Climate-Smart Healthcare Low-Carbon and Resilience Strategies for the Health Sector Investing in Climate Change and Health Series Climate-Smart Healthcare Low-Carbon and Resilience Strategies for the Health Sector © 2017 International Bank for Reconstruction and Development/The World Bank  The World Bank  1818 H St. NW  Washington, DC 20433  Telephone: 202-473-1000  Internet: www.worldbank.org  The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the governments they represent.  The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries.  Rights and Permissions  The material in this work is subject to copyright. Because the World Bank encourages dissemination of their knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H St. NW, Washington, DC 20433, USA; fax: 202-522-2422; email: pubrights@worldbank.org. Cover credit: Iwan Baan, aerial photo of the Butaro District Hospital. This document is part of the “Investing in climate change and health” series, which aims to enable management and task teams with the tools and resources necessary to improve development action on climate change and health. Current documents in this series include: • “World Bank approach and action plan for climate change and health” (2017) • “Geographic hotspots for World Bank action on climate change and health” (2017) • “Climate smart healthcare: low carbon and resilience strategies for the health sector” (2017)  Acknowledgments This report is a joint production of the World Bank Group (WBG) Health Nutrition and Population Global Practice, (WBG) Climate Change Cross-Cutting Solutions Area, Health Care Without Harm (HCWH), and Mobilizing Action Toward Climate Change and Health (MATCCH). Timothy Bouley led the work, with key advice and input from Montserrat Meiro-Lorenzo, Patrick Osewe, and Tamer Rabie. Contributing, main authors include Sonia Roschnik, Josh Karliner, Susan Wilburn, Scott Slotterback, Robin Guenther, and Peter Orris of HCWH and Toby Kasper, Barbara Platzer, and Kris Torgeson of MATCCH. The Nordic Development Fund (NDF) provided resources, and the team is indebted to the goodwill and support of the NDF team, particularly Pasi Hellman, Martina Jagerhorn, and Leena Klossner. The concept and impetus for this work originated at a meeting of the Prince of Wales’ Charity Foundation’s International Sustainability Unit, convened by HRH The Prince of Wales and with support from Justin Mundy, Eric Chivian, Andy Haines, Hugh Montgomery, and Laura Partridge. Overall guidance within the World Bank was provided by John Roome, Timothy Evans, James Close, Olusoji Adeyi, and Stephen Hammer. Important contributions were also made by Laura Bonzanigo, Paula Caballero, Shun Chonabayashi, Diarmid Campbell-Lendrum (World Health Organization), Mike Depledge (University of Exeter), Paula Garcia, Valerie Hickey, Marina Maiero (World Health Organization), and Nick Watts (Lancet). Peer review was performed by Martina Bosi, Ana Bucher, Kris Ebi (University of Washington), Laurent Granier, Joy Guillemot (World Health Organization/World Meteorological Organization), Gary Kleiman, Catherine Machalaba (Ecohealth Alliance), Ommid Saberi, and Richard Seifman. Damian Milverton of GlobalEditor.org performed the final edit and review. Formatting and graphic development were undertaken by Shepherd Incorporated. iii How to use this document This report was designed to be a flexible tool, to be read through or in parts. Certain sections (e.g., those in the first section) may be more relevant to the preparation of background sections or policy documents, given their emphasis on climate change and health links. Other sections provide approaches and tools that can be directly extracted and built into projects and programs. These are primarily located in chapters two and three. More than 20 case studies* appear throughout to illustrate the practical value in connecting climate change and health. Intended audience This document is primarily directed to development staff working on health sector and health system projects and programs. However, much of the content may be useful to staff working on related issues in environment and natural resources, water, energy, transport, urban, or others. As a cross-cutting discipline, climate change and health issues are germane to projects in many disciplines. Though some of the language in this document is topical to WBG policies and procedures (e.g., “task team leaders,” “global practices”), the document has value beyond this institution as other development banks, bilateral aid agencies, and communities are tackling common issues. Tools and approaches here can be applied in many of these contexts. Policy makers and managers likely will find this document useful as it provides strong context for climate change impacts and opportunities within the health sector that may inform higher-level dialogue and decision making. Operational teams should find value in the specific tools and approaches here that can be integrated within development lending programs. The many examples should also provide useful context for all readers. More succinct operational guidance will be produced after publication of this document to provide tools useful for those involved in direct lending. This more robust document was produced as a necessary first step to contex- tualize this climate change and health work and consolidate background, mitigation, and adaptation resources in a single resource. *Case studies Case studies have been categorized and color-coded by region. Middle East Africa and North Africa East Asia and Pacific South Asia Latin America Global/Other and Caribbean iv Contents Foreword vii Acronyms ix Executive Summary xi Operations Toolbox xv The Imperative, Context, and Rationale for Development Community 1.  Engagement 1 Connecting Health and Climate Change 1 Health Sector Contribution to GHG Emissions 2 Mitigation: Relevance of Healthcare to Low-Carbon Development 3 Health System Resilience in the Face of Climate Change 5 Rationale for Development Community Engagement through the Model of the World Bank 8 Development Community Role Promoting Climate-Smart, Low-Carbon 2.  Healthcare Solutions 9 Existing Initiatives 9 Relevance to Health Sector Strategy through the Lens of the WBG HNP Global Practice 12 Integration into WBG Project Preparation and Scoping 13 Projects and Interventions within the WBG 13 Low-Carbon Healthcare Interventions 15 Infrastructure Development 15 Operational Delivery of Healthcare Functions 19 Service Delivery and Models of Care 25 Financial Considerations 25 Development Community Role Promoting Climate-Smart Resilience 3.  in Healthcare 29 Diagnostic Tools That Can Help Assess the Impact of Climate on Health 29 Global Resources and Tools to Assess the Impact of Climate on Health 30 National Sources of Climate Information for Health Decision Making 31 Climate Change and Health Approaches, Interventions Viable for Health Sector Finance 32 Health System Responses to Build Resilience, Adapt to Climate Change 32 Making Approaches to Investing in Health Systems Climate Resilient 33 v c l im ate- s mar t he a lt hca r e Potential Areas for Development Investment in Resilience and Adaptive Capacity 36 Early Warning Systems 37 Potential Programmatic Responses to Climate Change 38 4. Policy and Partnership 41 The Climate Perspective in Ongoing Health Policy Dialogue 41 Engagement with Governments and Other Stakeholders 42 Participation of Health-Focused Development Staff in Broader Climate Policy Fora 42 Potential Partners for Health and Climate Projects 43 5. Conclusion 45 Appendix 1. Climate Change Glossary 47 Carbon Emission Hotspots Across the Health Sector Annex 1A.  in England by Setting 49 U.S. Healthcare GHG Emissions Annex 1B.  51 Environmental/Health Impacts of U.S. Healthcare Activities Annex 1C.  53 Annex 2. Community Health and Safety Safeguard 55 References 57 vi Foreword Climate change is a risk multiplier that threatens to unravel decades of development gains. Among the most critical and direct risks to humans is the impact of climate change on health. Heat stress will worsen as high temperatures become more common and water scarcity increases; malnutrition, particularly in children, could become more prevalent in some parts of the world where droughts are expected to become more frequent; and water- and vector-borne diseases are likely to expand in range as conditions favor mos- quitoes, flies, and water-borne pathogens. Worse still, these threats will be greatest in regions where the population is most dense, most vulnerable, and least equipped to adapt, pushing more people in poverty and reinforcing a cycle of environmental degradation, poor health and slow development. Addressing these climate-associated health risks is critical. Alongside risk, there is opportunity. Responses to climate change have unearthed significant potential for improving both human health and the environ- ment. Low carbon hospitals can draw upon the many advances made by the energy sector in developing cleaner and renewable resources. Pharmaceutical supply chains can benefit from more efficient and less polluting transport. And food and nutrition can be improved by the advances achieved through climate- smart agriculture. Climate change challenges are multi-sectoral and so too are the solutions. At the World Bank Group, we are tackling different dimensions of these environment and health threats in different ways. For example, the ‘Pollution Management and Environmental Health’ Trust Fund addresses air pollution, toxic land pol- lution, and marine litter. Work on Climate-Smart Agriculture aims to sustainably increase food productivity and human well-being in a changing climate. We are putting in place a new operational framework for strengthening human, animal, and environmental health systems in response to disease threats. And within the health sector, we have made Universal Health Coverage core and increasingly considerate of climate change and resilience. At the World Bank Group, we work with the broader development community to create solutions that can respond to and reduce these risks. Our work aligns with other global efforts aimed at improving envi- ronmental and human health, such as the work of the Climate and Clean Air Coalition, Global Alliance for Clean Cookstoves, One Health and Planetary Health communities, and broader efforts to achieve the Sustainable Development Goals. vii c l im ate- s mar t he a lt hca r e In this report we identify climate and health challenges to establish a basis for health sector action and solutions. The health sec- tor has a substantial role to play in both mitigating climate change through the adoption of low-carbon strategies, while also building resilience to climate impact in ways that plan for environmental change and expanded health threats. Taken together, these efforts comprise a “climate-smart” approach that will help health planners and decision-makers adjust to a new era of climate reality while improving health, environment, and development. The work