems from achieving its goals. scenarios? One outcome of the group exercises will be to identify what • Identifying new and emerging health threats associated investments and actions in addition to current policies and pro- with climate change? grams could reduce and manage increases in climate-sensitive • Developing new and innovative approaches to managing health risks. Guiding questions could include: health risks? • What is the level of effectiveness of current disease control Participants should consider what additional actions could programs to manage the current burden of disease? How reduce and manage the risks over what is already included in likely could the programs adjust to manage changes in the policies and programs (see Table 8). geographic range, seasonality, and intensity of transmission A rapporteur should capture the discussions and conclusions, of, for example, infectious diseases? Or, how quickly could with summaries for each module from each table presented in delivery of health services and supply chains be established the section detailing the next steps. The workshop participants in case of an extreme weather and climate event outside of should collectively agree on the major findings from the climate historic experience? and health diagnostic and on next steps for using the results to • Are there integrated monitoring and surveillance systems that inform policies to increase resilience in health systems to climate include, at a minimum, health and environmental data that variability and change. can provide place-based and timely information? These include The results should be summarized in a report for a number not just health systems but also environmental systems that of key stakeholder audiences, including: decision makers in the could warn of, for example, the likely timing of flooding events country health system, workshop participants, technical experts at and routine data collected on the socioeconomic conditions the WBG and other development organizations. The team should of the community. also collect names and affiliations of participants to ensure com- prehensive dissemination of findings. • Are these monitoring and surveillance data incorporated into strategic planning of resources (financial, infrastructure, 26 C on duc t a W or k sh op to L au nch th e  D iag no s t ic Table 8: Actions to consider for reducing and managing climate-sensitive health risks. Climate-sensitive health Considerations Possible actions, depending on current policies and programs Current burden of climate-sensitive Implement or strengthen integrated surveillance, monitoring, and control programs, paying attention health outcomes to whether there may need to be changes in data collection in preparation for climate change-related changes in the geographic range or seasonality of the disease Develop an early warning system using environmental information to warn of likely outbreaks, and develop response plans for when warnings are issued Effectiveness of the health system Ensure incorporation of health risks into national and subnational adaptation planning, to strengthen in managing the burden of climate- coordination and collaboration across sectors and ministries sensitive health outcomes Where needed, develop memorandums of understanding to facilitate access to environmental and other data, such as meteorological data Provide training and capacity building to healthcare professionals to better manage health burdens Future burden of climate-sensitive health Project how climate-sensitive health outcomes or other risks (e.g., food security, extreme weather, and outcomes: climate events) could change under different scenarios of climate change and development at time Availability of safe water (quality and periods of interest (e.g., 2030s) quantity) When not available or cannot be inferred from projections for other regions, partner with local or national Food safety and security universities to provide projections based on expert judgment Health outcomes associated with Consider how development choices could affect future health burdens; for example, the extent to extreme weather and climate events which unplanned settlements are likely to grow under government plans (which could affect population vulnerability to flooding, diarrheal disease, and other health impacts) Vector-borne and other infectious diseases Improve strategic planning and improve coordination of policies and programs across government agencies and departments Health outcomes associated with poor air quality Population displacement Environmental factors, including: Develop memorandums of understanding and collaborations with other sectors and ministries to ensure Wildfires access to and timely sharing of information and data Coastal erosion Develop linkages with local, national, and regional universities to keep current on research on the health risks of climate change, such as the implications of saltwater intrusion for pregnancy outcomes Saltwater intrusion Social and economic factors, including: Develop memorandums of understanding and collaborations with other sectors and ministries to ensure Community services timely access to and sharing of information and data Livelihoods Develop linkages with local, national, and regional universities to keep