COVID-19 AND CLIMATE-SMART HEALTH CARE Health Sector Opportunities for a Synergistic Response to the COVID-19 and Climate Crises CLIMATE INVESTMENT FUNDS © 2021 International Bank for Reconstruction and Development/The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory, or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. The World Bank encourages the dissemination of its knowledge; thus this work may be reproduced, in whole or in part, for noncommercial purposes, as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. COVID-19 AND CLIMATE-SMART HEALTH CARE Health Sector Opportunities for a Synergistic Response to the COVID-19 and Climate Crises CLIMATE INVESTMENT FUNDS CONTENTS Acknowledgments..........................................................................................................................................6 Acronyms......................................................................................................................................................... 7 Section 1. Introduction........................................................................................................ 9 Section 2. Links Between COVID-19, Climate, and Human Health ............................13 Section 3. Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities............................................................................................................ 23 3.1 Public Health Surveillance and Risk Assessment....................................................................... 24 3.2 Emergency Preparedness, Planning, and Rehabilitation.......................................................... 29 3.3 Capacity for Testing, Isolation, and Treatment........................................................................... 32 3.4 Supply of Essential Medical Commodities.................................................................................. 36 3.5 Health Services for Non-COVID-19 Conditions ......................................................................... 39 3.6 Nonpharmaceutical Interventions................................................................................................. 41 3.7 Public Health Risk Communication.............................................................................................. 45 3.8 Vaccine Readiness, Procurement, and Deployment.................................................................. 46 3.9 Building Back Better....................................................................................................................... 51 Section 4.Conclusion........................................................................................................63 4 | COVID-19 and Climate-Smart Healthcare TABLES Table 3.1 Country Case Studies Showcasing Climate-Smart Interventions in COVID-19 Response and Recovery..............................................................................................................................................23 Table 3.2 Menu of Interventions for Climate-Smart Health Care Actions for COVID-19 Response........54 BOXES Box 2.1 World Bank’s Health Emergency COVID-19 Response..........................................................................13 Box 2.2 World Bank’s Investments in Climate Action...........................................................................................16 Box 3.1 The World Bank’s Work on One Health and COVID-19........................................................................25 Box 3.2 World Bank’s Climate Change and Health Diagnostic in Madagascar............................................28 Box 3.3 Principles for New Investment in Cold-Chain Infrastructure and Technology...............................47 FIGURES Figure 2.1 COVID-19’s Impacts on the Sustainable Development Goals....................................................... 15 Figure 2.2 Temporary Reductions in Greenhouse Gases (GHG) Resulting from Lockdowns...................17 Figure 2.3 Climate-Smart Health Care as the Convergence of Sustainability and Resilience................. 18 Figure 2.4 Climate-Smart Interventions throughout the Different Phases of Pandemic Response........ 19 Contents | 5 ACKNOWLEDGMENTS This report was produced by the Health-Climate and Environment Program in the Health, Nutrition and Population Global Practice of the World Bank. The report was authored within the World Bank by Stephen Dorey, Tamer Rabie, and Maria Gracheva, with input from Fatoumata BM Barry and support from Chris Boyer and Caroline Anitha Devadason. The World Bank case study contributions were also received from the following: from The Gambia, Samuel Lantei Mills; from Ghana, Anthony Theophilus Seddoh, Enoch Oti Agyekum, and Kazumi Inden; and from the Republic of Yemen, Jorge Coarasa, Miyuki Parris, Iryna Payosova, Ebrahim Mohammed Yahya Al-Harazi, and Takahiro Hasumi. The World Health Organization Country Office in the Republic of Yemen also contributed to that country’s case study. The World Bank peer reviewers were Edson Correia Araujo and Natalie Marie Weigum. Report writing was supported by Health Care Without Harm (HCWH)a, with authors including Renzo Guinto, Sonia Roschnik, and Josh Karliner, as well as the following contributions to the case studies and report: from Colombia, Claudia Lorena Paz, Antonella Risso, Marcela Medina Galaz, and Carolina Gil Posse; from India, Shweta Narayan and Huda Jaffer; from Nepal, Mahesh Nakarmi, Ruth Stringer, and Sagar Rajbhandari (Shukraraj Tropical Infectious Disease Hospital); and from the Philippines, Marianne Bongcac, as well as Stacia Clinton, Andrea Hurtado Epstein, Xiaoyi Jin, Poornima Prabhakaran, Megha Rathi, Ramon San Pascual, Ravikant Singh, Jennifer Wang, Clare Westwood, Pam Wellner, and Susan Wilburn. Loreta Rufo and Xianfu Lu from the Climate Investment Funds (CIF) Administrative Unit provided technical input to the study. The World Bank teams wish to thank the CIF for providing the financial support for this study. a Health Care Without Harm (HCWH) is an international nongovernmental organization (NGO) seeking to transform the health sector worldwide so that it becomes ecologically sustainable, as well as a leading advocate for environmental health and justice, www.noharm.org. 6 | COVID-19 and Climate-Smart Healthcare ACRONYMS AIDS Acquired Immunodeficiency MDB multilateral development banks Syndrome MPA multiphase programmatic approach CCB climate co-benefit NDC nationally determined contribution CEEW Council on Energy, Environment NGO nongovernmental organization and Water NPI nonpharmaceutical intervention CO2 carbon dioxide NTCC National Technical Coordination CREDA Chhattisgarh Renewable Energy Committee Development Authority OPD outpatient department DFY Doctors for You PCR polymerase chain reaction DIC drop-in-center PHC primary health care center DRRT district rapid response team PPE personal protective equipment eIDEWS Electronic Integrated Disease Early Warning System PPP public private partnerships FTCF Fast-Track COVID-19 Facility PV photovoltaic GDP gross domestic product RRT rapid response team GHG greenhouse gas RT-PCR reverse transcription polymerase chain reaction GHSA Global Health Security Agenda SDG Sustainable Development Goals GiZ Deutsche Gesellschaft für Internationale Zusammenarbeit SHiPP Sustainable Health in Procurement Project GRID Green, Resilient and Inclusive Development SIDA Swedish International Development Cooperation Agency GRRT governorate rapid response team SMS short messaging service GWP global warming potential TWG technical working group HCWH Health Care Without Harm UHC universal health coverage HECAF360 Health Environment and Climate UN United Nations Action Foundation UNDP United Nations Development HIV Human Immunodeficiency Virus Programme HWC Health and Wellness Center UNFCCC United Nations Framework Convention on Climate Change IBRD International Bank for Reconstruction and Development UNICEF United Nations International Children’s Emergency Fund IDA International Development Association V&A Vulnerability and Adaptation IFC International Finance Corporation VOC Volatile Organic Compounds INDC intended nationally determined WASH water, sanitation, and hygiene contributions WHO World Health Organization IPD inpatient department WMO World Meteorological kWp kilowatts peak Organization Acronyms | 7 8 | COVID-19 and Climate-Smart Healthcare SECTION 1. INTRODUCTION A ffecting almost every country in the world, the COVID-19 pandemic, driven by the SARS- CoV-2 coronavirus, has been a stark reminder of the perennial threat of emerging infectious diseases and the chronic fragilities of the world’s health systems, economies, and societies. The global impacts of COVID-19 are far-reaching and diverse, including death, ill health, widespread mental distress, worsening poverty, and widening inequality within and between countries. Like COVID-19, climate change has immediate and projected wide-ranging, long-term impacts on human health, including stressing food systems, economies, and communities as well as pushing more people into poverty, through the frequent occurrences of extreme weather events. The serious difficulties facing health systems and other institutions in tackling the ongoing pandemic underscore the likelihood that many may also be ill-equipped to protect and save lives under the stress of climate change. It is also important to consider that these crises are occurring simultaneously, not one after another. As the world struggles to respond and recover from the COVID-19 pandemic, it must simultaneously cope with climate change. The convergence of COVID-19 and the climate crisis has compounding impacts. Climate-related disasters are complicating the COVID-19 response in several parts of the world. For example, in November 2020, the Philippines was hit by two major typhoons, displacing hundreds of thousands of people and leading to overcrowded evacuation centers. Amidst the circumstances, it was not possible to maintain the physical-distancing restrictions necessitated by the COVID-19 crisis at these centers. Similarly, when the state of California (in the United States) was ravaged by weeks of wildfires in late 2020, destroying houses and leading to the relocation of entire communities, people were faced with dual respiratory threats. Conversely, COVID-19 can exacerbate the ongoing climate change-related vulnerabilities of communities. For example, the health systems of small-island developing states, which are already challenged by sea-level rises and other climate-related hazards, must assume additional responsibilities related to the pandemic response. The COVID-19 crisis has naturally focused global attention on the health sector. This attention and increased scrutiny need to also extend to the health sector’s own contribution to the climate crisis through its carbon footprint. This contribution is a nontrivial matter, particularly in high- and middle-income countries: the sector’s energy consumption, transport systems, and supply chain make up 4.4 percent of net global greenhouse gas (GHG) emissions, and so far shows little sign of shifting from current trajectories. The serious difficulties facing health systems and other institutions in tackling the ongoing pandemic underscore the likelihood that many may also be ill-equipped to protect and save lives under the stress of climate change. Introduction | 9 Growing health care waste from personal protective Building on the World Bank’s equipment (PPE) has overwhelmed many hospital climate-smart health care waste-management systems, posing significant threats to human health and the environment. As approach and integrating its COVID-19 vaccine campaigns scale up around Multiphase Programmatic the world, the challenges of managing vaccine Approach (MPA) into the global waste in a broad diversity of settings are also a concern. Investments in cold-chain technologies COVID-19 response, this report and infrastructure risk locking many countries into suggests a series of areas to be carbon-intensive vaccine systems for decades to addressed, with corresponding come. Concomitantly, investments in climate-smart, energy-efficient cold chains offer the possibility of interventions to guide ongoing transformation. The pandemic, therefore, adds a as well as pipeline activities layer of sustainability challenges, but also presents and investments targeted at opportunities for the health sector. the pandemic. Today, there exists a unique opportunity, indeed a necessity, to take on the pandemic and the climate crisis in tandem. Response to and recovery from leapfrog toward climate-smart universal health COVID-19 creates a moment for accelerating coverage (UHC). The report is also illustrated by climate action worldwide. It makes sense for this case studies showcasing where low- and middle- action to begin with the health sector. The objective income countries have incorporated sustainable of this report is to describe some of the actions that interventions in their health sectors to strengthen the health sector can take during the COVID-19 their COVID-19 emergency responses, while also response and recovery efforts to tackle both the assisting with climate adaptation or mitigation. COVID-19 pandemic and enhance resilience to This report is targeted at leaders and operational climate change threats, including limiting carbon teams in multilateral development banks (MDBs) dioxide (CO2) emissions. and other development finance institutions, The report begins with a description of the links particularly those working in the areas of health, between COVID-19, climate change, and human nutrition, and population. It can guide the ongoing health. Building on the World Bank’s climate- smart design of health investments that address the health care approach (World Bank 2017) and global COVID-19 health emergency response integrating the World Bank’s Multiphase Program- and recovery efforts as well as help prepare for matic Approach (MPA) into the global COVID-19 the next pandemic and potential future social or response ( World Bank 2020), this report suggests environmental crises. The messages of this report a series of areas to be addressed, with corre- will also be useful for other development agencies, sponding interventions to guide ongoing as well nongovernmental organizations (NGOs), ministries as pipeline activities and investments targeted at of health, and health agencies, as well as policy the pandemic. These interventions are suggested makers committed to building enduring, resilient, because they would enable the health sector to and sustainable health systems. 10 | COVID-19 and Climate-Smart Healthcare REFERENCES World Bank. 2017. Climate-smart Healthcare: Low Carbon and Resilience Strategies for the Health Sector. Washington, DC: World Bank. http://documents1.worldbank.org/curated/en/322251495434571418/pdf/113572-WP-PUBLIC-FINAL- WBG-Climate-smart-Healthcare-002.pdf. World Bank. 2020. “Project Paper on a Proposed Additional Financing to the COVID-19 Strategic Prepared- ness and Response Program Using the Multiphase Programmatic Approach (Global COVID-19 MPA).” Washington, DC: World Bank. http://documents1.worldbank.org/curated/en/882781602861047266/pdf/World-COVID-19-Strategic-Pre- paredness-and-Response-Program-SPRP-using-the-Multiphase-Programmatic-Approach-MPA-Pro- ject-Additional-Financing.pdf. Introduction | 11 12 | COVID-19 and Climate-Smart Healthcare SECTION 2. LINKS BETWEEN COVID-19, CLIMATE, AND HUMAN HEALTH T he emergence of the COVID-19 pandemic has brought with it a sharp focus on public health services and health systems as well as shed light on the chronic lack of capacity to manage emerging public health risks. Climate change further exacerbates this challenge. In combination with COVID-19, the climate crisis presents a clear and present risk of disrupting and overwhelming health systems, health care facilities, and the health care staff upon which these systems rely. This risk is of particular concern in those settings with already weak health systems, leadership challenges, insufficient resources, and limited capacities. Despite these concerns, the collective global effort to respond to COVID-19 and recover from it also presents important opportunities for implementing profound cross-cutting efforts within the health sector to tackle both the pandemic and the climate crisis (box 2.1). BOX 2.1 WORLD BANK’S HEALTH EMERGENCY COVID-19 RESPONSE As the magnitude of the COVID-19 pandemic became evident, the World Bank made a strong commitment to provide exceptional support in speed, scale, and selectivity to countries, as they tackled the unprecedented threats posed by the crisis. It launched the Fast-Track COVID-19 Facility (FTCF) to provide immediate support to help countries respond to COVID-19. This facility supported the fast tracking of USD14 billion in financing, complemented by policy advice and technical assistance. The financial package, drawn from the International Bank for Reconstruction and Development (IBRD), the International Development Association (IDA), and the International Finance Corporation (IFC), was globally coordinated to support country-based responses. The original FTCF that committed to providing USD2.7 billion from IBRD, USD1.3 billion from IDA, and USD8 billion from IFC (including USD2 billion from existing trade facilities), was further complemented by a reprioritization of USD2 billion from the World Bank Group’s existing portfolio. This funding envelope was further expanded in October 2020 with the approval of the additional financing of USD12 billion for developing countries to finance the purchase and distribution of COVID-19 vaccines, tests, and treatments for their citizens. Source: World Bank 2020c. Links Between COVID-19, Climate Change, and Human Health | 13 The COVID-19 pandemic has caused tremendous A useful way of thinking about disruption at a scale not seen for at least a century; climate change and health is it is a stark reminder of the ongoing challenge of emerging and reemerging infectious diseases. as a threat multiplier, making This exceptional challenge to public health, food those already vulnerable more systems, global economies, and social norms is so, potentially pushing millions not only leading to millions of deaths and ill health, but also pushing tens of millions more back into into poverty in the coming extreme poverty, substantially increasing the years. prevalence of undernutrition, and likely contributing to significant future chronic disease and mental millions into poverty in the coming years. Without health burdens. Combined with the ever-growing further action to reduce extreme poverty, provide number of deaths and strain on global systems, access to basic services, strengthen resilience, the pandemic is having profound socioeconomic and increase adaptive capacity, climate impacts impacts. For the first time in over 20 years, global could push an additional 100 million people into extreme poverty is expected to rise in 2020, and it poverty by 2030 (Hallegate et al. 2015). is estimated that the COVID-19 pandemic will push It is clear that the planet is now locked into a certain up to 150 million people into extreme poverty by degree of climate change. Health systems must, 2021 (World Bank 2020a). In addition, COVID-19 therefore, adapt to the coming changes. However, also threatens to delay the achievement of the we must also take every opportunity to mitigate Sustainable Development Goals (SDG) (figure 2.1) against that to which we cannot adapt. Actions with its potential to reverse the hard-won health to limit the health impacts of climate change thus and human capital gains achieved over recent require adaptation and resilience-building actions, decades (UN/DESA 2020). combined with rapid global action to reach zero Climate change presents just as serious a threat net, to stabilize the climate and maintain average to human health and health systems as COVID-19. global temperature increases below 2°C. Delaying action until 2030 would increase total mitigation However, unlike COVID-19, the health risks of costs by 50 percent (IPCC 2018). To help accelerate climate change are projected to rise over the climate action, the World Bank has been working coming decades, unless rapid and profound to incorporate climate change in its operations and action is taken. Rising temperatures, changing supporting countries to shift toward low-carbon rainfall patterns, sea-level rises, shifting disease and climate-resilient development (box 2.2). vector ranges, along with extreme weather and climate events, threaten human health and Despite climate change not being directly well-being through a number of direct, indirect, implicated in the emergence or transmission of and synergistic pathways (Smith et al. 2014). A COVID-19, there are several important interactions useful way of thinking about climate change between the health impacts of the COVID-19 and and health is as a threat multiplier, making those the climate crises. Each shares several overarching already vulnerable more so, potentially pushing drivers and impacts similar vulnerable populations. 