presented here is expected to assist the development community in further mainstreaming climate change and health into development operations so that we may address the emerging needs of vulnerable communities, particularly women and children. We are committed to working with development practitioners around the world on climate change and health, capitalizing upon associ- ated opportunities and technologies, and contributing to the overall goals of ending extreme poverty and boosting shared prosperity. James Close Olusoji Adeyi Director Director Climate Change Group Health, Nutrition, and Population World Bank World Bank viii Acronyms AIDS Acquired Immune Deficiency MATCCH Mobilizing Action Toward Climate syndrome Change and Health BEM Building Energy Management MDR-TB Multi Drug Resistant Tuberculosis BREEAM British Research Establishment NDGAIN Notre Dame Global Adaptation Ltd—Environmental Assessment Initiative Method NHS National Health Service (UK) CCSA Cross-cutting solutions area N2O Nitrous Oxide CFL Compact Fluorescent Lightbulb PAHO Pan American Health Organization CO2 Carbon Dioxide QALY Quality Adjusted Life Year CO2e Carbon Dioxide equivalent SE4ALL Sustainable Energy for All CPF Country Partnership Framework SDG Sustainable Development Goal EDGE Excellence in Design for Greater SMART Specific, Measurable, Achievable, Efficiencies Relevant, Time-bound GAVI Global Alliance for Vaccines and tCO2 Tons of Carbon Dioxide Immunizations UNEP United Nations Environment GDP Gross Domestic Product Program GHG Greenhouse Gases UNFPA United Nations Population Fund GP Global Practice (previously UN Fund for Population HCWH Health Care Without Harm Activities) HFC Hydrofluorocarbon UNHCR United Nations High Commissioner HIV Human Immunodeficiency Virus for Refugees HNP Health, Nutrition and Population UNICEF United Nations Children’s (World Bank Global Practice) Emergency Fund HVAC Heating, Ventilation, & Air UNITAID Not an acronym, this is a global Conditioning health initiative, hosted by WHO to IPCC Intergovernmental Panel on Climate tackle deficiencies in management Change of HIV/AIDS, Tuberculosis and kBTU/sf/yr Kilo (x1000) British Thermal Unit Malaria per Square Foot per Year UNOPS United Nations Office for Project LED Light Emitting Diode Services LEED Leadership in Energy & USAID United States Agency for Environmental Design International Development MAC Marginal Abatement Curve WHO World Health Organization ix Executive Summary Climate Change Affects Health Climate change is damaging human health now and is projected to have a greater impact in the future. Low- and middle-income countries are seeing the worst effects as they are most vulnerable to climate shifts and least able to adapt given weak health systems and poor infrastructure. The cumulative threats of climate change to health has been extensively discussed for decades and understanding is growing, but so too are the impacts. Climate change could drag more than 100 million people back into extreme poverty by 2030 (World Bank, 2016), with much of this reversal attributable to negative impacts on health. There is clear and mounting evidence that health outcomes will predominantly be negatively affected by rising sea levels and temperatures, different patterns of precipitation, and more frequent extreme weather. Several of the emissions that drive climate change also affect health directly, resulting in respiratory and cardio- vascular disease. An effective response to these new challenges will necessarily require engagement and coordina- tion across many sectors. Chief among these is, of course, health. Hospitals, health centers and public health workers are first responders to the health effects of climate change. Health systems need to be resilient and remain operational to provide care during extreme weather events. They must also respond to the longer-term, climate-induced changes in disease patterns. While vastly differing in scale, each nation’s health sector also releases greenhouse gases while delivering care and procuring products and technologies from a carbon-intensive supply chain. An Opportunity for Low-Carbon Healthcare Solutions Middle- and low-income countries increasing their investment in more robust health systems can seize the opportunity to support technology and management systems that are less expensive, more produc- tive, and less carbon intensive. A low-carbon approach can provide effective, cheaper care while at the same time being ‘climate smart’. Low-carbon healthcare can advance institutional strategies toward low-carbon development and health-strengthening imperatives and inspire other development institutions and investors working in this space. Low-carbon healthcare provides an approach for designing, building, operating, and investing in health systems and facilities that generate minimal amounts of greenhouse gases. It puts health systems on a climate-smart development path, aligning health development and delivery with global climate goals. This approach saves money by reducing energy and resource costs. It can improve the qual- ity of care in a diversity of settings. Low-carbon healthcare strengthens health systems by increasing facilities’ resilience to extreme weather events and other disasters, while also promoting approaches xi c l im ate- s mar t he a lt hca r e to adaptation. In low-resource, energy-poor settings, powering safe water use, safe waste disposal, and the purchase of locally healthcare with low-carbon solutions can enhance access to care, and sustainably produced food, wherever possible. contributing to institutional goals. At the WBG, this is particularly Development institutions can also advocate that industries important for the advancement of universal healthcare for the in the healthcare supply chain develop low-carbon and environ- poor and most vulnerable. mentally sustainable manufacturing and distribution practices. By prompting ministries of health to tackle climate change Key elements of low-carbon healthcare include: mitigation and foster low-carbon healthcare, the development • Health system design and models of care based on appropriate community can help governments strengthen local capacity and technology, coordinated care, emphasis on local providers, support better community health. It can foster discussions that and driven by public health needs can help remove barriers in the system and generate further • Building design and construction based on low carbon approaches momentum across the sector by, among other things, tackling the lack of financial incentives for healthcare to deploy renewable • Investment programs in renewable energy and energy efficiency energy and revising the requirements for diesel backup electrical • Waste minimization and sustainable healthcare waste generation to allow alternatives. Additionally, development advice management should encourage opportunities for natural ventilation and natural • Sustainable transport and water consumption policies lighting at health facilities and incentivize low-carbon innovations. • Low-carbon procurement policies for pharmaceuticals, medical devices, food, and other products Supporting Resilient and Adaptive Health Systems • Resilience strategies to withstand extreme weather events Such low-carbon approaches within a healthcare framework Building resilience to the health impacts of climate change is promise several co-benefits, including improved health through a largely about risk reduction. It is widely understood and accepted reduction in environmental pollution and climate change, as well that climate change will have broad impacts on human health and as more efficient, less costly health systems. Tailoring technology that it will be the poorest and most vulnerable that feel its full and models of care to the environment and disease burdens can force. Though it may not be possible to diminish this risk of health further slow the rising burden of health-related expenses, and impact to zero, the world can take steps to predict and prevent low-carbon healthcare can also stimulate and strengthen local impacts, and build resilient health systems that will be sturdy in economies. the face of future threats; whether be that pandemic outbreak, A few health systems are already implementing low-carbon economic collapse, or global environmental change. healthcare strategies in low- and middle-income settings in every Health risks from climate change vary in both nature and WBG region, providing a growing wealth of experience and type of climate risk that precipitates them. So far, there has been information. considerable discussion of the types of potential health impact, including infectious disease, undernutrition, and heat stress. Aligning Development Institution Just as important, however, are the magnitude and pattern of Strengths to Deliver on the Promise risks from climate change, stemming from: the characteristics of the hazards created by changing weather patterns; the extent of of Low-Carbon Healthcare exposure of human and natural systems to the hazard; the sus- Given extensive experience and resources across both the health ceptibility of those systems to harm; and their ability to cope with and climate areas, development institutions often have tools to and recover from exposure. To establish truly resilient systems, work with a range of actors to find innovative solutions in all each of these components should be considered singly. Such an aspects of climate mitigation, low-carbon development, and health approach would establish starting points for efficient and effective sector strengthening. resilience strategies and adaptation, like community vulnerability, Specifically, development institutions can aim to encourage a health system’s capacity before, during and after exposure to health ministries to develop a carbon baseline for their sector, a hazard, or the hazards created by a changing climate. Each of identify carbon reduction targets where appropriate, and foster these categories highlights important areas for planning around low-carbon health sector development. They can call for the intro- adaptation and resilience. Climate change represents too broad a duction of low-carbon or carbon reducing, health-focused invest- perspective, and a focus solely on this aspect makes assumptions ment initiatives and catalyze health sector investment in renewable about the roles of vulnerability and exposure that could prevent energy, energy efficiency, local transport systems, sustainable and effective action. xii E x e cu ti v e S u mma ry To achieve rapid, yet long-term solutions to climate change, adaptive capacity in projects. Some of them are specific to health development institutions can build climate-sensitive health sys- impact, some to climate hazard, and some to both. Nevertheless, tem resilience through investment in two areas: Health system there is a menu of options from which to select to improve health strengthening to improve resilience and build capacity to prepare sector