current on research on the socioeconomic determinants of health and how changes in these determinants could affect vulnerability Social capital to climate variability and change Economic resources Infrastructure Health delivery: Assess the capacity of health systems to deliver services, including maintaining access to facilities and Ability to deliver services maintaining supply chains, during epidemics, extreme weather and climate events, and other disasters Access to healthcare facilities Conduct desk-based exercises to explore capacities during disasters outside the range of experience Supply chains, particularly during extreme weather and climate events 27 stage 3 Conduct Interviews and Site Visits Stage 3 consists of two primary components: A. Conducting interviews with key country experts and stakeholders B. Visiting relevant sites A.  Conduct Interviews To supplement the workshop, the diagnostic team should conduct interviews with key informants at the ministry of health and other government agencies. This would elicit expert opinions on health system capacity to manage projected changes in the burden of climate-sensitive health risks and on additional policies, programs, and investments that could increase their capacity to prepare for and manage the changes. It also could be beneficial to supplement the workshop with interviews with key stakeholders unable to participate in the workshop or with field trips to visit highly vulnerable infrastructure or locations. It may be helpful to hold one-on-one interviews and/or focus group discussions with officials, technical staff, and other stakeholders. Each technical specialist should be proactive in communicat- ing to the task team leader and/or local support the list of people with whom he or she would like to meet. It is preferable to meet with local officials and technical staff in their offices where they have all the materials that may be useful for the diagnostic readily available. B.  Visit Relevant Sites If considered relevant, field visits could be conducted to obtain further information about the current capacity to cope with significant weather-related events, such as flooding or drought. The selection of sites for field visits should be decided jointly by the task team and ministry of health or the national climate change team staff. The decision should be informed by the priority climate-sensitive health risks identified, the modifications suggested to health adaptation policies and programs, and other issues raised during the workshop. The objective is to gain a further understanding of risks to health systems by visiting locations that could be considered hotspots of vulnerability (existing and projected) and provide a good representation of challenges and achievements. Organizing the interviews and field trips can be a difficult task, involving travel planning, calls to multiple stakeholders, interpreters, and last-minute rescheduling. If possible, administrative sup- port should be requested from the Country Office to centralize this set of tasks with someone who is familiar with the ministry of health, climate change team, and other stakeholders, and who is fluent in the local language. 29 stage 4 Develop Recommendations and Prepare a Summary Report The objective of Stage 4 is to develop actions and investments to enhance health system resilience based on the data and document review, informal interviews, field visits, and the results of the climate and health diagnostic launch workshop. Work also begins to prepare a comprehensive report. Stage 4 consists of two primary components: A. Developing recommendations for investments B. Preparing a summary report A.  Develop Recommendations for Investments Timing. Development of recommendations takes place after the launch workshop, one-on-one inter- views, and field visits. Participants and roles. All task team members must participate in recommendation development. Recommendations will likely evolve and transform during the session and throughout Stages 4 and 5. Therefore, it is paramount that the experts who contributed to the Diagnostic are present to discuss and agree on the final set of recommendations, including technical staff from the health system. Their input benefits the process by providing additional insight on issues, feedback on preliminary recom- mendations, and ideas for increasing the ability to implement the proposed actions and investments. The Diagnostic coordinator, task team leader, or a professional facilitator will guide the prioritiza- tion process. If a facilitator is used, it is important that he/she is an unbiased, enabler of cross-sector dialogue so that all technical specialists feel that there is a level playing field for sharing ideas. It is helpful to identify an official note-taker prior to commencing the session. The facilitator may use large notepads or whiteboards to help organize suggestions and concepts but there should be someone taking detailed notes in addition. This will be helpful in preparing for the wrap-up session with health system leadership, drafting of the aide memoire, and developing the publication of findings. Prior to recommendation development, the task team leader will collect the recommendations for actions and investments, writing each on individual sheets or