14 | COVID-19 and Climate-Smart Healthcare FIGURE 2.1 COVID-19’s Impacts on the Sustainable Development Goals Reducing commitment Conflicts preventing Aggravating backlash to climate action, but e ective measures for against globalization, lessening fighting COVID-19 with but also highlighting environmental those in conflict areas the importance of footprints due to most at risk of su ering international decreased production devastating losses from cooperation on public and transportation COVID-19 health Supply and personnel Loss of income leading shortages leading to the vulnerable disrupted access to segments of society electricity, further and families to fall weakening health below poverty line system response and capacity Economic activities Potential disruptions of suspended, leading to food production and lower income, less distribution work time, and unemployment for certain occupations COVID-19 PANDEMIC Population living in Devastating e ect on slums face higher risk health outcomes of exposure to COVID-19 due to high population density and poor sanitation conditions School for many Women’s economic Supply disruptions and closed; remote learning gains at risk, increased inadequate access to less e ective and not level of violence against clean water hindering accessible for some women, and greater access to clean exposure to COVID-19 handwashing facilities — due to their prevalence one of the most important as working professionals COVID-19 prevention in the health care and measures social care sectors Source: UN 2020. Links Between COVID-19, Climate Change, and Human Health | 15 BOX 2.2 WORLD BANK’S INVESTMENTS IN CLIMATE ACTION The World Bank Group has been committed to tackling climate change—a major threat, particularly for the world’s poorest and most vulnerable. Soon after the world came together for the landmark Paris Agreement on climate change in 2015, the World Bank unveiled its first Climate Change Action Plan (CCAP20) 2016–2020, delivering USD83 billion in climate finance for developing countries. This has recently been updated with the Climate Change Action Plan 2021–25 (CCAP25), with a goal to integrate climate and development in order to maximize the impact of climate finance. The updated plan will direct climate financing toward mitigation, reduce greenhouse gas (GHG) emissions, and in terms of adaptation, help client countries, with support from the private sector, to prepare for negative climate effects. To deliver on the twin goals of reducing poverty and boosting shared prosperity, CCAP25 will prioritize climate action across six areas: 1. Increasing climate finance 2. Prioritizing resources for climate impact 3. Improving and expanding climate diagnostics 4. Reducing emissions and climate vulnerabilities in key systems 5. Supporting a just transition out of coal 6. Aligning financing flows with the goals of the Paris Agreement Over one-third (35 percent) of the World Bank Group financing will have climate co-benefits (CCBs) over the next five years, while 50 percent of the climate financing from the World Bank’s International Bank for Reconstruction and Development (IBRD) and International Development Association (IDA) will support adaptation and resilience. This represents a big step up from the 26 percent achieved on average during CCAP20 and an even bigger step up in dollar terms, because the World Bank Group’s total financing has also expanded. Source: Summarized from World Bank 2021. https://thedocs.worldbank.org/en/doc/d06622e74a388000e2e440 438d461b99-0020012021/original/CCAP-2021-25-Highlights.pdf Each frequently requires overlapping health sector in turn increase the risks of zoonotic spillover responses either to deal with current threats or events of infectious diseases from wildlife and to ensure opportunities to build back better are livestock to humans. not missed. • Several of the populations most vulnerable to • Climate change and its drivers are known to the health impacts of climate change overlap increase the risk of emerging and reemerging in- with the groups most at risk from COVID-19. fectious diseases, and therefore, of pandemics. They include elderly populations, people with For example, deforestation contributes to CO2 preexisting or chronic conditions (especially emissions and the destruction of habitats that those related to respiratory illness), minority 16 | COVID-19 and Climate-Smart Healthcare groups, and those of lower socioeconom- • Health sector responses to the COVID-19 ic status or in poverty. The dual threats of pandemic have the potential to make health COVID-19 and climate change, which exac- systems more resilient and better adapted to erbate existing inequalities, can overwhelm climate-related events. These measures include health systems and add layers of complexity strengthening the health workforce capacity; to already strained public health preparedness improving disease surveillance and health in- and response efforts. formation systems; enhancing the rapidity of medical supply chains; along with streamlining • Measures to control COVID-19 can also have health technology development processes to adverse implications for managing climate speed and scale up innovations, such as tele- risks. These include reducing the capacities medicine and vaccine development. of emergency shelters in times of windstorms, • The convergence of COVID-19 and climate flooding, and wildfires, due to social-distanc- change also offers opportunities for health ing requirements. Moreover, extreme weather systems to become more sustainable and move events related to climate change, such as heat further toward system decarbonization. Potential waves, tropical storms, and wildfires, as well measures include more efficient public health as ongoing issues like air pollution, have not systems, such as integrated surveillance, energy- disappeared during the COVID-19 pandemic, efficient health facilities and transportation, with any short-term reductions in CO2 emissions along with the incorporation of sustainable likely to be temporary (figure 2.2). cooling practices in the medical cold chain. FIGURE 2.2 Temporary Reductions in Greenhouse Gases (GHG) Resulting from Lockdowns 100 RESIDENTIAL PUBLIC Global daily fossil Co2 emissions, MtCO2 day-1 AVIATION POWER 95 INDUSTRY SERVICE TRANSPORT 90 85 80 February March April May June Year 2020 Source: Le Quere et al. 2020. Note: CO2 = carbon dioxide; MtCO2 day-1 = metric tons of carbon dioxide per day Links Between COVID-19, Climate Change, and Human Health | 17 OPPORTUNITIES FOR A LOW-CARBON, change mitigation and adaptation efforts that could CLIMATE-RESILIENT FUTURE be taken by the health sector (figure 2.3). The collaboration witnessed in the mounting of The climate-smart health care approach recognizes a global response to COVID-19 provides lessons and integrates the need to ensure that adaptation that can be replicated for addressing climate impli- and resilience measures are put in place for the cations for population health and health systems. changes we know will come, while at the same Ensuring that investments and resources for time, addressing the health sector’s own contri- recovery are structured with a longer-term green, bution to the problem by limiting its net global resilient, and inclusive development perspective GHG emissions. Climate-smart health care also in mind will provide greater value than immediate seeks to maximize the potential health co-benefits reactive response, thus breaking the cycle of of actions to mitigate climate change, which short-term panic that is in turn followed by neglect. promise to deliver further reductions in mortality and morbidity in a changing world. The following sections outline health sector interventions that contribute to a low-carbon, When applied to the stages of pandemic prepared- climate-resilient future, which could be integrated ness, response, recovery, and rehabilitation, into the COVID-19 response and recovery efforts. there are climate-smart interventions that may “Climate-smart health care” — a term coined by the be prioritized at one or more stages (see figure World Bank in 2017 — encompasses both climate 2.4). During preparedness, it is important that the FIGURE 2.3 Climate-Smart Health Care as the Convergence of Sustainability and Resilience • Lifestyle disease prevention • Care closer to home • Low Volatile Organic Compounds (VOC) materials • Local food suppliers • Waste recycling SUSTAINABILITY • Air quality • Backup generators • Health system strengthening • Universal health coverage (UHC) • Energy, water e ciency SUSTAINABILITY • Daylighting • Natural ventilation AND • Rainwater capture RESILIENCE • Solar shading • Risk and disaster preparedness and planning • Climate-related disease monitoring • Flood barriers RESILIENCE • Elevation • Backup generators Source: Bouley et al. 2017. 18 | COVID-19 and Climate-Smart Healthcare FIGURE 2.4 Climate-Smart Interventions throughout the Different Phases of the Pandemic Response Pandemic phase Alert phase Transition phase Interpandemic phase Interpandemic phase [ RIS K AS S E S S M E NT ] PREPAREDNESS RESPONSE RECOVERY REHABILITATION • One Health in disease • Low-carbon production • Environment-friendly • Health sector surveillance and distribution of vaccine production and decarbonization medical supplies deployment • Multihazard emergency • Climate-smart and plans • Enhancing of capacity for • Restrengthening of health pandemic-resilient testing and treatment services for non-COVID universal health care • Training of health workers conditions (UHC) • Dedicated financing for • Promotion of nonphar- maceutical interventions • Adoption of climate-smart • Sustainable food and health and environmental (NPIs) that enhance waste management transport systems disasters environmental health • Nature-based solutions for climate protection and Source: World Health Organization (WHO) 2017. pandemic prevention surveillance systems built consider human, animal, In the recovery phase where vaccines are an and environmental health by using a One Health option, their procurement should be performed approach. Emergency plans built need to be able with environmentally friendly production and to address multiple hazards by tapping into the low-carbon deployment, such as sustainable cold capabilities of diverse agencies so that they can chains. tackle concurrent climate threats. Furthermore, Health systems strengthening should be a key health workers and allied health professionals pillar of recovery to ensure a longer-term legacy, need to be trained. Finally, and most importantly, further ensuring against climate shocks. Adopting dedicated financing should be put in place for climate-smart waste management practices is also these multisectoral activities. useful, in particular against flood threats. Finally, In the response phase, medical supplies should in rehabilitation, the health sector can take further be distributed using the lowest carbon options measures to decarbonize and uncouple health reasonably available. Enhancing capacities for gains from carbon emissions, embed support testing and treatment will also improve capabil- for sustainable food and transport practices, and ities for dealing with climate shocks, and where employ nature-based solutions that are frequently possible, nonpharmaceutical interventions (NPIs) also the cheapest options, even in the short term. that promote environmental health should also be considered. Links Between COVID-19, Climate Change, and Human Health | 19 REFERENCES Bouley, Timothy, Sonia Roschnik, Josh Karliner, Susan Wilburn, Scott Slotterback, Robin Guenther, Peter Orris, Toby Kapser, Barbara Louise Platzer, and Kris Torgeson. 2017. Climate-Smart Healthcare: Low-Carbon and Resilience Strategies for the Health Sector. Washington, DC: World Bank. http://documents.worldbank.org/curated/en/322251495434571418/Climate-smart-healthcare-low-car- bon-and-resilience-strategies-for-the-health-sector. Hallegatte, Stephane, Mook Bangalore, Laura Bonzanigo, Marianne Fay, Tamaro Kana, Ulf Narloch, Julie Rozenberg, David Treguer, and Adrien Vogt-Schilb. 2015. Shock Waves: Managing the Impacts of Climate Change on Poverty. Washington, DC: World Bank. IPCC (Intergovernmental Panel on Climate Change). 2018. Global Warming of 1.5°C: An IPCC Special Report on the Impacts of Global Warming of 1.5°C above pre-Industrial Levels and Related Global Greenhouse Gas Emission Pathways, in the Context of Strengthening the Global Response to the Threat of Climate Change, Sustainable Development, and Efforts to Eradicate Poverty. Geneva: IPCC. https://www.ipcc.ch/site/assets/uploads/sites/2/2019/06/SR15_Full_Report_Low_Res.pdf. Le Quere, Corinne, Robert B. Jackson, Matthew W. Jones, Adam J. P. Smith, Sam Abernethy, Robbie M. Anew, Anthony J. De-Gol, et al. 2020. “Temporary Reduction in Daily Global CO2 Emissions during the COVID-19 Forced Confinement.” Nature Climate Change 10 (7): 647–53. Smith, Kirk R., Alistair Woodward, Diarmid Campbell-Lendrum, Dave D. Chadee, Yasushi Honda, Qiyoung Liu, Jane M. Olwoch, Boris Revich, and Rrainer Sauerborn. 2014. “Human Health: Impacts, Adaptation, and Co-Benefits.” In Climate Change 2014: Impacts, Adaptation, and Vulnerability. Part A: Global and Sectoral Aspects. Contribution of Working Group II to the Fifth Assessment Report of the Intergov- ernmental Panel on Climate Change, edited by C. B. Field, V. R. Barros, D. J. Dokken, K. J. Mach, M. D. Mastrandrea, T. D. Bilir, M. Chatterjee, et al., 709–54. Cambridge, UK, and New York: Cambridge University Press. UN (United Nations). 2020. Shared Responsibility, Global Solidarity: Responding to the Socio-Economic Impacts of COVID-19. New York: United Nations. https://unsdg.un.org/sites/default/files/2020-03/SG-Report-Socio-Economic-Impact-of-Covid19.pdf. UN/DESA (United Nations Department of Economic and Social Affairs). 2020. “Impact of COVID-19 on SDG Progress: A Statistical Perspective.” UN/DESA Policy Brief 81, United Nations, New York. https://www.un.org/development/desa/dpad/publication/un-desa-policy-brief-81-impact-of-covid-19- on-sdg-progress-a-statistical-perspective/. World Bank. 2020a. “COVID-19 to Add as Many as 150 Million Extreme Poor by 2021.” Press Release 2021/024/DEC-GPV, October 7, 2020. https://www.worldbank.org/en/news/press-release/2020/10/07/covid-19-to-add-as-many-as-150- million- extreme-poor-by-2021. 20 | COVID-19 and Climate-Smart Healthcare World Bank. 2020b. Five Years of Climate Leadership: The World Bank Group’s First Climate Action Plan. Washington, DC: World Bank. https://www.worldbank.org/en/news/immersive-story/2020/09/08/5-years-of-climate-leader- ship-the- world-bank-groups-first-climate-action-plan. World Bank. 2020c. Saving Lives, Scaling-Up Impact and Getting Back on Track. Washington, DC: World Bank. http://documents1.worldbank.org/curated/en/136631594937150795/pdf/World-Bank-Group-COVID-19- Crisis-Response-Approach-Paper-Saving-Lives-Scaling-up-Impact-and-Getting-Back-on-Track.pdf. World Health Organization. 2017. Pandemic Influenza Risk Management: A WHO Guide to Inform and Harmonize National and International Pandemic Preparedness and Response. Geneva: World Health Organization. Links Between COVID-19, Climate Change, and Human Health | 21 22 | COVID-19 and Climate-Smart Healthcare SECTION 3. INTEGRATING CLIMATE-SMART HEALTH CARE INTO COVID-19 RESPONSE AND RECOVERY ACTIVITIES T he World Bank’s COVID-19 Strategic Preparedness and Response Program, using MPA (World Bank 2020b), provides a common operational framework for supporting individual countries’ specific needs in preventing the spread of COVID-19; strengthening public health and essential medical care structures; building resilience to emerging and reemerging infectious diseases and reducing their risks; along with procuring and deploying vaccines. MPA can be seen as a menu of options for structuring national-level health emergency responses that are supported by the World Bank. This menu provides an opportunity to incorporate climate-smart health care into COVID-19 responses to ensure that this unprecedented global health investment also contributes to global climate goals. Several examples of countries implementing practical measures to address the combined threats of COVID-19 and climate change were used to inform this report. They are summarized in table 3.1. TABLE 3.1 Country Case Studies Showcasing Climate-Smart Interventions in COVID-19 Response and Recovery COUNTRY CLIMATE-SMART INTERVENTION COVID-19 RESPONSE AND RECOVERY COMPONENT Colombia Sustainable procurement Supply of essential medical commodities Gambia, The Health care waste management Capacity for testing, isolation, and treatment India Renewable energy Capacity for testing, isolation, and treatment Nepal Medical waste management Health services for non-COVID-19 conditions Philippines Disaster risk management Emergency preparedness, planning, and rehabilitation Yemen, Rep. Disease surveillance Public health surveillance and risk assessment Ghana Vaccine cold chain Vaccine readiness, procurement, and distribution Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 23 To ensure an efficient and effective pandemic 3.1 PUBLIC HEALTH SURVEILLANCE response while also tackling climate change, AND RISK ASSESSMENT real and perceived trade-offs must be carefully considered in the design and implementation of International policy frameworks, such as the Inter- any climate-smart interventions. This requires a national Health Regulations (WHO n.db.) under the high level of innovation and collaboration across auspices of the World Health Organization (WHO), multiple sectors, and it is, therefore, useful to follow as well as the Global Health Security Agenda a number of key principles to guide the process. (GHSA n.d.), have outlined the principles and policy These include evidence-based decision-making, measures for building the national capacities of country ownership, multisectoral approaches, along countries to prepare for and respond to pandemic with iterative