resilience, including: for the varied environmental impacts and health impacts caused Early warning systems. These comprise interventions leverag- by climate change; and programmatic (e.g., disease-specific) ing climate information to improve health outcomes that shift the responses to address the changing burden of disease related to focus from surveillance and response to prediction, preparedness, climate change. and prevention. They can address specific disease burdens, specific The ultimate success of the development work on climate change hazards or multi-hazard frameworks, and specific lead times. and health will hinge upon integrating climate as a transversal ele- Disaster preparedness systems. These have broad use well ment into routine work, informing and shaping components that beyond climate and health impacts, although they can be critical are not specific to climate change and health, including investments tools for discrete hazards associated health impacts, such as in in infrastructure and human resources. Climate change increases times of extreme heat, flooding, or other natural disasters. uncertainty across domains that influence both the supply of, and Disease-specific responses. Many diseases, such as malaria, the demand for, health services, and this unpredictability demands dengue, waterborne diseases and others, have specific programs that development operations are sufficiently flexible from the outset. and adjustments to these programs to include a climate response WBG operations, and health systems strengthening in general and can have significant impact. should focus on opportunities that align with comparative advan- Nutrition-focused responses. Climate change has significant tage. For example, adding climate-smart dimensions to ongoing effects on both the quantity and quality of food production; projects or by raising the profile of climate-smart healthcare through connecting climate and nutrition and highlighting multi-sector higher-level policy dialogue with other international and national responses to nutrition challenges can enhance project impact and level actors. Lending for health, nutrition and population projects expand the circle of relevant stakeholders. at the WBG has increasingly shifted from input-based financing (through investment project financing) to results-based financing Naming a New Approach: Climate-Smart (either through the Programs for Results or through investment Healthcare financing tied to the results at the facility level), but the WBG still makes considerable investments in key health systems inputs. Areas As hospitals and health systems explore opportunities for low most relevant for adaptation to climate change are infrastructure carbon healthcare, they are finding significant overlap between and supply chains and human resources for health. mitigation or “sustainability” measures and climate change resil- A generalized risk of new hazards is insufficient for planning ience interventions. Working on only one side of this equation purposes, as not all areas are equally at risk, even within one sometimes makes sense, other times it does not. Nevertheless, country. This means that before major investments are made, there is value in establishing a collective term that includes both potential climatic shifts at the local level and the impact on fre- of these dimensions. Building upon the example of how globally quency, intensity and duration of extreme weather events should recognized and significant climate-smart agriculture is, we shall be assessed and factored into facility design. Secondly, responsible refer to low carbon and resilient healthcare as simply climate-smart resilience planning must consider the location of new facilities, healthcare—enabling a new, user-friendly way of describing this requiring exploration of existing catchment areas (and occasionally, critical and much needed work. disease profiles) that factor in climate projections or demographic projections based on current populations and trends in fertility Approaches through Policy and disease. Thirdly, redundancy is critical in supply chains as it and Partnership enables service provision to continue unabated in the event of an extreme event that might render part of a health system inoperable. Development institutions can take several steps during operational Climate change and associated hazards also affect demand and higher-level international dialogue to integrate climate-smart for health services, both by increasing (and occasionally decreas- healthcare into their strategies and policies, thereby influencing the ing) the burden of disease, and by influencing the movement of path of healthcare development in low- and middle-income countries: people. This means that the need for both general health staff and specialized expertise will shift, and if that is not properly factored • Support and fund health systems and sector actors to adopt into planning efforts, health outcomes will suffer. key elements of climate-smart healthcare There are several tools and approaches that can be integrated • Integrate climate-smart healthcare into current health sector into development projects to increase resilience and improve strategies for universal healthcare coverage xiii c l im ate- s mar t he a lt hca r e • Provide a blueprint for low-cost, health-promoting systems forefront of the fight against climate impacts, preventing and that reduce the burden of disease, mitigate greenhouse gas responding to human casualties caused by the changing envi- emissions and local pollution, and adapt new demands of ronment. Climate mitigation, adaptation, and low-carbon and efficiency and quality as well as to a changing climate resilient health development strategies reduce emissions, build healthcare climate resilience, and provide significant health and • Provide a blueprint for resilient systems that address both economic co-benefits. Climate-smart healthcare will strengthen infrastructure-specific and disease-specific climate impacts health sectors and communities by ensuring access to clean and • Encourage the integration of low-carbon and resilience prin- independent energy, safe water, clean transport, and clean waste ciples to measurement, planning, communication, investment, disposal mechanisms. It will stimulate the development and sup- implementation, monitoring, and evaluation ply of sustainable products, while also preparing the sector for a future of known and unknown health-related climate hazards. Conclusion The health sector contributes significant emissions worldwide through the energy and transport it relies on as well as the prod- ucts that it manufactures, uses, and disposes of. It is also at the xiv Operations Toolbox Provided below is a quick reference guide for teams that may have interests in discrete aspects of climate-smart healthcare. Tools for building low carbon healthcare: • Project phase correlated interventions (p. 13) • Carbon diagnostics (p. 14) • Low-carbon infrastructure development (p. 15) • Sustainable energy for healthcare (p. 19) • Low-carbon waste management strategies for healthcare (p. 21) • Low-carbon anesthetic gases (p. 21) • Sustainable water use in healthcare (p. 22) • Low-carbon transport and travel in healthcare (p. 23) • Low-carbon food in healthcare (p. 23) • Low-carbon procurement and supply chain (p. 24) • Low-carbon pharmaceuticals (p. 24) • Low-carbon health service delivery (p. 25) • Calculating return on and financial case low-carbon investment (p. 25) Tools for addressing climate-related health impacts: • Climate specific health system strengthening mechanisms (p. 34) • Alterations to infrastructure and supply chains (p. 34) • Resilient building designs (p. 35) • Human resource interventions (p. 36) • Early warning systems (p. 37) • Disaster preparedness systems (p. 38) • Protocols for climate-sensitive disease treatment (p. 38) xv c l im ate- s mar t he a lt hca r e Starting points for country specific climate information and • Consult climate change mitigation and adaptation specialists climate-health information: throughout health sector project design and implementation, as well as experts specialized in climate change and health • National Adaptation Plans at WHO, WMO, and other academic, civil society, and inter- (http://unfccc.int/adaptation/workstreams/national_ governmental institutions. adaptation_plans/items/6057.php) • Consult with specialists in related disciplines: energy, transport, • Nationally Determined Contributions urban, disaster management, risk management, etc.; low carbon (http://unfccc.int/focus/indc_portal/items/8766.php) and resilience thinking is sometimes more mainstreamed in (http://inde.worldbank.org) these sectors and experts here may have valuable and progres- • WHO Climate and Health country profiles sive insight relevant to health sector projects. (http://www.who.int/globalchange/resources/countries/en/) • Employ climate-smart healthcare tools and strategies to educate • Climate Change Knowledge Portal other health specialists and policy makers about the value of (http://sdwebx.worldbank.org/climateportal/) low-carbon and resilient healthcare, both in terms of dollars Programmatic recommendations for Task Teams: and human lives saved. • Consider low-carbon opportunities during project prepara- The Global Framework for Addressing Climate Change, Health, tion phase. and Sustainable Development Goal 13 of the UN’s Sustainable Development Goals1 (SDGs) • Consider climate change and health impacts during project calls for urgent action to combat climate change and its impacts. preparation phase, particularly at the national and subnational Additionally, other SDGs also support climate mitigation, adapta- level. tion, and resilience, specifically: SDG 3 (health and well-being), • Identify clear starting points and baselines for low-carbon SDG 7 (sustainable energy), SDG 12 (sustainable production and healthcare. This might include calculating the carbon foot- consumption), and SDG 15 (life on land/terrestrial ecosystems). print, running other carbon diagnostics (p. 14), and assessing Each are linked and progress in any one of these areas can lead capacity in community, country, and region. to collective achievement toward broader development goals. • Identify clear starting points and baselines for resilient and adap- The World Health Organization identifies climate change as a tive healthcare. This might include: assessing the vulnerability global threat2 increasing the likelihood of outbreaks of cholera and of a community and conducting climate health assessments to dengue, disruptions in food security, the ill health linked to indoor (i) determine capacity of health systems to prepare for, cope and outdoor pollution, and the need for emergency assistance with, respond to, and recover from exposure to hazards and following extreme weather events. These effects directly threaten (ii) understand climate-related hazards (p. 29). the World Bank Group’s (WBG) twin goals of ending extreme poverty and promoting shared