cards. Each card should list a specific recommendation and denote if it is an action or an investment. Technical specialists are asked to pres- ent their recommendations. Once all are presented, and any questions or clarifications addressed, the group will cluster the recommendations on a wall or whiteboard. Topics around which topics could be clustered include: • Proposed actions (institutional strengthening, capacity building, data collection, regulatory reforms, etc.) • Proposed investments (new infrastructure, rehabilitation of infrastructure, safety net systems, new programs, etc.) • Measures to address specific climate-sensitive health risks 31 M etho do l ogical G u id a n c e : C l i m at e C h a n ge a n d H ea lth D ia gn ostic • Measures to protect specific communities, groups, or assets B.  Prepare a Summary Report and address equity concerns • Short-term versus medium-term measures The next step is to commence writing of a summary report. The report should provide an overview of the climate change and health • Low-carbon development to increase resilience diagnostic, with annexes for further reading. The report aims to • Opportunities for cofinancing of recommendations be a comprehensive overview of the latest climate and health The recommendations should consider whether there are information in the country, summarizing risks and opportunities, specific communities, regions, or infrastructure that could be assessing systems, and recommending actions and investments considered hot spots, and whether revising the list of key climate- (or line items in projects). The latter should take into account sensitive health risks could impact the composition of people or factors such as the eminence of the threat, competing demands, assets at high risk. There also should be discussion of ways to windows of opportunity based on current and planned projects bring the recommendations into better alignment with the health and investments, and stakeholder concerns and preferences. The system goals and with enhancing resilience. process is iterative and will require follow-up conversations with At this point, it is not necessary to consolidate or remove task teams, government partners, and experts. This process may specific recommendations. However, if there is early consensus take weeks to months to ensure comprehensive and vetted results to consolidate, remove, or revise, the group should do so. are achieved. Recommendations should be made with specific WBG invest- The diagnostic reports should be structured according to the ments in mind. They can be made for any point along the project outline in Table 9. cycle (Figure 7). Figure 7: Interventions throughout the project cycle. Embed climate Problem scoping Deploy diagnostic and health Project of the full range of tool to identify interventions preparation and potential climate country-specific into project design, approval benefits; work climate and health including broader with task teams to risks and outcomes (e.g., food determine relevance opportunities and nutrition security) Develop systematic Engage with project plans to establish Link on-going Communicate with team, including WBG timelines, actions project stakeholders about staff, client and and monitoring Implementation outcomes with climate and health expert networks mechanisms that climate and strategies and their about climate-smart reinforce climate health priorities implementation role health interventions and health interventions Measure and report Measure added Embed climate and progress against value from health updates in Appraisal core climate and application of project revisions health indicators climate-smart where necessary and objectives approach 32 D e velo p R ec ommen dat i on s a n d  Pr e pa r e a Sum m ary Repo rt Table 9: Content of the climate and health diagnostic findings report. SECTION CONTENT Introduction and background Presents the objective of the climate and health diagnostic and any relevant background information. Executive summary Provides a summary of the main climate and health risks facing health systems and recommended priority actions and investment. Benefits of conducting a country- Describes the benefits of a climate and health diagnostic for the country to enhance climate resilience specific climate and health diagnostic and describes the qualities of health system resilience. Low-carbon development Describes the short- and long-term benefits of low-carbon development. Overview of the climate and health Describes the objective of the climate and health diagnostic, its stages. diagnostic Section 1: Methods Describes the methods to (i) ensure transparency of the approach used, and (ii) illustrate how the approach outlined in Climate Change and Health Diagnostic: A Country-Based Approach for Assessing Risks and Investing in Climate-Smart Health Systems (World Bank 2017b) was followed and adapted. Section 2: Climate Drivers, Impacts, Provides key information on health, socioeconomic, geographic, climatic, and service delivery. This and Vulnerable Populations section is a resource for those wishing to understand the scope and magnitude of climate-related impacts and risks. It includes data and discussion on climate change and climate-health risks, and although scientific in nature, is prepared