monitoring, evaluation, and learning. threats. The perennial threat of infectious Building on the World Bank’s climate-smart pathogens underscores the need for constant health care approach (World Bank 2017) and integrated disease surveillance, prompt diagnosis, integrating MPA, this report identifies nine key and robust research to understand the basic areas of the COVID-19 response, based on the biology of new organisms and our susceptibilities MPA components, and details climate-smart health to them, as well as develop effective countermea- care interventions that could be integrated into sures to control them. Without comprehensive ongoing and future activities. Each intervention and timely data, it is difficult to detect cases and area is briefly explained and then opportunities for clusters, mount immediate containment responses, climate adaptation and mitigation are presented. and plan for eventual mitigation and suppression efforts. Critical components of strong surveillance include integrated health information systems; clear channels and protocols for routine data To ensure an efficient and collection, reporting, analysis, and interpretations; effective pandemic response capacity for screening, case detection, contact tracing, and trends monitoring; along with early while also tackling climate warning functions. A well-functioning surveillance change, real and perceived system also generates the information needed tradeoffs must be carefully for assessing risks, including what kinds of risks exist and which populations face higher risks than considered in the design and others. While countries generally had some form implementation of any climate- of surveillance and information systems before the smart interventions. pandemic, many of them were compelled to set up new surveillance systems targeted at the pandemic situation, while some have further enhanced their existing surveillance procedures and technologies to cope with the scale and rapidity of the COVID-19 spread. These mechanisms can be made more effective by ensuring that they are integrated and managed in a climate-friendly way. 24 | COVID-19 and Climate-Smart Healthcare CLIMATE ADAPTATION AND RESILIENCE and decision-making in the health sector (WHO and WMO 2016). The development and delivery Adopting the One Health approach in disease of health-tailored climate products and services surveillance and environmental monitoring will help enhance the ability of health systems to (including climate services for health) for the early prepare for and cope with the health impacts of detection of climate-sensitive infectious diseases. climate change and variability. COVID-19 is a stark reminder that viruses and other infectious pathogens circulate in nature. Hosted Strengthening surveillance for climate-sensitive by animals, they can easily jump to human beings diseases, such as dengue, heat-related illnesses, and produce an epidemic subsequently when air pollution-related diseases, and nutritional not contained. One Health — a unified approach deficiencies, using lessons from COVID-19. that recognizes links among human, animal, and COVID-19 has motivated many countries to review environmental health (Destoumieux-Garzón et al. and improve their national disease surveillance 2018) — can inform the development of integrated systems in order to cope with the increasing surveillance systems for both human and animal demands of the pandemic. These COVID-19 diseases as well as environmental determinants surveillance systems can be leveraged to enhance (box 3.1). In the face of climate change, there is surveillance systems, particularly for other climate- also a growing recognition of the importance of sensitive infectious diseases. Ultimately, a robust “climate services for health” — the use of reliable and highly integrated disease surveillance system climate information to help improve planning should cater to all types of diseases and hazards, BOX 3.1 THE WORLD BANK’S WORK ON ONE HEALTH AND COVID-19 For more than a decade, the World Bank has worked to promote and operationalize One Health approaches and mainstream them into health sector investments worldwide (Berthe et al. 2018). It was previously estimated that building One Health systems would require financial investments ranging from USD1.9 billion to USD3.4 billion per year (World Bank 2012). These amounts are substantially below the average USD6.7 billion per year in losses due to the six major zoonotic disease outbreaks in 1997–2009. One Health responses are already a key feature of the World Bank’s global COVID-19 Multiphase Programmatic Approach (MPA). For instance, One Health is integrated across all the components of the India COVID-19 Emergency Response and Health Systems Preparedness Project — from disease surveillance and control to stronger laboratories to integrated information and communication management. The Emerging Infectious Diseases Prevention, Preparedness and Response Project in China also has a strong One Health focus, as reflected in components, such as the risk-based surveillance systems for zoonotic and other emerging health threats, as well as the improved protocols for information sharing between agencies responsible for human and animal health. Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 25 including those related to climate change, such and up-to-date data, there is a growing opportunity as heat-related illness and air pollution-related for developing integrated approaches to assess diseases. Such an all-hazard approach to disease multiple interconnected hazards, including surveillance will ensure the systematic and timely pandemics and climate change. collection and utilization of data to inform public health responses, whether for future pandemics CLIMATE MITIGATION AND LOW-CARBON or health consequences due to climate change HEALTH CARE (see country case study 3.1). Integrating low-carbon and energy-efficient Integrating risk and vulnerability assessment surveillance systems for health, weather, and to include pandemics and climate change with environment. In addition to more coordinated special attention on identifying vulnerable data analysis and utilization, an added benefit of populations. Risk assessments at organizational, integrated surveillance systems for health and national, and global levels are central to both environment is the resultant efficiency in data pandemic and climate adaptation planning in collection, processing, and storage, which can the health sector. However, risk assessment translate into reduced and more efficient use of tools are often implemented in parallel with one energy. To further lower the amount of GHG emitted another. Pandemic risk assessments, evaluations by disease and environmental surveillance systems, of preparedness capacity, and business continuity health- and environment-oriented agencies should plans, conducted by health care organizations, also consider the adoption of low-carbon data had failed to anticipate the magnitude of this storage and processing technologies, as well as current pandemic. WHO has supported at least make sure that facilities are powered with clean 34 developing countries in assessing their climate renewable energy. and health vulnerabilities. The World Bank is also beginning to conduct these national-level Adopting low-carbon and energy-efficient rapid- assessments that will be able to feed directly into testing and contact-tracing technologies. While recommendations for the World Bank’s operations. viral detection, using the reverse transcription The Climate Change and Health Diagnostic, polymerase chain reaction (RT-PCR) technology, conducted in Madagascar, is one such example, remains the gold standard for COVID-19 diagnosis, with others in the pipeline (see box 3.2) (Berry et al. rapid tests with similar levels of diagnostic accuracy 2018). There is a need for more country-level and are also now being developed (Guglielmi 2020). subnational assessments, as well as support for The cartridges for the RT-PCR machines contain a operationalizing assessment findings and ensuring complex mixture of reagents that can be hard to that climate considerations are mainstreamed dispose of safely. Similarly, rapid test kits, designed into public health programming. Stress-testing for single use and made of nonrecyclable plastics, exercises to assess health system readiness for can produce environmental harms through their climate risks have also been proposed, but this production and disposal. Therefore, rapid test method has yet to be widely adopted by health development should incorporate environmental ministries and other organizations (Ebi et al. and energy considerations and support improved 2018). Although COVID-19 reinforces the critical waste management to ensure that these new importance of risk assessments, backed by robust technologies do not contribute to worsening 26 | COVID-19 and Climate-Smart Healthcare Country Case Study 3.1 Republic of Yemen: REP. OF YEMEN STRENGTHENING DISEASE SURVEILLANCE TO COMBAT COVID-19 AND CLIMATE IMPACTS Violent conflict has spiked dramatically in the Republic of Yemen since 2010, BY THE NUMBERS with climate change compounding the country’s fragility. The COVID-19 Electronic Integrated pandemic has added even greater stress to the already complex situation Disease Early Warning in the country. Despite the challenges, the existing disease surveillance System (eIDEWS) system — previously used to detect outbreaks of diseases, including cholera and malaria, in the country — has been utilized for the COVID-19 response. The functionality, utility, and universality of the surveillance system are shown 2017 in its ability not only to respond to disease outbreaks related to escalating eIDEWS program conflict and climate vulnerabilities but also to capture relevant data in COVID-19 launched in the detection and response. This has enabled mobile teams in the country to Republic of Yemen respond rapidly to the outbreak and monitor disease trends within the districts. Under the World Bank financing, the Electronic Integrated Disease Early Warning System (eIDEWS) was expanded in 2017 to cover 1,991 sites con- 1,991 sites covered in 2019 sisting of 22 governorates and 333 districts in 2019.i It was established to strengthen routine disease surveillance, predominantly in the early detection of epidemic-prone diseases, and was initially designed as an early warning 28 system (Dureab et al. 2020). The eIDEWS collects data on 28 diseases from diseases under health facilities, including vector control and disease outbreaks of cholera, surveillance dengue fever, and malaria. It is directly implemented by the Republic of Yemen Ministry of Public Health and Population at various levels (health facility, district, governorate, and central levels) with the close support of WHO 21 (World Bank 2019). The aim of eIDEWS is to reduce morbidity and mortality COVID-19-specific through the early detection of and rapid response to disease outbreaks. facilities received case eIDEWS generates alerts that flag the need for epidemiological investiga- management training tions in affected districts in the Republic of Yemen. This has allowed for the reporting of notifiable diseases in a timely manner and the issuance of weekly eIDEWS bulletins to health partners and other stakeholders. 84 priority districts with eIDEWS has now been galvanized in the COVID-19 response. In anticipation activated Rapid of the second wave, health care staff in 21 COVID-19-specific facilities were Response Teams (RRT) trained on case management. In addition, surveillance trainings (such as contact tracing and case definition) were conducted. Further, governorate rapid response teams and rapid response teams (RRTs) were mobilized with the World Bank financing to respond to COVID-19. These RRTs function at Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 27 different levels (district, governorate, and central) as first-line responders to conduct investigations and provide rapid responses to any outbreak. COVID-19-specific RRTs were activated in 84 priority districts, based on criteria that included districts declaring confirmed and/or probable coronavirus cases and/or districts where contact tracing and contact follow-ups needed to be initiated. Under extremely tenuous circumstances in the Republic of Yemen, involving dealing with multiple outbreaks, including cholera and COVID-19, the eIDEWS disease surveillance system has kept the fragile health system of the country functioning. With unstable internet connectivity, data can be received via phone calls, with focal points trained to input the data received, thus allowing for the flexibility of the surveillance system (Dureab et al. 2020). Additionally, it is available as needed 24/7. Even with the global pandemic of COVID-19 causing severe disruption, eIDEWS has continued to follow other disease outbreaks, including cholera, while being utilized in the COVID-19 response. The utility of a national surveillance system for disease detection, such as eIDEWS, in a conflict zone indicates the value of investing in such an infrastructure not just for strengthening health systems or monitoring disease outbreaks due to a changing climate, but also for its universality. i Information comes from “Update on Project Implementation, 19–27 October 2020,” MS PowerPoint presentation. BOX 3.2 WORLD BANK’S CLIMATE CHANGE AND HEALTH DIAGNOSTIC IN MADAGASCAR The World Bank piloted a Climate Change and Health Diagnostic in Madagascar in 2018 (World Bank 2018b). This is an island country highly vulnerable to the health effects of climate change, such as undernutrition, waterborne diseases, vector-borne diseases, climate-related disasters, and air pollution (World Bank 2018a). The diagnostic exercise, facilitated by the World Bank and external experts, along with the participation of government officials and other stakeholders, revealed that the health sector’s ability to respond to future climate-related health shocks and stresses is hugely constrained by a chronic lack of financing, inequitable service delivery, and poor quality of service. Low levels of access are a particular cause for concern with regard to the system’s ability to manage climate-related stresses, including increases in patient numbers during extreme weather events. It was concluded that because of the country’s vulnerability to multiple climate-related health impacts and major constraints in resources and capabilities across the entire system, a holistic approach is needed. It should not focus simply on modifying current public health programs to manage each climate-related hazard, but instead, it should increase the health sector’s overall performance in the face of climate change by using a range of interconnected climate-smart interventions. The World Bank is now building on the diagnostic to develop a revised methodology for Climate and Health Vulnerability Assessments (CHVAs) that will be published in late 2021. 28 | COVID-19 and Climate-Smart Healthcare environmental pollution and climate change. similar capacities and resources, such as robust Provided that data privacy protections are put in information systems, the deployment of relevant place, electronic means of contact tracing using emergency health personnel, and effective public mobile phones and QR codes may also aid in risk communication. Moreover, future multihazard rapid case finding, improved energy efficiency, emergency plans must also be flexible enough to and a reduced ecological footprint associated with be scaled for varying levels of need — from the the manual methods of contact tracing requiring most vulnerable or the hardest hit to those less transport and other resources. affected, as well as for events outside the range of historical experience (see country case study 3.2). Setting up coordinated governance mechanisms 3.2 EMERGENCY PREPAREDNESS, (including community networks), service PLANNING, AND REHABILITATION protocols, and information systems from a multihazard approach to address external Existing disaster risk reduction and management shocks. The multihazard approach to emergency plans — for instance, those that anticipate climate- preparedness also applies to governance change-related disasters, such as typhoons and mechanisms and service protocols that enable flooding — were activated for the pandemic anticipatory planning, timely decision-making, and response. However, these plans rarely consider immediate emergency response. Since pandemics, infectious disease outbreaks and often prove insuf- climate-related disasters, and other health ficient for responding to the pandemic. COVID-19 emergencies require policy and programmatic has renewed attention on emergency prepared- coordination across various government agencies ness and crisis management, thus providing an and other stakeholders, new legislations can opportunity to revisit and improve these plans help formalize such multisectoral and multilevel to enhance the capacities of communities and governance structures to ensure a high level of countries to respond not just to pandemics but also preparedness. Most importantly, these governance to all forms of external shock, including extreme mechanisms must include leadership from weather events associated with climate change. communities or community-based organizations that have firsthand knowledge of community needs CLIMATE ADAPTATION AND RESILIENCE and experience with them. Adopting a multihazard approach to emergency Training health workers and other personnel for planning that covers pandemics, climate-related deployment in times of emergency. The COVID-19 disasters, and other external shocks. The next pandemic highlighted the importance of having an generation of country and community emergency adequate and steady supply of well-equipped and preparedness and response plans should be motivated health workers and other emergency applicable to all forms of external shocks, including personnel. In this era of pandemics, compounded infectious disease outbreaks and climate change. by the emerging threat of climate change, countries While each type of shock has its unique charac- need support to increase their capacity to train teristics, these abrupt and catastrophic events health workers, especially those who are equipped share many common characteristics that require to respond to highly complex emergency situations. Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 29 Country Case Study 3.2 Philippines: PHILIPPINES LEVERAGING MULTIHAZARD DISASTER PREPAREDNESS FOR COVID-19 RESPONSE Visited by approximately 20 typhoons each year, the Philippines is one of the world’s most climate-vulnerable countries. Apart from these extreme weather events, the country is also affected by the expected slow-onset long-term changes, such as its sea-level rise that is growing at an even faster pace than the global average rate in certain parts of the Philippines. Both extreme weather and slow-onset events will generate a wide range of health effects, including climate-sensitive infectious diseases, such as dengue and malaria as well as heat-related illness. In response to the COVID-19 pandemic, the local governments took advantage of the local emergency response systems designed for climate-related disasters, such as typhoons and extreme flooding, by utilizing these existing capacities to organize multisectoral responses. Having been sensitized to previous emergency situations related to climate change, local government staff and communities alike already had systems and practices in place to move rapidly to enforce strict COVID-19 protocols in local communities when the pandemic hit. Pre-pandemic disaster mechanisms were activated. One key example is the Local Disaster Risk Reduction and Management Council composed of different officials who comprise municipal mayors; all relevant appointed officials (including the municipal health officer); chiefs of police, fire protection, and the military; along with sectoral representatives from the civil society and the private sectors. Because national mandates compel local governments to invest in disaster preparedness, local governments were also quick to realign local budgets and mobilize initial financing for COVID-19-related activities. While certainly not adequate for the magnitude and long duration of the COVID-19 pandemic, these multisectoral governance and anticipatory budgeting mechanisms helped local communities to mobilize for the early pandemic response. The early experience of the Philippines in tackling COVID-19 has demonstrated that pre-pandemic investments in disaster risk reduction and climate-change adaptations can be harnessed for mounting an immediate response to an unprecedented viral pandemic. While the physical manifestations of climate-related disasters and infectious disease epidemics may vary, there are principles, capacities, and resources common to both. At the same time, the Philippine experience has also shown that disaster preparedness and climate adaptation plans do not often consider infectious disease outbreaks, whether they are climate-related or not. The relationship between climate-adaptation measures and pandemic-resilience building can be iterative and self-reinforcing. As countries leverage climate adaptation and resilience efforts to tackle COVID-19, many of the lessons from the pandemic response can also strengthen climate adaptation and resilience strategies. The early experience of the Philippines in tackling COVID-19 demonstrated that pre-pandemic investments in disaster risk reduction and climate change adaptation can be harnessed for mounting an immediate response to an unprecedented viral pandemic. 30 | COVID-19 and Climate-Smart Healthcare In addition to multiplying their number, countries Country Case Study 3.3 Philippines: must ensure that health workers receive advanced training in areas relevant to disease outbreaks PEOPLE’S SURVIVAL FUND and extreme weather events, such as infection control, ventilatory support, first aid (even basic In anticipation of the future impacts of climate surgery for disaster-induced wounds and injuries), change on local governments, the Philippines triage, and sustainable waste management. It is created the People’s Survival Fund (CCC 2017) also recommended to include training that ensures — an annual fund that amounts to ₱1 billion (ap- the maintenance of essential services, such as proximately USD19.3 million). It is appropriated waste management during a crisis. Training drills by the congress each year and administered by or simulations can be integrated into emergency the Land Bank of the Philippines. The purpose preparedness, as can formal mechanisms to rapidly of this fund is to provide further financial support train student health professionals and other health to local governments for their climate adaptation volunteers. initiatives. Through the fund, local governments Establishing multihazard disaster financing are invited to submit project proposals that are for pandemics, climate-related disasters, and assessed on certain criteria, such as the munici- other external shocks. This activity would include pality’s level of climate risk, the project’s poverty strengthening mechanisms to fund key commu- reduction potential, and the presence of potential nity-based organizations that serve high-risk spillover benefits beyond its jurisdiction. The fund communities. To augment annual budgets for was established in 2011 through an amendment emergency preparedness and infectious disease of the 2009 Climate Change Act. However, until control and prevention activities, new funding today, only six local governments have benefited mechanisms are needed to earmark financial from the fund, and none of the approved projects resources for different types of external shocks, relate to public health. Given the growing rec- including pandemics and extreme weather ognition of the connection between pandemics events. These activities would benefit from being and climate change, there is a new opportunity established at the country level, with new funding for local governments to submit health-focused sources tapped by national and local governments project proposals that combine pandemic pre- for immediate responses, thus enhancing their paredness and climate adaptation. ability to prepare and plan for future shocks (see country case study 3.3). Setting up such domestic funding mechanisms can also help reduce the BY THE NUMBERS reliance of countries on external funding, including ₱1 BILLION grants, loans, and aid. They may become more limited when many countries are experiencing 2017 shocks at the same time, as is happening now in People’s annual financial the COVID-19 pandemic. Survival support for climate Fund created adaptation initiatives Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 31 CLIMATE MITIGATION AND LOW-CARBON Maintaining and restoring degraded lands and HEALTH CARE environments around health care facilities to support cooling and minimize flooding impacts. Establishing sustainable low-carbon backup Hospitals and health care facilities can spearhead options for electricity [for example, solar initiatives to plant native trees and restore other photovoltaic (PV)], clean water, adequate food natural environments, such as grasslands and supply, medical supplies, and transport. Preparing wetlands in the vicinity. Such measures can provide for future emergencies, whether pandemic- or shade (and hence cooling effects), as well as climate-related, means ensuring that there is an ensure greater water filtration into the ground to adequate and reliable backup supply of essential minimize the risks of erosion and floods. Increased resources. The adoption of sustainable, low-carbon, vegetation near health facilities can also enhance and energy-efficient forms of production, storage, patients’ exposure to greenness that has been and commodity transport also strengthens the shown by studies to improve mental health and readiness of services and reduces the carbon surrounding air quality. footprint associated with emergency response activities. Adopting low-carbon and energy-efficient devices 3.3 CAPACITY FOR TESTING, (flashlights, vehicles, and so forth) used in ISOLATION, AND TREATMENT immediate emergency response. The emergency response and recovery material commodities The COVID-19 pandemic exposed the limitations used by the health sector should also have the of the general capacities of hospitals, labora- following characteristics. They should be produced tories, and primary care facilities, which are all sustainably, as well as recyclable or reusable. essential in the different aspects of infectious Moreover, they should utilize efficient-energy disease screening, diagnosis, and treatment. In storage technologies and electricity generated by many countries, existing health care facilities were clean renewable energy. These devices can then upgraded and expanded, including, in some cases, contribute to reducing GHG emissions associated the construction of new hospitals and isolation with crisis responses. centers. For example, China pioneered the new Incorporating green sustainability principles in concept of a fangcang shelter hospital—a large- rehabilitation plans for affected or destroyed scale, temporary hospital that is rapidly built by health care facilities and other infrastructure. converting existing public venues, such as stadiums The rebuilding, renovation, or retrofitting of health and exhibition centers, into health care facilities care facilities during the rehabilitation and recovery (Chen et al. 2020). In addition, many developing phase presents an opportunity for incorporating countries oversaw the construction of new sustainability considerations, such as energy laboratory facilities that meet advanced biosafety efficiency, low carbon, and resilience, as well as standards, with the necessary equipment to handle minimum standards for the construction and design and process highly dangerous virus-containing of cooling infrastructure post-COVID-19 and/or specimens. These new health care facilities should post-climate-related disaster. be leveraged and sustained as part of providing better access to health care and enhancing the 32 | COVID-19 and Climate-Smart Healthcare health system capacity to tackle future health Revitalizing national plans for human resources crises, including pandemics and the long-term for health as well as volunteers and workers from consequences of climate change. Improved other sectors to sustain the COVID-19 response waste management also needs to be incorporated and prepare for climate-related health risks. Prior into these plans to help avoid situations where to COVID-19, massive shortages in health personnel countries are burning unsegregated health care already existed in many countries. These shortages waste in municipal incinerators. were further magnified during the pandemic. The enormous strain caused by COVID-19 on the health CLIMATE ADAPTATION AND RESILIENCE workforce helps illustrate the potential of future Ensuring the resilience of health facilities against shocks and stresses on the health system, such climate-related disasters and their effects (such as those caused by climate-related disasters. as electricity disruption). Hospitals and other Countries should, therefore, begin to revisit national health care facilities dedicated to the COVID-19 health workforce plans to consider augmenting response should be constructed or upgraded training capacity, revising curriculum to incorporate with the consideration of future shocks, such relevant skills and competencies for tackling health as climate-related disasters and other impacts, challenges related to pandemics and climate including heat stress or droughts (see country change, and ensuring the equitable distribution case study 3.4). This includes strengthening the of scarce health workers across populations and physical infrastructure of health care facilities geographies. to withstand environmental shocks, building community resilience, and improving systems to CLIMATE MITIGATION AND LOW-CARBON prevent the disruptions of essential resources, such HEALTH CARE as electricity, food, and water. Adopting low-emissions energy and energy- Strengthening referral networks and contingency efficiency measures for COVID-19 testing, plans to ensure the continuity of COVID-19 services isolation, and treatment facilities (including during climate-related disasters. The resilience of natural lighting and ventilation). The COVID-19 hospitals will be enhanced by ensuring that they are pandemic triggered the augmentation of laboratory connected to robust referral networks consisting and treatment capacities in many countries, often of other health facilities, health centers, and com- resulting in the expansion of existing services munity-serving institutions that can provide backup and/or the construction of new health facilities. care in case of disruptions. Care for COVID-19 patients, whether supportive or intensive, must New laboratories, isolation facilities, and hospitals be continuous for moderate to long periods (for should, therefore, use this opportunity to adopt instance, at least 14 days), and therefore, health measures that improve energy efficiency and services cannot be interrupted. Contingency plans reduce carbon emissions. Passive cooling also that address these aspects, including emergency offers co-benefits by enhancing air flow and further surge capacity, emergency response procedures, preventing the airborne spread of COVID-19, as on-site rescue, field hospital, and hospital facility well as reducing energy demand. Ultimately, the medical equipment, can limit the disruptions of next generation of health facilities needs to be health services during emergencies. climate-smart and embrace clean renewable Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 33 Country Case Study 3.4 India: INDIA HEALTH FACILITY ENERGY RESILIENCE FOR CLIMATE AND COVID-19 RESPONSE Energy security is key to better and uninterrupted health services, given that it helps in improving equipment functionality, better delivery systems, more functional neonatal care units, and the retention of staff. In light of the COVID-19 outbreak, the solarization of health centers has not only saved money but also provided energy security, and thus, quality health care to the communities. It has also strengthened the already existing health infrastructure so that it can be prepared to face future health challenges, epidemics, outbreaks, or any climate change-induced adversity and deal with them. As the following examples from two of the lowest-income states in India — Chhattisgarh and Bihar — attest, needs- based solarization can result in the reliable management of cold chains for medicines and vaccines, as well as efficient care services for vulnerable populations, such as pregnant women, newborns, and the elderly, while also maintaining the internet, data sharing, communication, and information systems. State of Chhattisgarh: Timely Action on COVID-19 and Strengthening Health Centers to Make Them Low-Carbon, Pandemic-Prepared, and Climate-Resilient For several years, the state has striven to integrate most of the 10 components of the operational framework of climate-resilient health systems, as prescribed by WHO. Nowhere is the connection between Chhattisgarh’s COVID-19 response and climate change clearer than in its program for the solarization of its health Solarization has increased the centers. institutional delivery of health The state, through its agency, the Chhattisgarh Renewable Energy Development in the state. It has ensured Authority (CREDA), has been implementing the solarization of health centers that mothers stayed for at throughout Chhattisgarh since 2012. Between 2012 and 2019, CREDA installed least 48 hours at the facility, off-grid solar photovoltaic (PV) rooftop systems in 906 health centers across which decreased the maternal the state. mortality rates, and newborn Based on these outcomes, in the midst of the COVID-19 pandemic in 2020, care corners and newborn the state ramped up its commitment; it now aspires to solarize an additional stabilization units in the centers 705 health centers. This would allow it to achieve 100 percent renewable elec- have been functioning better tricity in its government health centers. This health system strengthening will and thus quality of care has make Chhattisgarh more pandemic-prepared and more capable of delivering a improved. There is better cold COVID-19 vaccine. chain maintenance to ensure The aim of the solarization effort is also to design solar solutions based on the smooth execution of the immu- specific needs of the health centers, including their vulnerabilities with respect to prevalent extreme climatic events, such as floods, droughts, heat waves, and air nization program. Solarization pollution. This approach fits into the state’s more comprehensive plan to tackle has increased the footfall of the health impacts of climate change, as described in its State Action Plan for patients and generated trust in Climate Change and Human Health (based on the guidelines of the National the public health systems.” Program on Climate Change and Human Health, as prescribed by the National Niharika Barik Singh Center for Disease Control, Ministry of Health and Family Welfare). Former Health Secretary 34 | COVID-19 and Climate-Smart Healthcare The COVID-19 pandemic highlights how powering health with renewable energy can build resilience, not only for health system strengthening and climate resil- ience, but also for pandemic preparedness. Solarization of the health center Masarhi, Bihar: A Climate-Resilient COVID-19 Care Hospital has helped cut electricity costs with Staff Quarters by almost 58 percent in the facility. Given the unknowns Implemented by the Indian nongovernmental organizations (NGO) — the SELCO Foundation and Doctors for You (DFY) a hospital in Masarhi, Bihar is a new solarized around COVID-19, especially COVID-19 care facility with a six-bed inpatient department, two procedural rooms, about how long the pandemic and 15 staff accommodation rooms. It is built with sustainable materials and 100 would last, cost uncertainties percent- powered by renewable energy. It is a potentially scalable example of are plaguing health facilities. how the COVID-19 response, climate resilience, cost savings, and achieving To top this, COVID-19 care itself greater access to care can be embodied by a single health facility. is an expensive proposition. Solar photovoltaic (PV) at the Masarhi hospital is powering, among other things, Solarization of the health center ventilators for COVID-19 care, a laboratory for testing and analysis, as well as helps reduce and balance the water pump for the facility. Solarization has ensured 24/7 power for the the costs for a COVID-19 Care hospital, resulting in improved staff retention and increased trust from the public; women patients are more willing to stay at the hospital for care because they hospital. feel safe there. Ravikant Singh Doctors for You The hospital has adopted a holistic approach to climate resilience wherein en- ergy-efficiency measures have been deployed in combination with renewable energy infrastructure. Given the precarious situation of the electricity supply in the region, the hospital is fully powered by a 15-kilowatt solar PV array with battery backup. Although it is connected to the grid, it can continue to operate fully, even in the event of grid power disruptions. In addition, the hospital has incorporated diverse innovative measures that reduce its energy footprint and minimize energy needs. The facility has eco-friendly walling and flooring made from compressed Agri Fiber panels that are manufactured by using crop residue. These panels provide enhanced insulation compared to conventional walling and flooring panels, thereby leading to a decreased need for air conditioning during the summer. Examples of other incremental building solutions added to improve the quality of the space with respect to natural lighting, ventilation, and thermal comfort, leading to the early recovery of the patients, included the following features: • addition of skylights and turbo ventilators to the roofing; • windows with exhaust fans; along with • cool-roof solutions, such as cool-roof paints, modulable roofs made of recyclable materials (also known as mod roofs), and false ceilings to reduce the heat gain through roofing. Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 35 energy to help diminish the ecological footprint prolonged use of PPE, such as face masks, thereby of the health sector. compromising infection control and health worker safety. The global production of PPE and other Establishing sustainable health care waste commodities is catching up, but this has often been management in testing, isolation, and treatment done at the expense of using more sustainable facilities, including waste minimization, and deeply considered processes. An opportunity segregation, safe recycling, and incineration exists to encourage and develop shorter and more phaseout in favor of steam-based disinfection. The resilient supply chains that can respond to all types demand for health care materials and the amount of shocks, including pandemics and climate-related of health care waste have increased dramatically disasters, while reducing emissions and protecting during the COVID-19 pandemic, therefore requiring planetary limits. more sustainable waste management approaches. Waste from COVID-19 should be treated as any CLIMATE ADAPTATION AND RESILIENCE other normal waste (HCWH 2020b; WHO 2020a). The improper management of health care waste Ensuring the steady supply of PPE, mechanical contributes to proximate environmental pollution ventilators, medicines, and other essential (for instance, of air quality and water resources). commodities, including non-mercury-based Incineration also greatly contributes to air pollution thermometers and waste collection bins and and GHG emissions, whereas alternatives, such bags, throughout the entire COVID-19 response as steamed-based mechanisms, have proven to and in preparation for potential climate-related be effective (see country case study 3.5). Health shocks. Building shock-resistant supply chains at facilities should address the entire cycle of health the local, national, regional, and global levels will care waste by improving health care protocols support the continuous provision of health care for enhanced efficiency and reduced waste supplies during this pandemic as well as enhance generation, as well as adopting green practices the health sector’s capacity to immediately respond and technologies for recycling and disposal. This to future crises, including climate-related disasters. can include disabling, disinfecting, and recycling Factories and transportation services must put in syringes and ensuring the sustainable disposal place backup options, including for electricity and of testing kits. manpower, to ensure the continuous production and distribution of essential supplies, especially in times of shock. 3.4 SUPPLY OF ESSENTIAL Using energy-efficient and low-carbon mechanical MEDICAL COMMODITIES ventilators and diagnostics, including X-rays and microscopy, which can function despite The COVID-19 pandemic has driven a surge in electricity disruptions resulting from a climate- demand for essential health care supplies, such related disaster. The initial surge of COVID-19 as PPE, mechanical ventilators, and medicines. cases worldwide exposed the global shortage of Because suppliers, distributors, and health facilities mechanical ventilators — a key medical device for failed to anticipate the immense need for health respiratory illnesses, resulting in difficult patient care commodities brought about by the pandemic, allocation decisions, improvised adaptations supply shortages have led to the repeated or in care protocols, and even the invention of 36 | COVID-19 and Climate-Smart Healthcare Country Case Study 3.5 The Gambia: THE GAMBIA MOVING FROM INCINERATION TO SUSTAINABLE HEALTH CARE WASTE TECHNOLOGY IN RESPONSE TO COVID-19 In reaction to the mounting COVID-19 cases in The Gambia, the government took the initiative to address the infec- tious health care waste generated by the COVID-19 response. While responding to the public health emergency, it showed that sustainable health care waste management, including maintaining a low-carbon footprint, is possible by replacing incineration with microwave technology. Health care waste management is a notable issue in developing countries, where air contamination, surface and groundwater pollution, and the spread of diseases are concerns. While incinerators have traditionally been the waste management solution of choice, they have serious drawbacks. Burning waste emits significant amounts of carbon dioxide (CO2) and other pollutants, including dioxins and furans, carcinogens, and endocrine disruptors. These pollutants persist in the environment for hundreds of years and build up in the food chain, resulting in their transmission from mother to child. As part of the COVID-19 response, one of the key components proposed was to improve health care waste manage- ment in the sanatorium treatment center in the western region of the country, where most of the confirmed cases would be treated. Under the World Bank-financed COVID-19 operation, procurement moved from incinerators to a more sustainable technology. The health care waste management technology selected by the government of The Gambia uses microwave disinfection technology as a cleaner method for managing and treating medical waste, thereby providing an environmentally friendly, simple, and reliable solution for health care waste management, particularly in the urban areas. The technology is energy-efficient, requiring little energy as well as few staff, no water, steam, and no production of toxic waste. Noting that laboratories and relevant health facilities that are being used for the diagnostic testing and isolation of patients can generate biological waste, chemical waste, and other hazardous bioproducts from COVID-19, the management and handling of highly-infectious biomedical waste are critical as part of the pandemic response. Throughout the process, the government of The Gambia engaged in initiatives to protect health, while considering its environmental and climate change commitments. It took the initiative and served as the driving force behind the process—researching the options available as well as considering environmental and social safeguards to maintain the health of the population and the environment. Social and environmental safeguards are essential for preventing and mitigating undue harm to people and their environment in the development process. In order to move forward with addressing climate change, while responding to COVID-19, the country will need to take the initiative to maintain a sustained and viable response. Ultimately, country ownership and leadership are key to sustainability and addressing climate change, while responding to COVID-19. While responding to COVID-19, The Gambia showed that sustainable health care waste management, including maintaining a low carbon footprint, is possible by replacing incineration with microwave technology. Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 37 low-cost options by local producers. In settings Sustainably managing all waste, including the that are highly vulnerable to electricity disruption waste minimization and segregation of all items, (for example, during climate-related disasters), such as used PPE that includes masks and sustained ventilatory support for critical patients medicine packaging. Suppliers and distributors of becomes even more challenging. The next essential commodities, such as PPE and face masks, generation of mechanical ventilators must be as well as the pharmaceutical industry, should share adequate in supply and reliable in times of energy responsibility for the environmental implications shortages. It is also important to explore innovative of their products across the entire life cycle. This design opportunities that promote sustainability requires encouraging segregation and waste and reduced environmental impact. minimization, including avoiding the unnecessary use of chemicals and disinfectants. Reverse Strengthening local production and supply chains logistics channels for particular commodities can to ensure the steady supply of commodities also increase the possibility of the recycling and while reducing transport emissions. Producing return of used products to manufacturers that can and storing essential commodities closer to health then recycle them or ensure their safe disposal. facilities will significantly reduce the need for long-distance transport and, in turn, reduce fuel use Producing washable and reusable PPE made of and the emissions of GHGs. Local production and sustainable materials. Embedding sustainability storage can thus enhance the resilience of local principles, including low-carbon production, health systems and surrounding communities by transportation, and disposal, into the production ensuring timely responses to health emergencies, of vital COVID-19-relevant commodities, such as sustaining longer-term response operations without PPE and face masks, is an important consideration. outside aid, and supporting local economies. Moreover, next-generation PPE can be developed to be washable and reusable, while still providing CLIMATE MITIGATION AND LOW-CARBON similar safety and cost effectiveness, when HEALTH CARE compared with single-use alternatives. Adopting renewable energy and energy-efficiency Adopting sustainable procurement standards measures in the manufacturing, storage, and for PPE, other equipment, cooling devices, transport of essential commodities. Factories and and medicines, including prioritizing the transport services for the production, storage, and minimization of waste production and avoiding distribution of essential health care commodities the purchase of products with high carbon for the pandemic response should consider levels, high global warming potential (GWP), or environmental impacts, including air pollution and high energy consumption. Choices made in the GHGs, by shifting to renewable energy sources. selection and procurement of all health care-related In addition, some essential commodities, like equipment or products should be considered in vaccines and other medicines, require a carefully relation to specific procurement standards that maintained cold chain that should also shift to include references to minimizing waste production, low-carbon and efficient technologies in the coming low carbon emissions, low GWP, low energy years (K-CEP 2018). consumption, as well as the utilization of less toxic ingredients (see country case study 3.6). 38 | COVID-19 and Climate-Smart Healthcare Country Case Study 3.6 Colombia: COLOMBIA SUSTAINABLE PROCUREMENT AND COVID-19 HEALTH CARE RESPONSE In Colombia, having a sustainable procurement program in place has allowed several hospitals and health care systems to better cope with the health emergency caused by COVID-19. The health care supply chain plays a major role in many economies and has a significant impact on human health and the environment. At the same time, the pandemic has disrupted the global health care supply chain, thereby leading to shortages of PPE, single-use medical devices, disinfectants, cleaning products, and other key elements associated with the protection of health care workers as well as the diagnosis and care of COVID-19 patients. In response, a number of Colombian health care systems and facilities, already implementing sustainable procure- ment policies and practices in collaboration with Health Care Without Harm (HCWH) and the United Nations Devel- opment Programme (UNDP), were able to rapidly develop policies and actions to prioritize the use of reusable PPE, while also adapting formulas for disinfectants and detergents. These same hospitals have also been accelerating the use of telemedicine in consultations associated with the diagnosis and prevention of non-respiratory diseases. In the case of these Colombian hospitals, having a clear environmental policy on sustainable procurement in place made it easier to respond to COVID-19 and continue with a safe environmental approach as part of that response. This pandemic resilience has had associated climate benefits: by procuring supplies and services that prioritize reusables (PPEs) and reduce patient and staff transport (telemedicine), health care institutions have reduced the carbon and environmental footprint of their COVID-19 response and the health sector in general. 3.5 HEALTH SERVICES FOR focus on COVID-19 and changes in care-seeking NON-COVID-19 CONDITIONS behaviors. The strengthening of primary health care and health service delivery for non-COVID conditions is important, as it can have long-term A significant challenge facing the COVID-19 resilience-building attributes that reduce the impact response and recovery is maintaining pandem- of future health emergencies, including those ic-essential services, including testing, isolation, induced by climate change. and treatment capacities, while continuing to provide health services for other public health CLIMATE ADAPTATION AND RESILIENCE conditions. For example, reproductive, maternal, newborn, child, and adolescent health has, in Strengthening other non-COVID-19 public health some cases, seen neglect during the COVID-19 programs, including those for climate-sensitive pandemic due to the reallocation of resources to diseases. A high baseline status of health among Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 39 individuals is beneficial for preventing severe for health care, leading to greater out-of-pocket COVID-19 outcomes and reducing individual expenses and the further impoverishment of vulnerability to climate-related diseases, such as households due to health care spending on heat-related illness and water-borne infectious COVID-19 or other conditions. National health diseases. To ensure the maintenance of this systems should reevaluate national health financing baseline, there must be a sustained delivery of systems to find solutions that ensure sustainable prevention and treatment measures that reduce the financial flows, for instance, through new sources of excess burden of other diseases, for instance, non- revenue. Furthermore, to protect households from communicable diseases, such as cardiovascular the financial risk that results from hospitalization, diseases, diabetes, and cancer — all of which are benefit packages for the treatment of COVID-19 and key risk factors associated with the COVID-19 other diseases, including those linked to climate infection. Moreover, climate-sensitive health change, should be developed. Finally, health risks, such as vector- and water-borne diseases, financing should be made equitable, ensuring heat-related illnesses, and undernutrition, are highly that the poor are not left behind. preventable by intensifying existing disease-fo- Integrating mental health and well-being cused public health programs and incorporating programs for health staff and volunteers into a climate lens. health emergency response and recovery efforts, Enhancing resilience against climate-related including those related to the pandemic and impacts and their effects (such as electricity climate-related disasters. Health workers and disruption) on health facilities that render emergency response volunteers responding to n o n - C OV I D - 1 9 s e r v i c e s . S i m i l a r t o t h e COVID-19 and climate-related disasters are likely to recommendation for COVID-19-dedicated health experience mental stress and burnout. The failure facilities, hospitals and primary care centers to address the mental and emotional vulnerabilities assigned to manage patients with other conditions confronting the health workforce may impede the must be protected from the destruction resulting effective delivery of health services to patients. from climate-related disasters. Hospital buildings Psychosocial support must be made available to all must be made resistant to strong winds and health personnel, with extra support envisaged for flooding. Furthermore, off-grid options for electricity the emergency response and the recovery process. and water supply as well as communication channels must always be available as backups. CLIMATE MITIGATION AND LOW-CARBON HEALTH CARE Strengthening health-financing mechanisms to ensure universal coverage to people with Promoting low-carbon and energy-efficient COVID-19 and other non-COVID-19 conditions, telemedicine services (along with support including climate-sensitive diseases. The for increased access to communication COVID-19 pandemic has exerted tremendous devices and wireless connectivity) to ensure stress on national health-financing mechanisms, the continued provision of primary care and whether they are tax-financed or based on social close last-mile delivery gaps. The demand for health insurance. The impact is especially serious telemedicine services has increased during the in settings with high levels of private financing pandemic, especially for nonemergency health 40 | COVID-19 and Climate-Smart Healthcare needs. Telemedicine not only provides a safe, freezer), energy efficiency and low carbon intensity effective, and affordable alternative to face-to-face should be prioritized in the procurement criteria. primary care consultations but also presents an Strengthening climate-smart health care waste opportunity for maximizing professional time management. More capacity to treat and dispose and reducing the carbon footprint of health of health care waste safely and sustainably is care associated with electricity use in health needed; as such, efforts should embrace non- facilities and air pollution from patient transport. incineration technologies to reduce the carbon Telemedicine can also support the continuity of footprint of the health sector (see country case care for patients with chronic conditions and offer study 3.7). Key steps include the minimization of the a possible solution for hard-to-reach or remote amount and toxicity of waste through well-informed populations lacking access to basic primary care. procurement policies; segregation at source of The expansion of telemedicine must be coupled waste streams; steam-based disinfection; and with improving access to low-carbon and energy- recycling. The bio digestion of organic waste, efficient communication devices (for example, including pathological waste (the largest volume mobile phones and tablets) as well as wireless of which is composed of placentas) as well as internet connectivity. Technology literacy through food and kitchen scraps, will yield methane-rich education must also be enhanced among biogas that can be used onsite for cooking or vulnerable populations. water heating, thus preventing emissions from Improving the efficiency of care pathways to incinerating pathological waste. Other organics ensure health provision, reduce emissions, and should be sent to landfills. save costs. Measures that enhance the efficiency of care pathways, such as telemedicine and optimized treatment regimens, will help reduce 3.6 NONPHARMACEUTICAL waste and GHG emissions, while ensuring that INTERVENTIONS more patients receive health care in resource-con- strained settings. In addition, efficiencies can lead While health care provision is essential for to cost savings that can be reinvested in other improving outcomes and reducing mortality among health-improving interventions. those contracting COVID-19, NPIs, such as physical Adopting low-carbon and energy-efficient distancing and the universal wearing of masks, technologies as well as cooling practices for have also proved effective in preventing further health care provision. Cooling, especially as viral transmissions. When NPIs achieve their goal temperatures increase, is needed to maintain the of slowing the spread of the virus, the number of functioning of laboratory equipment, keep food COVID-19 patients will be lessened and the health safe, guarantee a cold chain for vaccines and care system not as overwhelmed. The success of medicines, and more. Passive cooling should be NPIs relies not only on the capacity of health care prioritized in every new construction project (for facilities and services but also the awareness and example, shades, natural ventilation, or reflective abidance of the broader public, including strong roofs). When active cooling is needed (for example, cooperation among other sectors. for air conditioners or the purchase of a new Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 41 Country Case Study 3.7 Nepal: NEPAL INTEGRATED SUSTAINABLE HEALTH CARE WASTE MANAGEMENT SYSTEMS TO REDUCE COVID-19 RESPONSE POLLUTION BY THE NUMBERS The COVID-19 pandemic has threatened to overwhelm the waste management Sukraraj Tropical systems of some hospitals and health centers. The delivery of the new COVID-19 and Infectious vaccine is expected to bring another stream of waste. A multiparty partnership in Disease Hospital in Nepal is demonstrating that safe and environmentally sustainable health care waste Kathmandu management systems can bolster normal operations and help take on COVID-19 1st waste issues while building health system resilience. Investments in integrated hub-and-cluster systems, based on careful waste segregation, the autoclave disin- fection of waste, and the recycling of as much waste as possible, offer the greatest dedicated COVID-19 all-round benefits. The bio digestion of organic waste completes the portfolio of hospital in Nepal climate-smart and resilient waste treatment technologies for health care facilities in low- and middle-income countries. 