prosperity. WBG’s commitment to • Explore financial dimensions and cost savings of low-carbon tackle climate change facilitates these goals and promotes human and resilient healthcare (p. 25). health and well-being. • Ensure low-carbon and resilient approaches are integrated throughout project design and implementation using proven tools and techniques. • Draw on, replicate, and adapt existing initiatives and approaches in low-carbon and resilient healthcare (examples in colored boxes throughout report). xvi Chapter 1 The Imperative, Context, and Rationale for Development Community Engagement Connecting Health and Climate Change Climate change is impacting people’s health now will continue to do so in the future if the root causes and effects are not rapidly addressed. Extreme heat, rising sea levels, changes in precipitation result- ing in flooding and droughts, intense hurricanes, migrating disease vectors, and degraded air quality, directly and indirectly affect our physical, social, and psychological health.3 The Intergovernmental Panel on Climate Change (IPCC)4 has described the types of impacts that climate change may have on human health outcomes globally, including: • A risk of mortality and morbidity from an increase in the frequency or intensity of heatwaves, principally in older age groups and among the urban poor • Increased risks of infectious disease, particularly in low-income countries following extreme weather patterns, flooding, and displacement • An increase in vector-borne infections, particularly in populations at the margins of the current distribution of diseases • An increase in the number of undernourished people in low-income countries, following more vulnerable food supplies in drought or flooding conditions • Increases in morbidity and mortality following exposure to ozone and other air pollutants • In some settings, the impacts of climate change may cause social disruption, economic decline, and displacement of populations. The health impacts associated with such socioeconomic dislocation and population displacement are substantial. Many of the impacts of climate change and its drivers are preventable through a range of proven interventions (for both adaptation and mitigation) that can reduce emissions or increase resilience. According to the IPCC, there is substantial potential to reduce climate impacts on health across eight dimensions5 by shifting to higher levels of adaptation than those currently proposed. Whether in infec- tious disease, heat waves, or natural disasters, history has shown that preparedness and response to threats can greatly limit the losses to health, human life and economies. For example, in 1970 a Category 3 hurricane battered East Pakistan (present day Bangladesh) result- ing in 500,000 deaths. Similar storms hit Bangladesh again in 1991 and 2007, causing 140,000 and 3,400 deaths, respectively. Collaborative adaptation over the intervening decades led to these dramatic reductions in lives lost (Smith et al., 2014) by increasing Bangladesh’s resilience to natural disasters. The country shifted to a higher level of adaptation that included improving general disaster education (greatly assisted by rising literacy rates, especially among women), deployment of early warning systems (which included community mobilization), building a network of cyclone shelters, relocation efforts, and increasing connectivity of health facilities in high-risk areas. 1 c l im ate- s mar t he a lt hca r e Figure 1.1: Exposure pathways by which climate change affects health. Mediating factors Environmental Social infrastructure Public health capability conditions and adaptation Direct exposures • Geography • Warning systems • Baseline weather • Flood damage • Socioeconomic • Soil/dust • Storm vulnerability status • Vegetation • Heat stress • Health and nutrition • Baseline air/water status quality • Primary healthcare CLIMATE CHANGE Indirect exposures HEALTH IMPACTS Mediated through natural • Precipitation systems: • Undernutrition • Heat • Allergens • Drowning • Floods • Disease vectors • Heart disease • Storms • Increased water/air • Malaria pollution Via economic and social disruption • Food production/ distribution • Mental stress Source: Smith et al., 2014. Mitigation, in addition to delivering long-term health effects mortality while simultaneously damaging health infrastructure.7 by reducing the levels of greenhouse gas (GHG) emissions, can Conversely, more widespread adoption of UHC can fight climate also have an immediate impact on health outcomes due to lower change impacts in ways outlined briefly in Box 1. pollution levels. A significant proportion of morbidities (illnesses) It is important to recognize that the picture is not entirely and mortalities can be avoided with stringent climate mitigation, bleak. As a recent Lancet Commission noted, tackling climate given air pollution’s role as a co-emitted byproduct of fossil-fuel change could be the greatest global health opportunity of the combustion. Additional health impacts are also avoidable through 21st century:8 “When climate change is framed as a health issue, mitigation of black carbon and methane, the so-called short-lived rather than purely as an environmental, economic, or technological climate pollutants or SLCPs (Rogelj et al., 2014). challenge, it becomes clear that we are facing a predicament that Only 15 percent of countries that have developed plans for strikes at the heart of humanity. Health puts a human face on what climate change refer to health,6 and few countries have developed can sometimes seem to be a distant threat. By making the case comprehensive multi-sector impact assessments. The World Health for climate change as a health issue, we hope that the crisis we Organization (WHO) is developing national climate change and face will achieve greater public resonance. Public concerns about health impact assessments to supplement current global knowl- the health effects of climate change, such as undernutrition and edge with information about regional and local vulnerabilities. food insecurity, have the potential to accelerate political action in Climate change may undermine growth prospects and impose ways that attention to carbon dioxide emissions alone do not.”9 significant economic costs in several client countries. It will also hamper the path to universal health coverage (UHC) both by Health Sector Contribution putting additional long-term stresses on health systems (e.g., to GHG Emissions through increased and altered patterns of disease transmission, increased direct effects such as heatstroke, reduced food produc- The health sector contributes emissions worldwide through energy tion, population shifts) and by increasing the risk of extreme events use, transport, and products manufactured, used and disposed (e.g., floods, cyclones, heat waves) that can cause morbidity and of. Unfortunately, few countries have undertaken comprehensive 2 T h e I mp erat i v e , C ont e xt, and Rati o nal e fo r De v e lo pm e nt C o mmu ni ty Enga g e m e nt would rank thirteenth in the world for GHG emissions, ahead of Box 1: Efforts to Achieve UHC Can the entire U.K.12 Also Address Health and Climate In the European region, WHO reports that: “Healthcare pro- through . . . vision accounts for approximately 10 percent of gross domestic product (GDP) in the WHO European Region. Health services in Short term: some developed countries are responsible for between 5 percent • Diminished disease burdens in populations sensitive to climate and 15 percent of carbon emissions.”13 impacts through greater efforts in prevention, education, and There is little information on the carbon footprint of the health community health influence sector in developing countries. The health sector in these nations • Earlier identification of health threats worsened by climate change is also frequently considerably less capital-intensive and studies and reduction of associated morbidities, e.g., respiratory and are needed to accurately quantify healthcare’s global contribution cardiovascular diseases to climate change. However, it could be conservatively extrapo- • More effective and immediate treatment of morbidity associated lated, based on European and U.S. figures, that health systems in with heat stress or extreme weather impacts low- and middle-income countries may contribute to between 3 • Better access to antibiotics, antiparasitic and antiviral drugs that and 5 percent of their countries’ greenhouse gas emissions (see can be used in acute outbreaks of vector-borne or waterborne diseases worsened by climate change Table 1.1 for examples). Averaging this with the higher-consuming • Decreased morbidity from undernutrition or nutrient-deficiency developed nations, it is also possible to estimate that the health associated diseases sector contributes, on average, 5 percent of all greenhouse gas emissions globally. Based on this figure, it could be conservatively Long term: estimated that the healthcare sector generated 2.6 billion out of • Reduced overall climate vulnerability by improving access to and the 52 billion metric tons of CO2e emitted globally in 2011.14 quality of healthcare • Diminished climate-sensitive disease burdens through cumulative Mitigation: Relevance of Healthcare protection measures against certain transmissible diseases • Diminished impact of mental health issues that could be wors- to Low-Carbon Development ened by climate impacts, including displacement • Improved labor productivity and better financial returns that As nations and international institutions move toward low-carbon would otherwise be lost from climate-sensitive health impacts and low-emissions development strategies,15, 16, 17 the health sector • Improved childhood development and social outcomes from bet- must also participate in this transition. ter nutrition and avoidance of stunting and impaired neurological The Action Agenda from the WHO’s Second Global Conference development on Health and Climate in July 2016 helped define what such a transition might look like when it called on the health sector to, “lead by example, advancing models of low-carbon healthcare that improve access to healthcare services, reduce occupational healthcare carbon footprint measurements. One of the best examples and environmental health risks and save energy costs across is the United Kingdom where researchers at the U.K. National high-, middle-, and low-income settings. This includes scaling Health Service found the healthcare sector carbon footprint in up energy access for health facilities in low- and middle-income England to be 26.6 million tons of carbon dioxide equivalent countries via renewable and other clean energy sources, reducing (MtCO2e) in 2015, representing 39 percent of England’s public carbon emissions associated with healthcare in large facilities in sector emissions.10 high- and middle-income countries, and implementing sustainable, In the United States, a study based on 2007 figures found that low-carbon procurement, energy efficiency, transportation, and 8 percent of all emissions are healthcare related, of which about healthcare waste management policies in all settings.” half are generated by the provision of care, and the remainder Development institution investment in this approach can help from manufacturing healthcare products and equipment.11 A more catalyze the transition to low-carbon healthcare by focusing in recent study found that in 2013 U.S. healthcare emissions had several key areas: reached 9.8 percent of the national total, or 655 million metric 1. Carbon footprint reduction: While significant differences tons of carbon dioxide equivalents (see Annex 1A for a breakdown exist, every country has a health sector that provides care in similar by national health expenditure category over the last decade, ways, with comparable relations between caregivers and patients. Annex 1B for US GHG emissions, and Annex 1C for a chart of Health expenditures also comprise a significant portion of GDP other environmental health impacts from healthcare). If the U.S. in most national economies.18 Consequently, while differing in healthcare sector were itself a country, the study points out, it 3 c l im ate- s mar t he a lt hca r e scale, each nation’s health sector releases greenhouse gases while 34 and 56 coal fired power plants, or installing between 29,000 delivering care and by procuring products and technologies from and 49,000 wind turbines.19 a carbon-intensive supply chain. 