with a general policy audience in mind. Section 3: Climate-Smart Healthcare Provides relevant facts and figures to inform climate change and health decision making, while exploring Assessment dimensions of the sector to determine the degree to which it is climate smart. This section identifies pressure points in the health system where interventions may be most useful. Section 4: Recommended Prioritizes the recommended actions and investments for enhancing health system resilience, interventions highlighting policies and programs that the health system can start implementing immediately to increase resilience. This includes what can be done, in terms of resilience and low-carbon or co-benefit opportunities for the health sector; what can be done in other sectors; and what has already been recommended by international and in-country experts. This information should be broadly useful to anyone working on climate variability and change and health in the country. Section 5: Linking to Investment Identifies entry points and recommends a pathway for future engagement. Annexes Provides detailed information on certain aspects highlighted in previous sections (such as in-depth climate change projections, listings of relevant partners, reference documents, and other resources) that may be interesting to certain audiences but that are beyond the immediate scope of the report. 33 stage 5 Present and Validate Report Findings and Recommendations The objective of Stage 5 is to discuss the findings of the diagnostic with the leadership of health systems and government partners, review recommendations, and agree on next steps. Prior to sharing the draft recommendations, the management from the WBG or other development partners may ask to be briefed. The task team leader should confer with the CMU early in the diagnostic process to ensure that ample time for briefing is allocated. The time between the prioritization session and the review meeting may be quite short, and therefore, the task team leader and CMU should agree in advance on the timing. Stage 5 includes the following steps: A. Reviewing the diagnostic report with country stakeholders B. Finalizing the diagnostic report C. Making the findings public D. Setting the path for future engagement A.  Review Meeting and Second Stakeholder Consultation Depending on the local context, the review meeting may be with a small group of health system offi- cials or with the same stakeholders who participated in the launch workshop. The format and size will inform the type of materials that need to be prepared. For a small-scale gathering, the task team should prepare hard copies of the talking points to share. For a larger event, it may be more appropriate to also prepare a PowerPoint presentation. An aide-memoire should be prepared that captures the main findings of the climate change and health diagnostic, presenting recommendations for priority actions and investments and agreed next steps. Importantly, this should reflect input and feedback from the review meetings and highlight any data gaps that could significantly alter its recommendations. Depending on management norms, the aide-memoire should be delivered to the health system within one week of the review meeting. 35 M etho do l ogical G u id a n c e : C l i m at e C h a n ge a n d H ea lth D ia gn ostic Table 10: Climate change and health workshop #2 agenda template. Module Component Presenter(s) Objectives Welcome and introduction Welcome Country director/ • Clarify the objectives of the workshop program leader and • Demonstrate the commitment of ministry of health and senior official the national climate change team leadership Overview of workshop Task team leader • Self introduction of meeting participants and ministry of health focal point Present results of the Review priority climate- Task team leader • Review priority health risks launch workshop and sensitive health risks as • Describe the results of the preliminary prioritization of interviews identified in the launch climate-sensitive health risks workshop and interviews Confirm the results of Agree on recommendations Task team leader or • Discuss the climate and health diagnostic process the Climate Change for health system investments ministry of health and outcomes, particularly the extent to which health and Health Diagnostic coordinator systems could likely cope with changes in the burden of prioritization of health climate-sensitive health risks risks (breakout group • Identify populations and communities who are discussions) particularly vulnerable to climate variability and change over shorter and longer time scales • Agree on recommendations on policies and programs to proactively address the challenges identified • Identify opportunities for development partners to support implementing the recommendations, including possibilities for cofinancing • Identify key knowledge gaps • Discuss potential costs of such exercises where there is sufficient information available Multi-sector interventions Agree on linkages across Task team leader • Discuss and agree on linkages across sectors, such as sectors meteorology and agriculture, that would increase the effectiveness of investments to promote resilience Low-carbon and climate- Discuss opportunities for Task team leader • Identify