100 The Sukraraj Tropical and Infectious Disease Hospital in Kathmandu — the nation’s hospital beds — capital — is Nepal’s only dedicated infectious disease hospital. Operated by the half dedicated to government of Nepal, it has 100 beds, with half now dedicated to COVID-19. It is COVID-19 the country’s first COVID-19 hospital, serving more than 1,000 outpatient cases per day, while also collecting and handling more than 900 swabs per day for COVID-19 tests. The Sukraraj Hospital has a small waste treatment center, with an autoclave 1,000+ donated to help treat COVID-19 waste. The autoclave is not large enough to cope outpatient cases with all the infectious waste from the hospital; so currently, only the COVID-19 waste served per day is being treated. The Sukraraj Hospital is being supported to manage waste from COVID-19 patients by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ) Nepal and the Health Environment and Climate Action Foundation (HECAF360). 900 COVID-19 testing Nearby, spread across the Kathmandu Valley, are five drop-in-centers (DICs) that swabs collected and offer harm reduction services, including Human Immunodeficiency Virus (HIV) testing handled per day and syringe exchanges to persons who inject drugs. The DICs are operated by diverse Nepali community-based organizations and NGOs. While financial support comes from the Global Fund to Fight AIDS, Tuberculosis and Malaria as well as 5 Save the Children Nepal, technical support is obtained from HECAF360 and Health Nearby DICs Care Without Harm (HCWH). The DICs have been searching for a safe way to participating in a dispose of their waste. With neither the space nor resources for the equipment hub-and-cluster and personnel to treat the HIV test kits and used syringes from their clients, the model for enhanced DICs have accumulated substantial stockpiles of waste, while awaiting a solution. waste management 42 | COVID-19 and Climate-Smart Healthcare In response to this situation, the facilities, their backers, and technical support teams are now cooperating to create a system that meets the needs of both the hospital and the DICs. This “hub-and-cluster model” is effective in locations where there is no centralized waste management facility. Larger health care providers with the technical expertise to treat waste safely also treat that of smaller facilities nearby. They provide a valuable service and, in turn, can subsidize the use of their staff and equipment by charging waste treatment fees. This sustainable health care waste management system has the following characteristics: SEGREGATION. At each of the participating facilities, waste will be strictly segregated to minimize the amounts requiring treatment. TREATMENT. Autoclaves that use high-temperature, high-pressure steam to kill pathogens will disinfect the waste. RECYCLING. Much of the waste from the Sukraraj Hospital can be recycled. Noninfectious waste, including paper, plastics, and glass, which have been segregated at source, will be brought directly from the Sukraraj Hospital’s wards to the “green” section of the waste treatment center from which it will be sent for recycling. After treatment in the “red” section, some of the previously infectious waste can also be recycled. In previous research, HCWH and HECAF360 were able to recycle immunization waste, including vaccine vials and packaging; the only exception was the cut needles. Investing now in sustainable health care waste management systems can address the problems associated with COVID-19 treatment and vaccination, while also developing infrastructure that can continue to be useful once the pandemic abates. Actions taken to counter the spread of the virus can also present potential long-term benefits. CLIMATE ADAPTATION AND RESILIENCE vulnerable who generally lack proper access to WASH services. This promotion will contribute to Consistently promoting regular hand washing meeting SDG, including those related to health and and other personal hygiene practices to prevent climate, along with the achievement of universal COVID-19 and climate-related waterborne access to quality health care (WHO 2019, 2020). diseases. The COVID-19 pandemic provides an opportunity to reinforce basic behaviors for disease Designing temporary shelters for victims of cli- prevention, such as regular hand washing and mate-related disasters to ensure the continuation proper cough etiquette. In addition, climate-sen- of physical-distancing measures. In countries that sitive water- and food-borne diseases as well as are highly vulnerable to extreme weather events, COVID-19 can be prevented by strengthening such as typhoons and extreme flooding, the design water, sanitation, and hygiene (WASH) in health of temporary shelters and evacuation centers care facilities, communities, and households. for disaster victims must allow the continuous Special attention must be given to the poor and observance of NPIs, such as physical distancing Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 43 and regular hand washing. Hand-washing facilities, decarbonization, without harming the economy, including faucets, soap, and other disinfectants, impoverishing citizens, and communities, and must be adequately available in these temporary exacerbating socioeconomic inequalities, should settlements. Specific beds or quarters of individuals be explored. and households should be adequately spaced Moreover, air pollution exposure has been to ensure the observance of physical distancing. demonstrated to be an important factor in Natural ventilation and the appropriate design of increasing the risk of mortality from COVID-19, air flow within evacuation centers can also reduce which should further motivate ambitious air the risk of airborne transmission of COVID-19. pollution interventions (Pozzer et al. 2020). Designing adaptive social protection programs, Measures to reduce air pollution should be particularly for communities at high risk to guided by the road map for an enhanced global different forms of external shocks, such as response to the adverse health effects of air pandemics and climate-related disasters. NPIs, pollution, adopted by the WHO member states such as stay-at-home orders, school closures, at the Sixty-Ninth World Health Assembly in 2016 and travel restrictions, can have socioeconomic (WHO n.da). impacts, including income and job loss as well Promoting healthy, low-carbon, and COVID- as reduced access to food and other essential compliant environments, travel, and lifestyles. resources. Similar impacts can be anticipated in One of the potential consequences of the the aftermath of climate-related disasters. The lockdowns and other NPIs is the decline of active COVID-19 pandemic provides an opportunity lifestyles among populations, which can exacerbate for designing (or redesigning) social protection the already obesogenic environments in which programs, such as social insurance schemes, along people lived before the pandemic. There is a need with social assistance and welfare services, in order to design local environments that will still promote to help ensure adequate support for populations physical distancing, while encouraging more vulnerable to the unintended consequences of physically active lifestyles and increasing access pandemics, climate change, and other forms of to healthier food options provided closer to home. external shocks. Interventions include addressing food insecurity through food pantries and food distribution CLIMATE MITIGATION AND LOW-CARBON programs; promoting safe and convenient walking HEALTH CARE and protected cycling routes; mitigating urban heat Maximizing temporary improvements in air island effects through increasing access to green quality due to lockdowns by identifying long-term spaces; and supporting outdoor food vending, such measures for reducing air pollution. Lockdowns as farmers markets. Communities can establish imposed during the COVID-19 pandemic have vegetable gardens that utilize agroecological led to the downscaling of many human activities, methods to promote the local production of especially transport that has, in turn, led to dramatic, nutritious foods. This can also help to reduce the yet short-lived, reductions in air pollution and carbon emissions associated with large-scale food GHG emissions. Nevertheless, the possibility of production and long-distance transport. more sustainable interventions that lead to lasting 44 | COVID-19 and Climate-Smart Healthcare 3.7 PUBLIC HEALTH RISK to public health risk communication. Furthermore, COMMUNICATION such an integration maximizes limited resources, enhances the system’s robustness through repeated use, and sensitizes the public to unified The COVID-19 pandemic highlights the sources of information. importance of timely and effective communication of evidence-based information to protect and Incorporating relevant climate change and save lives. While the availability of social media environmental sustainability messages into has enabled the rapid dissemination of information, COVID-19 advisories to convey links between it has also created new challenges, such as climate change and COVID-19. The availability of misinformation, mistrust, and the propagation information about COVID-19 in traditional and social of conspiracy theories related to COVID-19. Risk media has heightened public awareness about communication during emergencies must happen the disease and the importance of public health in real time and engage a range of stakeholders, in general. There is an opportunity to integrate including experts, policy makers, community information on the health risks of climate change leaders, and the public. Accurate and timely into ongoing public-health risk-communication information aids in the planning and design of mechanisms. Journalists can be powerful allies responses by government agencies and other in communicating climate and health messages stakeholders, while shaping the decisions and during a pandemic; thus, there is a need to build behaviors of individuals and households. Key journalists’ capacities to convey information factors that contribute to effective public health accurately and in a way that can be fully understood risk communication include the truthfulness and by their target audiences (HCWH 2020a). Climate packaging of the messages; the authority and change-related health problems and COVID-19 trustworthiness of the messenger; the accessibility are happening in concert, and the dissemination and appropriateness of the channel; as well of life-saving information about climate change as meaningful engagement with information should not be delayed. recipients, particularly policy makers, implementers, Targeting COVID-19 communication with climate- and the public, among others. relevant information for populations vulnerable to climate-related disasters and other health effects. CLIMATE ADAPTATION AND RESILIENCE Certain populations — such as the poor, elderly, Developing integrated, robust, and cross-sectoral those with underlying conditions, and indigenous risk-communication plans and channels that communities — face the compounding burden of can be applied to all types of external shocks, the dual crises of COVID-19 and climate change. including pandemics and climate-related Relevant information that is tailored and targeted disasters. The establishment of harmonized, must be designed and delivered to these groups adaptable communication plans and channels in a timely and effective manner to enhance their linking different sectors is increasingly important for capacity to cope with these external shocks and countries to reduce the adverse impacts of global protect their health from both COVID-19 and climate- environmental change. Integrated communication sensitive diseases. Alternative and analog channels platforms can simplify a government’s approach must also be utilized to convey vital information to Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 45 hard-to-reach and geographically disadvantaged Incorporating health promotion messages in populations as well as those without access to the COVID-19 advisories that encourage healthy internet or mobile phones. and low-carbon lifestyles while surviving the pandemic. There is an opportunity to incorporate Raising the health, climate, and risk literacy of information and messaging on healthy and communities to prepare for and adapt to future sustainable lifestyles into COVID-19-related public external shocks and stresses. The effectiveness health advisories. As people continue to observe of public health risk communication also relies on physical-distancing restrictions, they could benefit the baseline readiness of the population to receive, from routine advice on how to adopt energy- process, and act on the information obtained. The efficiency measures and sustainable healthy diets COVID-19 pandemic emphasized the importance while staying at home. In addition, messaging on of heightened health literacy among the public the safe disposal of used PPE and waste from the to ensure the rapid uptake of information and home-based care of COVID-19 patients as well as adoption of healthy preventive behaviors. The the maintenance of recycling programs should be high level of awareness about COVID-19, infectious encouraged. diseases, and public health in general should be sustained beyond the pandemic and reinforced with additional public health information, including 3.8 VACCINE READINESS, the health risks of climate change. Communication messages should also be understandable and PROCUREMENT, AND DEPLOYMENT actionable so that the new knowledge acquired is translated into healthy habits — for instance, The COVAX Facilityb — convened by the Coalition proper hygiene against infectious diseases or the for Epidemic Preparedness Innovations, the Global preparation of basic emergency supplies at home. Alliance for Vaccines and Immunization, and WHO — aims to support the building of manufacturing capa- CLIMATE MITIGATION AND LOW-CARBON bilities and the advanced procurement of two billion HEALTH CARE COVID-19 vaccine doses for equitable distribution to participating countries by the end of 2021. To Transitioning to low-carbon and energy-efficient ensure the successful delivery of the vaccine to electronic systems for public information the world’s population, especially the vulnerable, dissemination. The carbon footprint of public countries must be supported to put in place robust communication can be further reduced and efficient vaccine delivery systems as well as by developing electronic devices that are comprehensive plans for vaccine allocation and manufactured through low-carbon production community preparation, including the capacity for processes and made of sustainable materials. non-incineration waste management. Furthermore, improving the energy efficiency of these devices, for instance, with batteries that have greater storage capacity and longer lifespans, will aid in further reducing the environmental impacts b Further information may be found at the COVAX website, of communication. https://www.who.int/initiatives/act-accelerator/covax. 46 | COVID-19 and Climate-Smart Healthcare CLIMATE ADAPTATION AND RESILIENCE systems. The comprehensive assessment of needs, gaps, efficiencies, and existing resources will aid in Establishing energy-efficient, climate-friendly minimizing the need for new equipment purchases cold chain infrastructure, technology, storage, from the outset. Meanwhile, investments in cold and distribution. The successful and universal -chain infrastructure (storage facilities, storage deployment of the COVID-19 vaccine will likely during transport, and logistics capabilities) and require major investments to address cold-chain technology (vaccine refrigeration) must consider capacity gaps (see box 3.3 and country case energy efficiency, the use of refrigerants with study 3.8). Some vaccine brands already available low GWP, and the reliance on clean renewable require ultracold-chain storage that is widely power sources (including microgrids). Building such unavailable in many low-income countries. Without next-generation vaccine delivery systems can help strategic intent, investments in cold-chain facilities achieve global health goals, such as pandemic could inadvertently lock in unhealthy, polluting control; lower carbon emissions to protect the infrastructure and technology, accompanied by planet; reduce the financial burden to power the higher operating costs. Alternatively, by following infrastructure; and ensure seamless vaccine access. a clear set of climate-smart principles, these Moreover, all these objectives can be accomplished investments could be channeled toward affordable, even in the face of future disruptions, as can result energy-efficient, and resilient vaccine delivery from climate-related disasters. BOX 3.3 PRINCIPLES FOR NEW INVESTMENT IN COLD-CHAIN INFRASTRUCTURE AND TECHNOLOGY The successful and universal deployment of COVID-19 vaccines will require major investments to address cold-chain capacity gaps. Without strategic intent, these investments could inadvertently lock in unhealthy, polluting infrastructure and technology, accompanied by higher operating costs. Alternatively, by following a clear set of climate-smart principles, these investments could be channeled toward affordable, energy-efficient, and resilient vaccine delivery systems. Recognizing that vaccines are urgently needed to save lives in all countries, there is an opportunity to establish energy-efficient and climate-friendly cooling systems for COVID-19 vaccines. A first step is to minimize the need for new equipment purchases from the outset, through the assessment of needs, gaps, efficiencies, and existing resources. Second, new investments in the cold-chain infrastructure (storage facilities and logistics capabilities) and technology (vaccine refrigeration) should be based on the following criteria: 1. Alignment and consistency with multilateral environmental agreements. Investments in infrastructure and technology for a COVID-19 vaccine cold chain should support the implementation of countries’ commitments under the Montreal Protocol (including the Kigali Amendment) and the UN Framework Convention on Climate Change (UNFCCC) (including the Paris Agreement). Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 47 2. Infrastructure investment. Energy-efficient, climate-friendly refrigerants, and clean renewable power sources (including microgrids) should, where feasible, be the central components of the investments in the COVID-19- vaccine infrastructure, such as cold transport and storage facilities, in order to ensure: • economic viability and the reduction of the governments’ financial burden to power the infrastructure; and • a resilient cooling infrastructure that is low carbon and aligned with both global health and climate goals. 3. Technology selection and program design for replacement. • The selection of technologies for vaccine delivery and storage, such as refrigerators and cold boxes, should prioritize available, affordable, WHO-prequalified equipment or other validated technologies that are energy efficient. Where countries have the capacity to use climate-friendly refrigerants, technologies should also have low or zero global warming potential (GWP). • Future WHO performance, quality, and safety criteria should include the minimum standards for climate- friendly refrigerants to inform the design of new cold-chain technologies, including ultracold-chain equipment. • Monitoring equipment should be included with all cold-chain technologies to ensure that the cold chain is appropriately maintained and unbroken, determine when vaccines are compromised, identify poorly performing equipment, and ensure greater energy efficiency. • Training programs should be an integral component of any investment to support the implementation and maintenance of technology choices. • The worst-performing equipment (poor functionality, wasteful energy consumption, and/or containing harmful pollutants) should be prioritized for replacement, both to preserve vaccine potency and increase the cold-chain efficiency. • Where replacements are made, program design should include provisions for the safe and sustainable disposal of old equipment that includes refrigerants. This could consist of a take-back component for vaccine-refrigerator programs that covers the proper recycling and disposal of obsolete equipment, with costs aggregated at scale. While the Covid-19 pandemic and the distribution of a vaccine to protect human life both create immense challenges for middle- and low-income countries, they also present a critical opportunity for guiding infrastructure investments toward long-term sustainability and the direct alignment of the global goals of health equity and planetary health. Increasing the capacity of the health workforce distributed in a sustainable manner. A revitalized for vaccine delivery for COVID-19 and other health workforce dedicated to COVID-19 vaccine climate-sensitive diseases. Health workers and delivery can serve as a springboard for other volunteers must be trained in the implementation immunization programs for climate-related of mass immunization programs for the release infectious diseases, such as meningococcal of the COVID-19 vaccine, both in terms of clinical meningitis. and logistical aspects. Finally, as these health workers may be inadvertently exposed to COVID-19 National COVID-19 vaccine planning to provide while delivering vaccines, the supply of PPE must a template for enhancing the vaccine coverage be adequate; thus they must be produced and for climate-sensitive infectious diseases. 48 | COVID-19 and Climate-Smart Healthcare Country Case Study 3.8 Ghana: GHANA BUILDING A SUSTAINABLE COLD CHAIN FOR THE COVID-19 VACCINE In November 2020, the government of Ghana engaged with the World Bank to receive financing to support preparatory activities for the future vaccine deployment, including the capacity strengthening of im- munization systems and a number of other activities. As part of climate change mitigation, the project financed improvements for the vaccine cold-chain delivery process by seeking to provide the following elements: • off-grid solar electricity for rural and peri-urban government health facilities to avert greenhouse gas (GHG) emissions from these facilities; • reequipping of primary health care facilities to be energy efficient and enhancing existing cold-chain facilities; • other logistics infrastructure and vehicles with highly fuel-efficient vehicles or vehicles running on low- carbon fuels or electric power; along with • training of health care delivery workers to support the deployment of low-carbon technologies through the cold chain (World Bank 2020a). In preparation for the vaccine delivery, the National Technical Coordination Committee (NTCC) and the Technical Working Group (TWG) on COVID-19 Vaccine Readiness and Deployment provided technical, advisory, and coor- dination support to the government of Ghana. Moreover, NTCC and TWG convened key donor agencies, such as WHO, the World Bank, and the United Nations International Children’s Emergency Fund (UNICEF), as well as private sector stakeholders, for collective decision-making on the COVID-19 response, including vaccine delivery. These platforms provide an opportunity for collective discourses on climate impacts among major partners supporting cold-chain and vaccine delivery. Additionally, there is a health development partner group that meets regularly to discuss various aspects of the health sector in Ghana, share good practices, and take collective stances on key health sector issues. Specifically, for vaccines, the group provides an avenue for discussions revolving around the procurement and deployment of vaccines as well as cold-chain-related matters, which is crucial for a coordinated response toward COVID-19. This group also provides an additional opportunity for discourses and collective actions on climate mitigation measures among key development partners involved in COVID-19 vaccine delivery in Ghana. The recognition and ownership, displayed by the government of Ghana in establishing a sustainable vaccine cold chain, has enabled an effective response to COVID-19, while still honoring commitments to the Paris Climate Agreement. The World Bank’s financing of the vaccine cold-chain process and infrastructure to ensure solar energy and sustainable practices will complement the country’s response in meeting its nationally determined contributions (NDC), while also enhancing the resilience of the health system to provide care for its population and addressing the COVID-19 outbreak. Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 49 During the release of the COVID-19 vaccine, and other material types for vaccines, syringes, and governments should begin to negotiate with packaging. An opportunity exists to innovate with individual pharmaceutical companies, participate more sustainable and nonhazardous materials for in discussions in the COVAX facility, and develop vaccine manufacturing, storage, and packaging national plans for vaccine deployment. These materials. This can help minimize waste and reduce efforts should build on existing vaccination policies the vaccine industry’s carbon footprint, while also and programs for known infectious diseases as ensuring vaccine safety, efficacy, and quality. The well as provide a template for future vaccination recycling and reusability of the vials, syringes, and programs for (re)emerging infectious and cli- packaging materials should be considered when mate-sensitive diseases. Equity considerations selecting materials in the production cycle. must also inform the allocation of these vaccines, Transporting vaccines to health facilities especially in the early phase of the rollout when and communities in a fuel-efficient manner. vaccines are limited and cannot cover entire The transportation of vaccines to countries, populations. Vaccine delivery systems that will communities, and clinics will also generate huge emerge from the COVID-19 response, which amounts of GHG emissions. Hence, fuel-efficient include the infrastructure and the workforce, must transport options must be heavily considered. also incorporate sustainability (including environ- These one-time investments in sustainable mentally sound waste management) and climate transport for health care commodities will also be adaptation. beneficial for sustaining the movement of supplies even beyond the COVID-19 pandemic, including CLIMATE MITIGATION AND LOW-CARBON in future climate-related disasters. HEALTH CARE Managing, recycling, and disposing of used Manufacturing vaccines in a manner powered by syringes and other waste from immunization renewable energy. As billions of doses of the new programs in an environmentally friendly COVID-19 vaccines are expected to be produced manner. National COVID-19 vaccination programs in the coming years, the global pharmaceutical are expected to generate enormous volumes industry will be using tremendous amounts of of used syringes, vials, and various forms of resources, including electricity, as part of vaccine packaging. These materials, if not disposed of manufacturing. The new generations of vaccines for properly, can create a new form of pollution that COVID-19 and other vaccine-preventable diseases will be detrimental to the environment and, in must be produced, using clean renewable energy turn, cause more harm to human health. Many and sustainable materials to help reduce the carbon countries currently lack adequate health care waste footprint of the entire pharmaceutical sector. As management systems: immunization waste is often part of the vaccine prioritization criteria, it may be burned, destroying recyclable materials, creating worth considering vaccines that can be supported significant carbon emissions, and leaving toxic ash by low-emission storage and distribution. containing needles and broken glass from vials. Making medical equipment and packaging out Systems that minimize waste, make syringes safe, of sustainable and recyclable or reprocessable segregate and disinfect waste, return reusable materials. There will be a surge of use of plastic items, and maximize recycling, as well as prevent 50 | COVID-19 and Climate-Smart Healthcare incineration that can deteriorate air quality, should CLIMATE ADAPTATION AND RESILIENCE be implemented. Investing in essential services, such as clean water and sanitation, to uplift the baseline health status of populations. The COVID-19 3.9 BUILDING BACK BETTER pandemic helped magnify the significant gaps in access to essential services, such as clean water Earlier sections of this report have focused on the and sanitation, as well as highlighted the key different aspects of the COVID-19 response — from role that adequate WASH can play in pandemic surveillance and testing to treatment and vaccine preparedness. Since more disease outbreaks and delivery. These actions need to be implemented climate-related health threats are anticipated in in such a way that they do not only address the the years and decades to come, it is imperative problems generated by the current pandemic, but that communities are guaranteed universal access also create stronger and resilient health systems to health-promoting services, such as water and sanitation services. Investments in WASH, including post-COVID-19. The response phase should in health care facilities themselves, will upgrade the help build the foundation for the recovery of baseline health status of populations, especially communities, health systems, economies, and the those who are vulnerable to infectious disease society at large. The challenge is to ensure that the outbreaks and the long-term health impacts of recovery process leaves systems and infrastructure climate change (WHO 2020b). on a much better footing than before. Proposals Investing in climate-resilient health care of green, healthy, and just transitions, such as infrastructure to build multifaceted resilience. the ones put forward by WHO (2020c) should COVID-19 has underscored the need for greater be adopted as part of the COVID-19 response and systems resilience so that health systems and recovery plans and investments. their supply chains can more agilely respond Building for a sustainable and resilient future to the shifting burden of diseases, including the emergence of new pandemics (WHO 2015). Health can enhance the ability of the global community, sector investments in the COVID-19 recovery era including the health sector, to set a course toward should focus on building multifaceted resilience. decarbonization. Further, it can also support There is an urgent need to build infrastructure communities and countries in their efforts to reduce resilience that allows hospitals and health care current and projected climate-related risks as well facilities to withstand extreme weather events as prevent future infectious disease outbreaks of precipitated or exacerbated by climate change. pandemic potential. Moreover, post-COVID-19 Finally, building back better also means health systems of health care, agriculture, energy, and systems should enhance their role as integral transport must ensure that equity and justice are members of the communities in which they are placed at centerstage so that COVID-19’s socio- situated to serve as an anchor for community economic impacts, disproportionately affecting climate and economic resilience. the poor and the vulnerable, do not recur during Revitalizing the momentum toward achieving future public health crises. UHC to protect citizens from future health shocks. Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 51 The massive disruption and additional burden CLIMATE MITIGATION AND LOW-CARBON caused by COVID-19 on health systems have led HEALTH CARE to delays in progress toward UHC, especially in Decarbonizing health care systems and low- and middle-income countries. At the same aligning the sector with the ambition of the time, the pandemic has reinforced the importance Paris Agreement. Countries have common but of ensuring universal access to quality health care differentiated responsibilities and respective for all, especially during moments of crisis. As capabilities to get to zero emissions in order to countries become more equipped to deal with meet the ambition of the Paris Agreement to keep the subsequent waves of infection, pre-pandemic the global temperature increase well below 2°C. health policy reforms and activities strengthening With health care making a substantial contribution the health system that are geared toward achieving to global emissions, health care investments in the UHC must be revitalized. Moreover, lessons learned era of COVID-19 recovery need to forge a path from the COVID-19 response must be considered toward zero-emission, climate-resilient health care in the recalibration of national plans for attaining by 2050. Hospitals and health systems everywhere universal coverage. Ultimately, health systems must reduce their GHG emissions and implement that do not leave the vulnerable behind are interventions that will ultimately fully decarbonize the best suited to respond to future pandemics, every aspect of their health care delivery and climate-related threats, and other forms of social, its supporting functions, while maintaining and environmental, or economic crises. improving patient care. This transformation must include clinical care and support services as well Investing in nature-based solutions to as facilities and infrastructure. Health care systems enhance the natural environment and protect must take action to move toward zero-emissions communities from climate-related shocks energy, buildings, travel and transport, and waste and future pandemics. The origins of the management, as well as low-emission pharmaceu- COVID-19 pandemic are a stark reminder of the ticals, sustainable food services, and more. Such importance of preserving nature to prevent future a fundamental transformation will require massive pandemics. Land-use change, particularly through collaboration and innovation at all levels of a huge deforestation for logging, agricultural expansion, sector of society (Karliner et al. 2021). and mining, contributes to increasing the likelihood Accelerating the shift from fossil fuel-based of pandemics. Moreover, these same activities electricity generation to clean renewable energy reduce the ability of forest ecosystems to sequester that is resistant to future shocks. Every aspect carbon from the atmosphere and protect human of the health care supply chain and delivery is communities from climate-related impacts, such as reliant on industries that provide energy, chemicals, intense flooding, landslides, and the emergence building materials, packaging, infrastructure, of infectious diseases. Future environmental transport, food, and more. The carbon emissions policies must promote forest ecosystem protection from these sectors, fueled primarily by a global and restoration to maximize the dual benefits economic system and a grid infrastructure, based of pandemic prevention and climate protection on the combustion of coal, oil, and gas, is the main emanating from healthy and sustainable forests. driver of the climate crisis. A rapid global transition 52 | COVID-19 and Climate-Smart Healthcare to clean energy would not only meet the Paris transport systems as part of a healthy recovery. Climate Agreement goal of keeping warming well Finally, as technological innovation advances, below 2°C, but also improve air quality to such an health care systems will increasingly be able to extent that the resulting health gains would repay procure electric and/or hydrogen fleet vehicles. the cost of the investment twice over (Markandya The purchasing power and political influence of et al. 2018).  