2. Low-carbon development strategies for healthcare sys- While further study is necessary to quantify more compre- tems: Just as important as reducing healthcare’s contribution to hensively healthcare’s contribution to climate change, there is no climate change is the need to foster ‘climate-smart’ development doubt that health systems in many countries contribute significant as middle- and low-income countries seek to invest in more robust greenhouse gas emissions. This opens the door for health systems healthcare systems. The imperative and opportunity exists to invest in every country to become leaders in contributing to the solution in and build these systems based on principles of low-carbon by forging a new model of low-carbon healthcare. healthcare outlined in this paper. As the numerous examples below For instance, if Argentina, Brazil, China, India, Nepal, the suggest, low-carbon healthcare can be economically beneficial Philippines, and South Africa reduced their existing healthcare emis- while improving health outcomes and protecting public health sions by 25 percent, they could take between 116 and 194 million from climate change through emission reductions. Low-carbon metric tons of CO2e out of the atmosphere every year. This would healthcare strategies can also improve health system resilience be the equivalent of removing between 24 million and 41 million and performance, supporting adaptation to climate change through passenger vehicles from the road, or decommissioning between design and operational innovations. Table 1.1: Estimated emissions from selected developing countries’ healthcare systems. Health sector Emissions Low Health sector Emissions High Country Total GHG Emissions20 Estimate (3% of total) Estimate (5% of total) Argentina 372,873,000 11,186,190 18,643,650 Brazil 2,953,040,000 88,591,200 147,652,000 China 12,064,260,000 361,927,800 603,213,000 India 2,828,845,000 84,865,350 141,442,250 Nepal 33,160,000 994,800 1,658,000 Philippines 163,797,000 4,913,910 8,189,850 South Africa 451,483,000 13,544,490 22,574,150 Total 15,541,545,000 466,246,350 777,077,250 (All data is from 2011 and all units are mtCO2e) Table 1.2: Estimated potential for emissions reductions in metric tons of CO2e. 25% Reduction in 25% Reduction in 50% Reduction in 50% Reduction in Country HC Emissions Low HC Emissions High HC Emissions Low HC Emissions High Argentina 2,796,548 4,660,913 5,593,095 9,321,825 Brazil 22,147,800 36,913,000 44,295,600 73,826,000 China 90,481,950 150,803,250 180,963,900 301,606,500 India 21,216,338 35,360,563 42,432,675 70,721,125 Nepal 248,700 414,500 497,400 829,000 Philippines 1,228,478 2,047,463 2,456,955 4,094,925 South Africa 3,386,123 5,643,538 6,772,245 11,287,075 Total 116,561,588 194,269,313 233,123,175 388,538,625 (All data is from 2011. All units are mtCO2e) 4 T h e I mp erat i v e , C ont e xt, and Rati o nal e fo r De v e lo pm e nt C o mmu ni ty Enga g e m e nt Investment in low-carbon healthcare systems in less-developed countries and middle-income countries can also foster clean and Box 2: Mitigation of Climate Change, independent energy, safe water, clean transport and clean waste Its Effects and Benefits disposal mechanisms. These can help create local capacity and services by strengthening the infrastructure needed for low cost, Low-carbon healthcare is planned, built, and delivered with mini- sustainable and resilient facilities while strengthening the market mal emission of greenhouse gases. Many interventions to reduce viability of low-carbon technologies. emissions will also have other health and environmental benefits (co- Low-carbon healthcare brings added benefits to health, local benefits), for instance by reducing air-polluting toxins and reducing economies, and in direct financial terms. The positive contribu- the associated burden of cardiovascular and respiratory diseases. tion to health is most easily demonstrated through reduced air Climate mitigation directly or indirectly reduces carbon emissions pollution and its subsequent reduction in the burden of disease and hence the severity of climate change and is viewed as mitigation as described in the WBG Climate Change and Health Hotspot or primary prevention. report.21 WHO highlights low-carbon interventions that bring Climate-sensitive disease mitigation reduces the impact that cli- additional benefits such as easier access to healthcare facilities22 mate change can have on the burden of disease, and is regarded as and improved safety for health workers. adaptation or secondary prevention. 3. Leading by example: Healthcare providers and health The benefits of climate change mitigation include: sector institutions are individually and collectively respected • Declines in respiratory and cardiovascular diseases through by policy makers and the general population. A recent report of reduced air pollution the most trusted professions around the world highlighted that • Fewer traffic-related injuries from clean, accessible transportation medical professionals rank very highly.23,24 As individuals trust • Improved safety for health workers, patients, and communities their most vital problems to healthcare professionals and expect thanks to improved waste management, accessible facilities and wise advice in prevention, it is logical this trust would extend to safe water climate mitigation, resilience, and adaptation considerations. WHO • Lower infection risks through improved natural ventilation has also highlighted that health professionals and institutions are • Reduced risk of exposure through less contact with toxic prod- ucts and chemicals well positioned to lead by example in mitigating against climate change.25 For instance, reducing greenhouse gas emissions and developing climate resiliency in health systems can influence Hospitals Initiative. The objective is to protect the operation of others to do the same (see case study of Georgetown Hospital in hospitals during emergencies and disasters so they may continue St. Vincent and the Grenadines in Case Study 19). to provide appropriate and sustained healthcare services.35 Building Low-carbon strategies can improve health system resilience on the Safe Hospitals Initiative, the Smart Hospital Initiative in and performance (Box 2), supporting adaptation to climate change the Caribbean was launched to aid health facilities in becoming through design and operational innovations including: siting health both more sustainable and disaster resilient. facilities for access to public transportation, on-site energy genera- tion including solar photovoltaics and other renewable sources, natural ventilation, energy-efficient medical devices, and changes Health System Resilience in the Face in health delivery, such as telemedicine.26 Many of these strategies of Climate Change can yield significant operational cost savings as well as facility resilience in the case of short-term grid energy loss.27 All new investments in the health sector should contribute to Combined heat and power, or on-site cogeneration provides building the resilience of the sector to climate change (Box 3). immediate savings in energy and enhances operational resilience This is important for meeting new demands (e.g., higher tem- and reliability.28, 29 On-site renewable energy sources such as solar peratures, increased precipitation, and stronger storms) and also photovoltaics for electricity and thermal solar energy for heating rising population pressures, local environmental degradation, reduce emissions from energy use, fuel production and transport and emerging infectious disease outbreaks, such as Ebola in West by increasing reliability.30, 31, 32, 33 Africa, which has highlighted evident failures and insufficiencies For instance, hospitals are finding measures that serve to of investments to build resilience to date. reduce their dependence on large power grids and infrastructure Resilience is particularly important in the context of climate also enable them to better withstand shocks, such as more fre- change given the complex, unpredictable, and multifaceted ways quent storms, that disable power grids and other infrastructure.34 in which climate change affects health systems and infrastructure. To reduce the vulnerability of health facilities, WHO and the Vulnerable health systems will be unable to cope with threats posed Pan American Health Organization (PAHO) launched the Safe by climate change, so many of the specific proposals discussed in the remainder of the document are intended to build resilience. 