current and planned investments where low- smart development low-carbon and climate-smart carbon and climate-smart development approaches can development be applied Next steps Conclusions and planning Task team leader • Explain the next steps and ministry of • Clarify the role of stakeholders throughout the process health focal point 36 P r e s en t a n d Va lid ate R eport Fi ndi n gs a nd R eco m m endati o ns community and by the government to facilitate communication Box 2. Lessons Learned from the with a broad set of internal and external stakeholders. Madagascar Workshops A suggested outline for the content of the publication can be found in Table 9. A debriefing from the Madagascar Climate Change and Health It is critical that this report is useful to both WBG lending Diagnostic Workshop on 4 October 2017 identified what worked teams, as well as government and other international partners. and what could have been done better. These are included here After completion of Stage 5 (final workshop), the report should so that teams may review in preparation of conducting their own be reviewed by technical experts in climate change and health, stakeholder consultations. environmental health, and country development plans. What worked The task team leader will take the lead in preparing the first i. Communications and level of engagement draft of the publication based on the final aide memoire, the discussions and results of the climate and health diagnostic, the ii. Buy-in from high-level government and other support notes from the prioritization session, and information collected iii. Advantage of building on a base of existing work during the pre-diagnostic review. The first draft is circulated to iv. Diversity of team and expertise as a useful asset the task team, and it is the responsibility of all team members to What could have been done better provide comments and revisions to ensure that the publication accurately reflects the diagnostic process and outcomes. i. Logistics  Given that the publication will be a public statement of recom- ii. Translation of documents is necessary, and provide docu- mendations for the health system, it is recommended that the draft ments ahead of time document be put through a peer review process. Once approved, iii. Note taker is necessary to ensure technical staff can focus it should be sent to counterparts for final review and approval. on core content iv. Facilitator enlisted from nontechnical staff would be helpful C.  Make the Findings Public in defining roles v. Would be helpful to have a local WBG staff to represent The purpose of the publication is to document the climate change investments and health risks the country is facing and highlight avenues to increase resilience through investments. Although targeted to vi. Engage the ministry of finance throughout the WBG, the publication should serve as a road map for other vii. Advertising this event so there is broader public awareness institutions wishing to work in this area. To effectively commu- could help with further government buy-in nicate the findings to a broad audience, it is recommended that viii. Greater government opinion helpful, in particular when the publication be relatively short (maximum 75 pages), rich balancing what the diagnostic process found with the with graphics and pictures, and use simple, accessible language. government’s own views of what was lacking It is also recommended that the publication be translated into the ix. Important to have local consultant to coordinate details local language and disseminated through local media channels. x. Prepare recommendations so they can be circulated weeks in advance D.  Set the Path for Future Engagement xi. Timing of project needs to expand beyond three months The climate change and health diagnostic is a beginning, not an end. xii. Clarification of messages  In parallel to the preparation of the findings publication, the task team xiii. Provide access to next steps and actual portfolio early continues a dialogue with the government as to how the WBG or in the day other development partners could support the recommended actions and investments. Depending on the nature of the recommendations, follow-up support may be guided by the task team leader or other B.  Finalize the Diagnostic Report technical specialists who participated in the diagnostic and include activities such as studies and surveys to fill data gaps, feasibility After agreeing on priorities and next steps, the task team should studies for critical programs, technical assistance, or a financing revise the climate and health diagnostic report (Stage 4) to high- operation. It is also likely that many of these recommendations will light the findings while incorporating direction and feedback from be adopted and absorbed into lending programs, and the initiating stakeholders. This step should consider additional research and team should provide any necessary support. verification, as applicable. This will be used by the investment 37 References Arup International. 2014. Toolkit for Climate Resilient Cities https://www.acclimatise.uk.com/login/uploaded/ resources/SiemensResilience_InteractPDF_2013-09-25.pdf Brundtland Commission (World Commission on Environment and Development). 