health care can help accelerate the broader market transformation required to build economies of scale Investing in low-carbon, healthy, and equitable and make these modes of clean transportation transport systems that ensure human mobility, more universally accessible, thereby reducing the in spite of situations of crisis. Local and national global burden of disease brought on by transpor- lockdowns around the world have led to massive tation-related air pollution and climate change. transport restrictions, disrupting human mobility. Lockdown-driven transport restrictions favor Transitioning to sustainable agricultural systems people who have the privilege of owning private that also provide a steady and equitable supply vehicles, while disenfranchised poor citizens have of nutritious food to communities. The COVID-19 to rely on public transport that is insufficient. pandemic demonstrated the primacy of having a To build back better, countries and communities continuous supply of adequate food, especially in should invest in high-quality public transport times of economic precarity and limited mobility. systems, coupled with infrastructure for active Currently, global food systems are heavily reliant transport, such as walking and cycling. Next-gen- on large-scale farming, postharvest processing, eration transport systems need to ensure equitable and long-distance transport. Apart from the fact mobility, even in times of crises, brought about that the foods produced are often rich in calories, by pandemics, climate-related disasters, or other fat, and other less nutritious ingredients, they also external shocks. They should be designed to emit more carbon and contribute to ecosystem help promote physical activity to contribute to the destruction, not to mention being prone to supply reduction of obesity and other chronic noncommu- chain disruptions in times of crisis. nicable diseases. Moreover, they should rely on The post-COVID-19 recovery plans for the low- or zero-emission technology in order to help future of food should promote the redesign of bring significant improvements to air quality and agricultural systems so as to limit their impact lower the GHG emissions coming from transport. on natural resources, reduce GHG emissions, and Health care can play an important role in this maximize the provision of high-quality nutrients effort. Health facility planning and colocation, that combat hunger and undernutrition, as well with access to public transportation hubs, will as curb the growing pandemic of chronic non- also improve access to facilities for patients and communicable diseases, including obesity, health workers, while supporting cleaner patient hypertension, and diabetes. The health systems’ and staff travel (Hosking, Mudu, and Dora 2011). procurement of sustainable, locally produced Health leaders can also advocate for more food as a build-back-better strategy can also help sustainable modes of public transit and safe build more sustainable, equitable, and resilient modes of active transport, thereby contributing local agricultural economies, thereby supporting to a broader transition to clean, sustainable improved population health. By leveraging health Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 53 care demand for food in the interests of low-carbon, Nine areas have been recommended for action, sustainable agriculture, health systems can support which are listed and elaborated upon in table 3.2 — local community-based agriculture, generate food Menu of Interventions for Climate-Smart Health preparation jobs, and develop a source of healthy Care Actions for COVID-19 Response. food for their own food systems. TABLE 3.2 Menu of Interventions for Climate-Smart Health Care Actions for COVID-19 Response Climate-Smart Health Care Actions COVID-19 Health Climate Adaptation Climate Mitigation and/or Response Areas and Resilience Low-Carbon Health Care A. Public Health • Adopting the One Health approach in disease • Instituting integrated (instead of separate) Surveillance surveillance and environmental monitoring surveillance systems for health, weather, and Risk As- (including climate services for health) for the and the environment that are powered by sessment early detection of climate-sensitive infectious renewable energy diseases • Conducting energy use audits and needs • Strengthening the surveillance of climate-sen- assessments of health care facilities to sitive health impacts (for example, dengue, inform energy-efficiency measures and malaria, heat-related illnesses, air pollution-re- the availability of alternative renewable lated diseases, and nutritional deficiencies), sources using lessons from COVID-19 • Integrating the health co-benefits of mit- • Conducting integrated risk and vulnerabil- igation options into risk and vulnerability ity assessments to include pandemics and assessments climate change [for example, Vulnerability and • Adopting low-carbon and energy-efficient Adaptation (V&A) assessments, stress testing, rapid-testing and contact-tracing technol- and business continuity plans], with special ogies (such as those enabled by mobile attention to vulnerable populations phones) as well as facilities (for example, conducting testing outdoors) B. Emergency • Adopting a multihazard approach to • Establishing sustainable low-carbon Preparedness, emergency planning that covers pandemics, backup options for electricity [for example, Planning, and climate-related disasters, and other external solar photovoltaic (PV)], clean water, Rehabilitation shocks adequate food supply, and transport • Setting up coordinated governance mecha- • Adopting low-carbon and energy-effi- nisms (including community networks), service cient devices (for example, flashlights protocols, and information systems, based on and vehicles) for immediate emergency a multihazard approach to external shocks response • Training health workers and other personnel • Incorporating green sustainability prin- for deployment in times of emergency ciples in rehabilitation plans for affected • Establishing multihazard disaster financing or destroyed health facilities and other for pandemics, climate-related disasters, and infrastructure other external shocks as well as strengthening financing for key community-based organiza- tions serving high-risk communities to reach out to them 54 | COVID-19 and Climate-Smart Healthcare • Maintaining and restoring natural environments around health care facilities to support cooling and minimize flooding impacts C. Capacity • Ensuring the resilience of health facilities • Adopting low-emission energy and en- for Testing, against climate-related disasters and their ergy-efficiency measures for COVID-19 Isolation, and effects, such as electricity disruption testing, isolation, and treatment facilities, Treatment • Setting up strong referral networks and including natural lighting and ventilation contingency plans to ensure the continuity • Establishing sustainable health care waste of COVID-19 services during climate-related management in testing, isolation, and disasters treatment facilities, including waste mini- • Revitalizing national plans for human mization, segregation, safe recycling, and resources for health, as well as volunteers incineration phaseout in favor of steam- and workers from other sectors, to sustain based disinfection the COVID-19 response and prepare for cli- mate-related health risks D. Supply • Ensuring a steady supply of personal protec- • Adopting renewable energy and ener- of Essential tive equipment (PPE), mechanical ventilators, gy-efficiency measures in the manufactur- Medical Com- medicines, and other essential commodities, ing and transport of essential commodities modities including non-mercury-based thermometers, • Establishing sustainable management for waste collection bins, and bags, throughout all waste, including waste minimization the entire COVID-19 response and in prepara- and the segregation of all items, such tion for potential climate-related shocks as used PPE that includes masks and • Using energy-efficient and low-carbon me- medicine packaging chanical ventilators, as well as diagnostics, • Producing washable and reusable PPE including X-rays and microscopy, which can made out of sustainable materials still function despite electricity disruptions resulting from climate-related disasters • Adopting sustainable procurement standards for PPE, equipment, cooling devices, and medicines, including prioritiz- ing the minimization of waste production and avoiding the purchase of products with high carbon levels, high global warming potential (GWP), or high-energy consumption • Strengthening local production and supply chains to ensure the steady supply of commodi- ties while reducing transport emissions Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 55 E. Health • Strengthening non-COVID-19 public health • Promoting low-carbon and energy-effi- Services for programs, including those for climate-sensitive cient telemedicine services (along with Non-COVID diseases support for increased access to communi- Conditions • Enhancing resilience against climate-related cation device and wireless connectivity) to impacts and their effects (such as electricity ensure the continued provision of primary disruption) on health facilities that render non- care and close last-mile delivery gaps COVID-19 services • Improving the efficiency of care pathways • Strengthening health financing mechanisms to ensure health provision, reduce that ensure universal coverage to people with emissions, and save costs COVID-19 and other non-COVID-19 conditions, • Adopting low-carbon and energy-efficient including climate-sensitive diseases technologies, as well as cooling practices, • Training health workers on the detection and for health care provision treatment of climate-related diseases, while • Strengthening the capacity to manage managing COVID-19 health care waste, using environmentally • Building the mental health resilience of friendly and safe techniques health staff and volunteers while responding to multiple crises, such as pandemics and climate change F. Non- • Promoting with consistency regular hand- • Maximizing temporary improvements in Pharmaceutical washing and other personal hygiene practices air quality due to lockdowns by identify- Interventions to prevent COVID-19 and climate-related ing long-term measures for reducing air waterborne diseases pollution • Designing temporary shelters for victims of • Promoting healthy, low-carbon, and climate-related disasters to ensure the contin- COVID-compliant environments, travel, uation of physical-distancing measures and lifestyles • Creating social protection programs informed by high-risk communities that can enable them to adapt to different forms of external shocks, such as pandemics and climate-relat- ed disasters G. Public • Developing integrated, robust, and cross-sec- • Transitioning to low-carbon and ener- Health Risk toral risk-communication plans and channels gy-efficient electronic systems for public Communication that can be applied to all types of external information dissemination shocks, including pandemics and climate-re- • Incorporating health promotion messages lated disasters into COVID-19 advisories to encourage • Incorporating relevant climate change and healthy and low-carbon lifestyles, while environmental sustainability messages into surviving the pandemic COVID-19 advisories to convey links between climate change and COVID-19 • Targeting COVID-19 communication contain- ing climate-relevant information at populations vulnerable to climate-related disasters and other health effects • Raising the health, climate, and risk literacy of communities to enable them to prepare for and adapt to future external shocks and stresses 56 | COVID-19 and Climate-Smart Healthcare H. Vaccine • Increasing the capacity of the health • Setting up energy-efficient, climate-friend- Readiness, Pro- workforce for vaccine delivery for COVID-19 ly cold chain infrastructure, technology, curement, and and other climate-sensitive diseases storage, and distribution Distribution • Putting national COVID-19 vaccine plans in • Establishing vaccine manufacturing that is place to provide a template for enhancing powered by renewable energy vaccine coverage for climate-sensitive infec- • Using medical equipment and packaging tious diseases made out of sustainable and recyclable or reusable materials • Adopting fuel-efficient modes of transport to deliver vaccines to health facilities and communities • Instituting environmentally-friendly man- agement, recycling, and disposal of used syringes and other waste from immuniza- tion programs I. Building Back • Investing in essential services, such as clean • Decarbonizing of health care systems and Better water and sanitation, as well as water, san- aligning the sector with the ambition of itation, and hygiene (WASH) in health care the Paris Agreement facilities, to uplift the baseline health status of • Accelerating the shift from fossil fu- populations el-based electricity generation to clean • Investing in climate-resilient health care infra- renewable energy that is resistant to structure to build multifaceted resilience future shocks • Revitalizing the momentum toward achieving • Investing in low-carbon, healthy, and universal health coverage (UHC) to protect equitable transport systems that ensure citizens from future health shocks human mobility during crisis situations • Investing in nature-based solutions to when fuel supplies are disrupted enhance the natural environment and protect • Transitioning to sustainable agricultural communities from climate-related shocks and systems that also provide steady and future pandemics equitable supplies of nutritious food to communities Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 57 REFERENCES Berry, Peter, Paddy Enright, Joy Shumake-Guillemot, Elena Villalobos Prats, and Diarmid Campbell Lendrum. 2018. “Assessing Health Vulnerabilities and Adaptation To Climate Change: A Review of International Progress.” International Journal of Environmental Research and Public Health 15 (12): 2626. 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World Bank. 2020b. “Project Paper on a Proposed Additional Financing to the COVID-19 Strategic Preparedness and Response Program Using the Multiphase Programmatic Approach (GLOBAL COVID-19 MPA).” Washington, DC: World Bank. http://documents1.worldbank.org/curated/en/882781602861047266/pdf/World-COVID-19-Strategic-Pre- paredness-and-Response-Program-SPRP-using-the-Multiphase-Programmatic-Approach-MPA-Pro- ject-Additional-Financing.pdf. 60 | COVID-19 and Climate-Smart Healthcare Integrating Climate-Smart Health Care into COVID-19 Response and Recovery Activities | 61 62 | COVID-19 and Climate-Smart Healthcare SECTION 4. CONCLUSION T he COVID-19 pandemic has reshaped the world, magnifying gaps in the health system and exacerbating existing inequalities. Similarly, climate change, in combination with current and future global health risks, will continue to threaten the ability of health systems to protect and improve population health. Nevertheless, opportunities exist to tackle these dual crises and future challenges through innovation and coordination. Building on the unprecedented international action around COVID-19, this report has outlined a number of existing practical measures for implementing synergistic actions to enhance health system resilience to both climate change and future pandemics. These measures can help to limit health sector contributions to the climate crisis and decouple progress toward UHC from GHG emissions. This report provides MDBs and other development partners with a menu of interventions that can be employed in the planning, design, and implementation of ongoing and pipeline health sector development activities to enhance resilience to climate shocks, facilitate climate adaptation, and mitigate GHG emissions. In the case of the World Bank and other MDBs, there is an additional requirement to assess all financing for CCBs. This menu approach is, therefore, also intended to support teams in the design of health sector operations to maximize the contributions to mitigation and adaptation. This report is aligned with the principles of the joint MDB methodology for tracking climate change mitigation and adaptation finance. Further additions and modifications to the menu of interventions contained in this report will be added, as new evidence becomes available and in response to later iterations of the Climate Change Action Plan (CCAP) and the joint MDB methodology. This report has also been developed for governments and development partners, not only as a response to the emergency phase of the COVID crisis, where immediate support to health systems and the deployment of COVID vaccines is needed, but also to what will come after this. Building back better requires an integrated approach to promoting strong and durable recovery and growth by providing a greener, more inclusive, and resilient recovery from the COVID-19 crisis. Building back better requires an integrated approach to promoting strong and durable recovery and growth by providing a greener, more inclusive, and resilient recovery from the COVID-19 crisis. Conclusion | 63 Health, arguably the most affected by the COVID but also at their cost effectiveness. This is key for pandemic, is perhaps the sector that most needs policy makers to be able to evaluate activities and to consider the principles of greener and resilient prioritize appropriately in the context of scarce recovery and access to information to make the resources. right choices for the future. Each of the categories Furthermore, this report did not look specifi- in the “Integrating Climate-Smart Health Care into cally at the roles of the private versus the public COVID-19 Response and Recovery Activities” sectors. However, it is clear that many of the section of this report has relevance to these measures contemplated in this report are signifi- principles. The final category, “Build Back Better,” cantly dependent on private-sector involvements. is specifically included with this in mind. It includes Hence, exploring synergies, for example, through suggestions for investing in essential services, such the direct financing of public private partnerships as clean water and sanitation along with climate- (PPP) for some of the stipulated measures, would resilient health care infrastructure, to enhance be important to consider moving forward. resilience and raise the baseline health status of populations. The section also proposes ways The information documented in this report is for revitalizing the momentum toward achieving intended to be used by public health profes- UHC and investing in nature-based solutions to sionals, policy makers, and operational staff to protect communities from climate-related shocks support their ongoing efforts to tackle both the and future pandemics. climate and the COVID crises. The World Bank and others can use this information as the basis for This document is structured to be a reference developing materials to further facilitate support to document for both adaptation and resilience, as well countries, such as topic-specific guidance notes, as mitigation, to support the work of development workshops, and other more focused capacity- partners engaged in climate change mitigation and building resources. COVID-related activities. The material in this report is also intended to inform further iterations of the The COVID-19 crisis highlights the importance NDCs and their implementation. of long-term planning in a pandemic response. It should also be the core principle in guiding Implementing any of the suggested measures the health sector’s approach to climate change. will require us to think about how we monitor and The case studies presented in this report will evaluate the impact of these activities. Hence, demonstrate how long-term planning for climate putting robust monitoring and evaluation in place change can also enable timely and effective will be of paramount importance. Although this response to the COVID-19 crisis. Tradeoffs must be document has not gone into these two areas in carefully considered in the design and execution of detail, they need to be carefully considered at the climate-smart interventions as part of the COVID-19 design stage of any future operations and similar response and recovery efforts. Striking a balance activities by other development partners. This between the pandemic response and climate would involve identifying development indicators protection requires a high degree of innovation and and other metrics, including, where feasible, those collaboration across sectors. Ultimately, incorpo- that do not look just at the efficacy of interventions, rating climate considerations into COVID-19 health 64 | COVID-19 and Climate-Smart Healthcare emergency response and recovery activities can Striking a balance between be a win-win outcome through the establishment a pandemic response and of a legacy of health systems that are pandemic ready and climate smart. climate action requires a high degree of innovation and collaboration across sectors. Ultimately, incorporating climate considerations into COVID-19 health emergency response and recovery activities can be a win-win outcome through the establishment of a legacy of health systems that are pandemic ready and climate smart. Conclusion | 65 OCTOBER 2021 CLIMATE CLIMATE INVESTMENT INVESTMENT FUNDS FUNDS 66 | COVID-19 and Climate-Smart Healthcare