5 c l im ate- s mar t he a lt hca r e low- and middle-income countries (WHO, 2015). WHO defines a Box 3: Features of a Resilient Health climate resilient health system as “one that is capable to anticipate, System respond to, cope with, recover from, and adapt to climate-related shocks and stress, so as to bring sustained improvements in Kruk et al.38 propose five elements for a resilient health system: population health, despite an unstable climate.” The framework • Aware: up-to-date information about health system assets is intended to support national adaptation planning and public (including strengths and vulnerability) and potential threats; health responses to a changing climate, and contains several useful • Diverse: able to respond to a range of threats; elements for the broader international community. • Self-regulating: able to contain threats before they overwhelm the For example, it introduces a set of considerations for building system; resilience that can be applied as a checklist or set of questions for • Integrated: bringing together the key actors needed to support assessing whether a proposed investment is contributing to build- the system, both within the health sector (including public and ing climate resilience. It asks whether the planned investment: private actors, and communities) and beyond it (e.g., transporta- tion, education, media); • Contributes to reduce vulnerability? • Adaptive: flexible enough to transform in the face of challenges in • Develops capacities? ways that improve performance. • Adds long-term perspectives for actions to be put into place today? It is also important to recognize that the health community • Employs adaptive management approaches (e.g., risk-informed, has a significant role to play in broader adaptation policy and iterative, flexible, using models and scenarios to understand societal resilience. The health sector must reframe climate change future contexts, embracing risk and uncertainty as ways to as a health issue36 and position health as a cross-cutting theme for increase learning)? overall adaptation strategies.37 It must also advocate for increased • Ensures community approaches and voices to strengthen awareness and a better understanding of the relationship between health action? climate and health specifically, while integrating evidence into both policy and practice.38 The Operational Framework contains 10 components that Recognizing the need for concrete guidance on how the health elaborate upon the six traditional building blocks of a health system sector can better respond to the challenges and opportunities in the specific context of promoting climate resilience (as shown presented by a changing climate, WHO has recently published: in Figure 1.2). As resilience is addressed in the remainder of this Operational framework for building climate resilient health systems, document, approaches contained in the Operational Framework aimed at public health officials and their partners, primarily in are applied to the context of development financing. 6 T h e I mp erat i v e , C ont e xt, and Rati o nal e fo r De v e lo pm e nt C o mmu ni ty Enga g e m e nt Figure 1.2: Building blocks of health systems that promote climate resilience. TE RESILIE I MA NC C L Leadership & E Governance & g a te ncin lim in a C hF lt a He Leadership & governance Health Vul acity & Financing ss ment Cap tation Prepa ency workforce Ada smen ner Ass redne abil nage es g p Emer i n g bl o c ity, ld ui & Ma k t B s s Health of Service em Clim th Pro information Ear itoring k Hea ea Mon ted Ris lth s y st delivery & h ng systems ate l arni -info rams gra ly W g rme Inte Essential d medical products & M technologies a En nag h De iro eme v h & arc p nm n e alt ese of ar tm en t of H R He e tal ate alt nts Climate Resilient lim h C & Sustainable Technologies and Infrastructure Source: WHO, 2015. 7 c l im ate- s mar t he a lt hca r e Box 4: Climate-Smart Healthcare: The Intersection of Low-Carbon Healthcare and Resilience The IPCC identified key risks from climate change that include flood impacts and landslides due to extreme precipitation, impacts on water availability, wildfire impacts, and heat-related mortality.42 All significantly impact health in the communities where they occur. As first responders, hospitals and health centers need to be resilient to these impacts and remain operational during and immediately following these events to safely shelter patients in place and provide needed medical care to communities and responders.43 As hospitals and health systems explore opportunities for low carbon healthcare, they are finding significant overlap between mitigation or “sustainability” measures and climate change resilience interventions. Accordingly, we propose a new term that captures both sides of climate-health impact and response equation: “climate-smart healthcare.” Sustainability Sustainability and Resilience Resilience Lifestyle disease prevention Health system strengthening Risk and disaster preparedness Care closer to home Universal health coverage and planning Low VOC materials Energy, water efficiency Climate related disease Local food suppliers Daylighting monitoring Waste recycling Natural ventilation Flood barriers Air quality Rainwater capture Elevation Solar shading Backup generators Source: Health Care Without Harm/World Bank. Rationale for Development Community as possible. In the past, technology constraints hampered such health-care planning. Today, advances in information technology Engagement through the Model provide a route for the seamless integration of such an approach of the World Bank with its immense co-benefits. As with the cell phone, these advances will allow low- and middle-income countries the advantage of Climate-smart healthcare is well aligned with both low-carbon high quality, economically viable healthcare.41, 42 development strategies39 and health strengthening and transfor- Other World Bank work, such as Turn down the heat,43 Con- mation strategies promoted by the WBG.40 Efforts to end extreme necting climate change and health,44 and Shaping an approach poverty and to promote well-being include promoting investments to climate change and health: geographic hotspots for World in the foundation of healthy societies. Climate-smart healthcare Bank action on climate change and health have summarized the improves health by reducing the environmental impacts of relationship between climate change and health and provide healthcare and emphasizing the transformation required to an in-depth resources for better understanding this relationship. integrated approach across primary, secondary, and tertiary care, Additionally, the Climate Change CCSA and HNP have developed with financial and technical emphasis placed on primary care. a Climate Change and Health Approach and Action Plan which Climate-smart healthcare requires the matching of workforce further articulates many of these issues and contextualizes them skills to locations and tasks, and institutions that provide the within the WBG. highest quality of appropriate care as close to local communities 8 Chapter 2 Development Community Role Promoting Climate-Smart, Low-Carbon Healthcare Solutions This section reviews the tools and approaches for low-carbon healthcare. Existing initiatives are pre- sented as models from which further work can be built and integrated into development projects and programs. Details of methods are provided wherever possible. Case studies providing examples of country implementation appear throughout to establish a sense of real-world applicability. Existing Initiatives The Intergovernmental Panel on Climate Change (IPCC) identifies several interventions that can reduce carbon emissions.45 Based on these, the World Health Organization issued a set of preliminary findings on the benefits and co-benefits of carbon mitigation in health facilities.46 It reviewed published evidence on eight IPCC and four extra mitigation strategy impacts by considering the evidence of: • improvements to health services • reduced environmental and occupational health risks • reduced risk of specific diseases • improved health equity and access to healthcare services The findings identified a range of mitigation measures common to structures and activities that might have special relevance to healthcare facilities for the provision of improved services. These are summarized in Table 2.1. The WHO findings also identify a need for more systematic measuring and benchmarking of health sector energy consumption and emissions, as well as of overall environmental performance in the context of ‘greener’ facility design and use of renewable energy sources. Together with Health Care Without Harm, WHO has also issued a discussion document detailing seven aspects of a climate friendly hospital, alongside global examples of carbon mitigation in health- care settings.47 The seven components of a climate friendly hospital relate to driving energy efficiency, utilizing green building design principles, adopting alternative energy generation, clean transportation, sustainable food, clean waste management, and water conservation. For example, Hospital General Dr. Agustino Neto in Cuba audited its energy consumption to iden- tify areas for improvement in energy practices and subsequently reduced their energy consumption by 21 percent.48 Peru’s Hospital Nacional Dos de Mayo was designed to maximize natural ventilation (with high ceilings, large windows, and orientation to take maximum advantage of local prevailing winds) to keep the hospital air fresh and comfortable. In Rwanda, there are health clinics with no connection to the country’s power grid, relying instead on more reliable and less polluting hybrid solar/diesel sources. The 2020 Healthcare Climate Challenge, led by Health Care Without Harm’s Global Green and Healthy Hospitals Network, can provide useful support for those seeking to assess their footprint, measure progress, and take part in a collaborative global effort. The 2020 Challenge has a three-pillar framework of mitigation, resilience, and leadership.49 It sets an ambitious target to mobilize hospitals and health centers on every continent in a collective effort to reduce the health sector’s greenhouse 9 c l im ate- s mar t he a lt hca r e Table 2.1: Mitigation strategies applicable to the health sector. Mitigation strategy Actions GHG impact Health benefits Improve energy • Fuel switching • Reduced transmission • Immediate energy savings and operational resilience/ supply and distribution • Energy recovery losses reliability efficiency • Distributed generation • Reduced emissions • Reduced air pollution exposures • Combined heat & power from energy use, fuel • Improved access to reliable healthcare production and transport • Better energy security On-site renewable • Solar photovoltaics • Reduced emissions • Improved operational resilience/reliability energy sources • Thermal solar energy from energy use, fuel • Long-term energy savings • Wind production, and transport • Reduced ambient air pollution • Other renewable energy • Better energy security sources Reduced-energy • Non-electric medical • Reduced emissions • Energy and operations savings and energy security devices devices from energy use, fuel • Improved functionality at night and device reliability • Direct-current devices production and transport • Improved diagnosis of tuberculosis with low-energy LED • Energy efficient appliances microscopes • Increased access to healthcare and energy security Passive cooling, • Natural ventilation in • Reduced direct • Energy and operations savings and energy security heating, and ventilation healthcare settings emissions from on-site • Improved indoor air quality strategies • Evaporative cooling energy production; • Decreased transmission of airborne infections • Desiccant dehumidification reduced emissions • Improved social welfare, productivity and patient health • Underground earth-pipe from energy use, fuel cooling production, and transport Facility wastewater • Advanced autoclaving • Reduced energy • Savings in waste/water disposal fees and solid waste of infectious healthcare emissions for waste and • Reduced waste volumes management waste water treatment • Improved compliance with local air quality regulations/ • On-site wastewater pre- • Reduced greenhouse guidelines treatment and sanitation gas (GHG) footprint • Improved hygiene around facility improvements from waste treatment • Reduced methane and other emissions • High-heat incineration processes in some • Reduced risks of exposure to infectious agents and to of pharmaceuticals with settings diarrhea and other waterborne diseases pollution scrubbers • Reduced aquifer and ecosystem damage Reduced GHG • Waste anesthetic gas • Reduced direct • Anesthesia cost savings with reuse emissions from recapture and scavenging emissions from • Reduced health risks for health workers exposed to gas anesthesia gas use anesthesia gas waste • Improved health worker productivity and disposal Reduced procurement • Better-managed • Reduced energy • Resource savings on unused/wasted products carbon footprint procurement of footprint in production • Reduced risks from use of outdated/expired products pharmaceuticals, medical and transport of unused devices, business pharmaceuticals and products and services, products food/catering, and other facility inputs 10 De v e lopm e nt C ommu ni t y R ol e P r o mo ti ng Cli mat e- Smar t, L ow - Car b o n He althca r e  S olu tion s Mitigation strategy Actions GHG impact Health benefits Telehealth/ • Home patient • Reduced emissions from • More cost-effective healthcare Telemedicine telemonitoring and healthcare-related travel • Reduced risk of travel-related injuries guidance • Improved management of chronic conditions, such as • Emergency response diabetes and heart disease, as well as emergency response • Health worker advice & • Better access to healthcare advice in poorly-resourced collaboration via mobile remote locations phones Health facilities in • Public transport options • Reduced transport- • Reduced traffic injury risk for health workers and hospital/ proximity to public mapped during planning related emissions from clinic visitors travelling to health facilities transport and safe of buildings to locate new health worker and • Potential for active transport by healthcare workers to walking/cycling facilities nearby hospital visitor travel reduce risks of hypertension, cardiac disease and diabetes • Employee incentives for • Improved facility access for health workers and visitors who public active transport use do not have cars and facilities Conserve and maintain • Water-efficient fixtures, • Reduced energy use for • Improved performance due to better access to safe water water resources leakage management, water extraction from • Savings in water fees water safety surface/aquifer sources, • Reduced water contamination from health facility activities • Onsite water treatment therefore lower emissions • Reduced disease transmission from unsafe water and and safe water storage in • Reduced truck transit of drinking water health facilities water resources • Improved access to safe, potable water in poorly resourced • Rainwater harvesting, health facilities greywater recapture/ • Reduced aquifer and ecosystem damage recycling • Better water security Source: Adapted from the World Health Organization. 50 gas emissions by 26 million metric tons annually by 2020. This • Albert Einstein Hospital in Sao Paulo, Brazil, developed and is equivalent to taking 5.5 million cars off the road or installing implemented a sustainability master plan in 2010 with initia- 7,000 new wind turbines every year. It has mobilized a growing tives that cut annual greenhouse gas emissions by 2,000 metric number of participants, representing more than 9,000 hospitals tons of CO2 or 41 percent. and health centers from 23 countries. Examples of accomplish- • South Korea’s Yonsei University Health System has set targets ments and commitments by 2020 Challenge participants51 that to reduce GHG emissions from its facilities by 27 percent by could inspire others include: 2020. Yonsei has instituted numerous low-carbon strategies • The Western Cape Government health system in South Africa including a building energy management system that reduces has made commitments to reduce its carbon footprint from overall energy consumption by 10 percent through LED lights energy consumption in government hospitals 10 percent by in parking structures and occupancy sensor lighting controls 2020 and 30 percent by 2050 (based on 2015 levels). They are in restrooms that yield US$60,000 and $50,000 each in annual incorporating green design principles in building projects by, savings, respectively. among other things, using natural light and ventilation where • The U.K.’s National Health Service (NHS) is working toward a possible, curbing the use of air conditioning, replacing lights 34 percent reduction in carbon emissions by 2020. Within the with efficient fluorescent and LED lighting in combination with U.K., England’s health sector achieved an overall reduction light-colored walls, installing heat pumps for hot water, and of 7.4 MtCO2e between 2007 and 2015; a 13 percent reduc- including green spaces in facility design. Coal- and oil-fired tion despite an 18 percent increase in activity.53 The NHS is boilers have been eliminated at nearly all hospitals. Annual a national public health and care system that has created a savings from hospital laundry efficiency measures alone in just system-wide approach to low-carbon healthcare; this included one hospital comprise more than 19 million liters of water, over a national analysis of its carbon footprint, nationwide strategies 550 metric tons of CO2e, and more than US$62,00052 in costs. and implementation tools, and publicly reporting on progress. 11 c l im ate- s mar t he a lt hca r e • South Western Sydney Local Health District in Australia has to developing countries through pre-qualified procurement reduced energy and water consumption, generating significant lists. Some can maintain the cold chain for a week or more financial savings and reducing annual CO2 emissions by 6,370 without any electricity. Given they require over-sized solar tons. In an effort that could be replicated in lower income arrays to ensure the cold-chain, surplus electricity from the countries, this local health district upgraded old and inefficient refrigeration system is often generated and tapped for other plant and equipment, including instituting lighting upgrades health facility loads.56 that saved $450,000 AUD per year.54 • Health-focused intergovernmental agencies are rapidly expand- Some World Bank-supported projects have also shown consider- ing their investment in solar-powered vaccine refrigeration. able results in hospital greening. Designed to provide state-of-the-art Solar refrigeration represented 13 percent of all refrigerators medical care to patients, the Keserwan Medical Center (KMC) in and freezers procured by UNICEF in 2013, and this share is Lebanon took an additional investment to achieve Excellence in expected to grow. Since 2007, the Global Fund to Fight AIDS, Design for Greater Efficiencies (EDGE) certification that it expects will Tuberculosis and Malaria has invested millions of dollars in the be repaid through lower utility expenses in little more than a single procurement of solar panels to power small-scale diagnostic year. The EDGE certificate specifies savings of 21 percent in energy, tools and laboratories in Asian and African health clinics. 25 percent in water, and 26 percent in embodied energy (consumed • Mini-systems, such as the “solar suitcase” (an example of a by all the processes associated with production of a building) saving portable solar system), have filled a niche for low-cost solu- at KMC hospital. Medlife, a healthcare provider in Romania and a tions that target the most immediate energy needs of front-line client of the International Finance Corporation (IFC), has committed health clinics that are without energy at all. These are used to to greater use of energy- and water-efficient technologies across its facilitate night-time obstetrics services or emergency surgery facilities, saving at least 20 percent on water and energy. in very small clinics and remote locations. Many healthcare systems and organizations are moving toward a low-carbon model. The WBG can encourage the development • Efforts by multilateral and bilateral institutions, such as the community and help institutionalize this momentum, while Powering Health initiative by the U.S. Agency for International providing support to those countries that have not yet started to Development (USAID), are focusing on large-scale investments consider low-carbon healthcare. in solar systems for developing country health clinics. Powering health in low-resource settings: Strategies to provide To scale up these positive examples, the report concludes that the reliable energy in low-resource settings also foster low-carbon, “health and energy sectors need to design new policies, standards resilient healthcare. A study published by the World Bank and and regulations to support procurement, installation, and sustain- the WHO55 explores the relationship between universal access to able operation of energy technologies, as well as innovative financ- efficient modern energy services and universal health coverage. The ing structures to catalyze investment in modern energy systems.” report identifies a series of energy strategies aimed at improving This recommendation is particularly relevant to large development the quality, safety, and accessibility of health services relevant to institutions, highlighting an opportunity for greater collaboration clinics and health centers at the primary and secondary tiers of among sectors and programs. The successful evolution of integrated health systems, which often struggle to access sufficient energy to and embedded climate and health solutions will require new com- power lighting, refrigeration, and basic medical devices. munities of practice, collaboration on analytical pieces and project Among 11 African countries assessed by WHO in 2014, an design, and regularly discussion around common issues. average of 26 percent of health facilities had no access to electric- ity. Only 34 percent of hospitals on average had reliable electricity Relevance to Health Sector Strategy across the eight countries for which such data was available. At through the Lens of the WBG HNP the same time the report stated: Global Practice • In the same 11 Sub-Saharan African countries, hundreds of clinics and hospitals were using on-site solar photovoltaic The WBG can actively encourage the health sector to be climate (PV) power sources, either as a primary or backup source. “In smart, while simultaneously supporting the development of health Uganda, some 15 percent of hospitals used PV solar to comple- and climate interventions in other global practices. Although every ment grid electricity access, and in Sierra Leone, 36 percent country has a different set of geographical, social, economic and of all health facilities and 43 percent of hospitals used solar demographic circumstances, key elements of low-carbon health- systems in combination with other electricity sources.” care can be integrated into investments. These elements must be • About a dozen types of solar refrigerators for vaccine and tailored to local circumstances to help communities thrive, be blood storage are approved by WHO for sale at reduced prices more sustainable, resilient, and healthy in a changing climate. 