1987. Our Common Future. Oxford: Oxford University Press. De Bruijne, Mark, Arjen Boin, and Michael van Eeten. 2010. “Resilience: Exploring the Concept and Its Meanings.” In Designing Resilience: Preparing for Extreme Events, edited by Louise K. Comfort, Arjen Boin, and Chris C. Demchak. Pittsburgh: University of Pittsburgh Press. https://www.researchgate.net/ publication/48323614_Resilience_Exploring_the_Concept_and_its_Meanings DFID (Department for International Development). 2005. Disaster Risk Reduction, a Development Concern, a Scoping Study on Links Between Disaster Risk Reduction, Poverty and Development. London: Department for International Development. Ebi, Kristie L. 2014. Health in the new scenarios for climate change research. Int J Environ Res Public Health 11 (1): 30–46. doi:10.3390/ijerph110100030 Ebi, Kristie L., N. H. Ogden, J. Semenza, and A. Woodward. 2017. Detecting and attributing health burdens to climate change. Environ Health Perspect 125 (8). DOI:10.1289/EHP1509 Hallegatte, Stephane et al. 2016. Shock waves: managing the impacts of climate change on poverty. Climate Change and Development Series. Washington, DC: World Bank. Hallegatte S., Green C., Nicholls R., Corfee-Morlot J. 2013. Future Flood Losses in Major Coastal Cities. Nature Climate Change 3.9: 802–06. Hallegatte Stephane, Mook Bangalore, Laura Bonzanigo, Marianne Fay, Tamaro Kane, Ulf Narloch, Julie Rozenbergt, David Treguer, and Adrien Vogt-Schilb. 2016. Shock Waves: Managing the Impacts of Climate Change on Poverty. Washington, D.C: World Bank Group. IPCC (Intergovernmental Panel on Climate Change). 2012. Managing the Risks of Extreme Events and Disasters to Advance Climate Change Adaptation. A Special Report of Working Groups I and II of the Intergovernmental Panel on Climate Change. Edited by Field, Christopher B., Vincente Barros, Thomas F. Stocker, Qin Dahe, David Jon Dokken, Kristie L. Ebi, Michael D. Mastrandrea, Katharine J. Mach, Gian-Kasper Plattner, Simon K. Allen, Melinda Tignor, and Pauline M. Midgley. Cambridge: Cambridge University Press. ———. 2014. “Glossary.” 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, edited by Christopher B. Field, Vincente Barros, and David Jon Dokken, et al. Cambridge: Cambridge University Press. Myers, S. 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WHO (World Health Organization). 2012. 40 annex A Relevant WBG Tools and Resources This section describes several existing tools within the WBG that may be useful in helping task teams address the recommendations and implement the interventions. Climate Change and Health Website The World Bank has been working to address climate change and health risks and opportunities for several years. As a result, there are a number of reports and knowledge resources generated that can assist in the operationalization of climate change and health project interventions. For example, The World Bank Approach and Action Plan for Climate Change and Health offers guidance on framing climate change and health. Climate Smart Healthcare: Low-Carbon and Resilience Strategies for the Health Sector offers a comprehensive list of tools and resources for climate-smart health programming. Geographic Hotspots for World Bank Action on Climate Change and Health provides a methodology for determining regions that are susceptible to climate change and health risks. Each of these, as well as other reports, training segments, factsheets, and links to non-WBG climate change and health work can be found at: http://www.worldbank.org/en/topic/climatechange. Climate and Disaster Risk Screening Tools WBG’s Climate and Disaster Risk Screening Tools developed provide a systematic means to consider- ing short- and long-term climate and disaster risks in project and national/sector planning processes. Screening is an initial, but essential, step to ensure these risks are assessed and managed to support mainstreaming of climate and disaster resilience into key development policies, programs, and projects. These self-paced tools provide high-level screening at an early stage of program and/or project development. The tools do not provide a detailed risk analysis, nor do they suggest specific options for increasing the project’s resilience. They are intended to help determine the need for further studies, consultation, and dialogue in the course of program or project design. These tools can be applied to a range of development sectors in support of national plans and strategies, and also project-level investments. The national/policy level tool targets national plans, sector-wide strategies, and development policy and institutional strengthening and reforms (https://climatescreeningtools.world bank.org). Environmental Health Capacity Assessment Tool WBG, in partnership with EcoHealth Alliance, has developed a tool for the country assessment of environmental health services. The tool aims to assist countries in: prioritizing and tracking capac- ity development; optimizing the use of existing infrastructure; and reinforcing progress in addressing other goals and action plans (e.g., climate adaptation, biodiversity conservation, tackling antimicrobial 41 M etho do l ogical G u id a n c e : C l i m at e C h a n ge a n d H ea lth D ia gn ostic resistance, disaster risk reduction, and health security). Structured In partnership with the International Recovery Platform (IRP) around core components of governance, technical, and focal (alien and Pan-American Health Organization (PAHO), WBG (through species) components, the tool establishes standardized criteria for GFDRR) has developed a guidance note for post-disaster health environmental health capacity, while noting that the participation sector recovery. The note is intended to provide action-oriented of multiple sectors is likely required for effective operations. advice and interventions for local and central government health The tool is designed to highlight relevant areas that can rein- sector officials who face post-disaster challenges. Milestones are force overall ecosystem resilience, intending to build directly on categorized by phases of recovery (immediate, short-term, and existing climate and disaster risk screening tools and risk reduc- medium- to long-term) and specify policy, planning, financial, and tion resources. It also supports country capacity to anticipate implementation decisions that go into developing and implement- how weather and climate change-related risks interact with other ing a health sector recovery plan. changing environmental factors. The tool’s development originated This guidance is available on the GFDRR website in English from the WBG Operational Framework for Strengthening Public and French (https://www.gfdrr.org/sites/default/files/2017-09/ Health Systems at the Human-Animal-Environment Interface (aka. Health%20Guidance%20Note.pdf). One Health Operational Framework), which emphasizes value- WBG has also developed the ‘Recovery Hub’, a ‘one-stop added application of One Health and the benefits of environment shop’ for disaster recovery operations of which health is one of sector involvement in the public health system. five featured sectors. The hub will feature knowledge resources, The assessment tool establishes an approach toward collect- case studies and project documents1 (https://www.gfdrr.org/ ing and analyzing available data sources to produce a qualitative recovery-hub). assessment report (modeling the assessment mission and report after the format used for the WHO’s Joint External Evaluations). Operational Framework Application of the tool includes the convening of a stakeholder for Strengthening Public Health meeting with participating ministries to present the pilot assess- Systems at the Human-Animal- ment findings while verifying capacity strengths and gaps with country partners. The stakeholder meeting also serves to review Environment Interface possible opportunities to leverage existing capacity and initiate The One Health concept recognizes the connections between discussion on prioritization of capacity building needs and areas humans, animals, and the environment and promotes coordina- of alignment and/or reinforcement of existing goals. This is also tion to better understand and manage risks. For over a decade, an opportunity to seek feedback on the tool’s overall utility and the WBG has worked to promote and operationalize One Health establish a possible scoring structure. Overall, this assessment approaches, supported by country partners, technical institutions, tool will highlight country leadership, experience, and expertise international organizations, and development funders. There has while advocating for capacity support to strengthen areas within been a considerable evidence base established on the topic, with environmental health services. reports and studies addressing various One Health dimensions, such as People, Pathogens, and Our Planet, the Investing in Climate Global Facility for Disaster Risk Change and Health series, and Drug-Resistant Infections: A Threat Reduction Resources to Our Economic Future. This analytical work has underpinned country operations like the Global Program for Avian Influenza and The Global Facility for Disaster Reduction and Recovery (GFDRR) Human Pandemic Preparedness and Response, and the Regional is a global partnership that helps developing countries better Disease Surveillance Systems Enhancement program. An Opera- understand and reduce their vulnerability to natural hazards and tional Framework for Strengthening Public Health Systems at the climate change. GFDRR is a grant funding mechanism, managed Human-Animal-Environment Interface (or One Health Operational by the WBG, that supports disaster risk management projects worldwide. Working with over 400 local, national, regional, and international partners, GFDRR provides knowledge, funding, and technical assistance. 1  Other related, publicly available disaster preparedness tools include ThinkHazard, In recent months, GFDRR has developed two tools that may which provides a general view of the threats, for a given location, that should be be of use to the climate and health community: guidance mate- considered in project design and implementation to promote disaster and climate resilience, and the INFORM Risk Index, an open-source risk assessment for humanitar- rial on post-disaster health sector recovery, and a knowledge hub ian crises and disasters. INFORM Risk Index can support decisions about prevention, concentrating on recovery operations. preparedness, and response. 42 R eleva n t W B G T ool s a n d R e so ur ce s Framework) now builds on this experience and provides guidance that are critical to include in projects, including specific country to help optimize One Health operations. requests for national priority issues. The approach presents steps The One Health Operational Framework supports country and provides technical guidance for actions and capacity that can lending programs and establishes a step-by-step, how-to meth- be taken at the country level along the ‘prevent-detect-respond- odology for applying One Health in development operations. It recover’ spectrum. It also provides examples of successful One outlines activities and interventions to target disease threats at Health projects to draw upon and replicate, while creating a platform the human-animal-environment (climate) interface, highlighting for engagement among international organizations, development mechanisms for institutional and technical implementation to build lending institutions, and national governments. more collaborative public health systems. It emphasizes elements 43 Annex B Connecting Climate Change and Health with “One Health,” “Planetary Health” and the Sustainable Development Goals Public health challenges stemming from environmental factors inherently span multiple sectors, and warrant holistic, society-level solutions. “One Health” (humans-environment-animals) and “Planetary Health” (earth systems and health) are related approaches that recognize the connections between humans and environment and that promote coordination to better manage risks and improve health. The intention of this climate change and health diagnostic firmly aligns with the goals and ethos of One Health and can be considered a tool employed under the broader One Health umbrella. Climate and health interactions fit clearly within the spheres of “human health systems” and “environmental health and management” below. Utilizing the “One Health” title is important because many countries implementing the legally binding International Health Regulations, including Madagascar, are taking measures to develop One Health coordination mechanisms, particularly for the control of zoonotic diseases. One Health model, as used within the World Bank Human Health Systems Animal Health Environmental Systems Health and Management Systems 45 M etho do l ogical G u id a n c e : C l i m at e C h a n ge a n d H ea lth D ia gn ostic The World Bank has worked for over a decade to promote and development and will soon be able to offer further tools toward the operationalize One Health, supported by country partners, techni- achievement of more sustainable health and environmental systems cal institutions, international organizations, and other develop- in and among many countries with which the WBG is engaged. ment funders. This has included the generation of a considerable knowledge base on the topic, with reports and studies addressing In recent years, support for a related framing has emerged. various One Health dimensions, such as People, Pathogens, and Planetary Health characterizes public health risks associated with Our Planet, Investing in Climate Change and Health series, and rapidly accelerating, anthropogenic environmental change. There an extensive portfolio on antimicrobial resistance. This research are a range of changes with the potential to significantly impact has underpinned country operations, like the Global Program for human health: climate change, biodiversity loss, fishery collapse, Avian Influenza and Human Pandemic Preparedness and Response, land-use change, urbanization, ocean acidification, sea temperature and the Regional Disease Surveillance Systems Enhancement and level increases, and freshwater scarcity. Accordingly, holistic program. At present, an Operational Framework for Strengthening interventions are required to safeguard the future health of both Public Health Systems at the Human-Animal-Environment Interface people and planet (Rockefeller Foundation-Lancet Commission (also referred to as the One Health Operational Framework) is in Report on Planetary Health 2016). Planetary boundaries, as defined by Steffen et al., 2015. Genetic Climate change diversity Biosphere integrity Novel entities Functional diversity ? ? Land-system Stratospheric ozone depletion change ? Atmospheric aerosol loading Freshwater use Phosphorus Ocean acidification Biochemical flows Nitrogen Beyond zone of uncertainty (high risk) Below boundary (safe) In zone of uncertainty (increasing risk) Boundary not yet quantified 46 Con n ect i n g C l i m at e C h a n ge a n d H ea lth a nd the sustai n able develo pm ent G o als The post-2015 sustainable development agenda currently systems perspective across environmental and health spheres, which includes 17 Sustainable Development Goals (SDGs). Goal 13 calls is at the heart of the One Health and Planetary Health approaches. for urgent action to combat climate change and its impacts, while Fundamentally, each of the goals is linked; progress in any one of Goal 3 aims to ensure healthy lives and promote well-being. Virtu- these areas can lead to collective achievement toward improved ally every other goal includes some dimension that touches upon development and a more sustainable future. health and/or climate, underscoring the relevance of integrated 47 world bank report number: 122328-9LB