12 De v e lopm e nt C ommu ni t y R ol e P r o mo ti ng Cli mat e- Smar t, L ow - Car b o n He althca r e  S olu tion s The WBG can integrate low-carbon healthcare into HNP’s benefits can be realized. Currently, WBG-supported projects strategy for universal healthcare coverage. It can provide elements (beyond, but including HNP) are screened for climate change; of a blueprint for low-cost health promoting systems that mitigate i.e., the degree to which climate change stands to impact project the burden of disease, adapt to new demands of efficiency and outcome and success. This is but one step in mainstreaming cli- quality, mitigate greenhouse gas emissions and local pollution, mate considerations across projects. Another would be to consider and adapt to a changing climate. how to reduce the impact of climate change by including low- The WBG’s Climate Change Action Plan calls on the institution carbon elements of project design; e.g., through the World Bank to strengthen and reinforce action on climate and health. The plan EDGE Green Building Certificate (which Bank projects are already states that, subject to available resources, the WBG will increase its encouraged to acquire). For instance, WBG should consider the capacity to respond to the 72 eligible countries that have included possibility of integrating health systems into community or district health as a focus area in their Nationally Determined Contribu- energy schemes or public transportation systems that reduce air tions (NDCs); 40 under the International Development Association pollution. Another option would be to integrate climate and health (IDA) and 32 through the International Bank for Reconstruction considerations into the Social and Environmental Framework, and Development (IBRD). drawing upon the expertise of safeguard specialists (see Annex 2 At a strategic level, the WBG will stimulate climate-smart for updated World Bank Safeguard policies that mention health). health care actions by discussing the health effects of climate These can be built into most projects when considered during the change, highlighting the opportunities for investing in low car- preparation, site selection, and scoping phases. bon solutions, and supporting greater climate resiliency across Low-carbon development requirements can be included in the health sector. It can also strengthen capacity by building every health project specification and contract. This can stimulate climate-smart investments, raising awareness across the health project partners or contractors to audit their own carbon foot- sector and increasing communication amongst related sectors and print, identify how it can be systematically reduced, and consider the community, and supporting health creating models of care. how to integrate a climate perspective into all aspects of project The WBG can encourage the following operational goals toward development. low-carbon healthcare: Carbon mitigation can be encouraged while also building climate resilience. As such, the two should be incorporated as a • Measurement: Encouraging carbon footprint measurement linked approach. An example of this would be investing in shade and public reporting as a norm across health systems, at the creation, as this would naturally help minimize temperatures dur- facility, institutional, city, state/province and/or country/ ing heat waves and hence also reduce the need for high-energy ministry levels air conditioning. • Planning: Integrating low-carbon approaches into planning Projects already consider local air, water and soil pollution processes, including the integration of climate analysis and impacts but the scope should be expanded beyond local consid- interventions into hospital safety assessments and plan- erations to include global pollution. The WBG needs to consider ning (e.g., PAHO Hospital Safety Index together with carbon carbon impact alongside health and financial issues to ensure it ­mitigation—SMART hospitals)57 realizes any opportunities for further reductions and integrates a • Investment and implementation: Stimulating investment in, wider triple bottom line approach in project preparation, imple- and implementation of, low-carbon strategies such as renewable mentation, and evaluation. It should also consider a social value energy and energy efficiency, waste minimization and sustain- of carbon metric for energy projects that could be applied to health able healthcare waste management, sustainable transport and projects as well. The same lessons can of course be extended to water consumption, and low-carbon procurement policies for other development institutions. pharmaceuticals, medical devices, and other products • Monitoring and evaluation: Tracking the health, economic, Projects and Interventions within the WBG and climate impacts of multiple actions and programs in a There are three phases essential to integration of climate-smart systematic manner health aspects in any project or intervention (Table 2.2). The first relates to establishing baseline data and identifying areas of focus, Integration into WBG Project and would relate to project identification, appraisal, and approval Preparation and Scoping phases within the Bank. The second relates to engagement and planning for the areas of focus, and most closely correlates to Every WBG health project or program could, feasibly, consider WBG implementation. The third relates to monitoring and report- climate change mitigation options from the outset so that wider ing progress, updating plans, and potential new areas of focus. 13 c l im ate- s mar t he a lt hca r e Table 2.2: Project intervention phases for integration of climate-smart considerations within the WBG as a model for other development institutions. PHASE 1 Project Identification, Appraisal PHASE 2 PHASE 3 and Approval Implementation Evaluation Baseline carbon footprint (and associated costs) to Deploy diagnostic tools to refine focus areas Measure and report progress through a determine focus areas transparent and public mechanism Assess basic capacities of institutions, individuals, Engage with staff and communities about low- Review areas of focus and update plans and technical and physical infrastructures carbon and climate-smart approaches Assess costs associated with low-carbon efforts Develop systematic plans to establish timelines, actions and monitoring mechanisms, that build resilience too Estimate the impact of climate change in 5, 10 Communicate with institution(s), health and 25 years to key local vulnerabilities professionals, local communities about the strategies and their role Assess climate mitigation opportunities in relation to energy efficiency, renewable energy and sustainable procurement strategies Within the first phase of project intervention, a climate-smart carbon intensities. This is achievable in most settings by match- approach should consider a number of early assessment areas for ing the financial information details with appropriate product low-carbon and climate mitigation strategies, including the reli- categories. ability of energy supply and the availability (within a country or region) of renewable energy technologies and financing options Carbon Diagnostics for renewable energy technology. Additionally, it should seek to The most commonly used indicator in climate change mitigation identify opportunities for: greater energy efficiency; improved waste is carbon dioxide equivalent emissions (CO2e). Various calculators management and segregation; improved water supply, conserva- and mechanisms are used worldwide to estimate carbon emissions tion, and protection mechanisms; and engagement with supply in relation to building energy, travel, and supply chain analysis. chains to consider low-carbon approaches to products and services. These all rely on carbon intensity conversion factors that are Health sectors have undertaken carbon footprint calculations updated on a regular basis because of efficiencies or changes to to different levels in various countries and settings. This section energy supply. For instance, as the automobile industry becomes details general diagnostic tools, as required under the second phase more efficient in its use of fuel, its carbon intensity will reduce of project interventions, for health systems and organizations; per kilometer driven. Where these factors are known, calculating specific tools related to intervention types are covered in Chapter 3. the carbon footprint is straightforward. However, where it is less clear, such as the footprint of the supply chain, an estimation is Diagnostics required to help indicate where to focus efforts. As the sector gets more proficient at calculating footprints of different types Many health sector organizations focus on direct energy use to of product, dependent on their provenance, these calculations calculate their organizational footprint and use this as a baseline will become more refined. In the meantime, estimator tools help for monitoring reductions. It is also possible to calculate a full prioritize action. footprint—including Scope 1, 2, and 3 emissions (Box 5)—and to do so at a system or national level, as the NHS has in England. Baseline Diagnostics However, such an approach might not be entirely possible in all It is important to specify which calculator and assumptions have countries.58 Estimating a full carbon footprint can be achieved by been made in these calculations so that comparisons are based using recent financial expenditure data and regionally-generated on equivalent levels of data. 14 De v e lopm e nt C ommu ni t y R ol e P r o mo ti ng Cli mat e- Smar t, L ow - Car b o n He althca r e  S olu tion s and compare their progress with similar facilities in their region Box 5: Sources of Greenhouse and globally. Gas Emissions1 Sustainability Diagnostics Scope 1 on-site (energy) GHG emissions typically are generated Other tools with wider scope to assess sustainability exist and by consuming a fossil fuel on site, such as burning oil or gas to heat help to establish areas for development and action. These include or boil water or power an emergency electricity generator. EDGE Green Building application, which includes a hospital mod- Scope 1 non-energy GHG emissions include on-site sources, such ule to calculate energy, water, and embodied energy, as well as as wastewater treatment, incineration, and waste anesthetic gas GHG emissions for projects in 125 countries. The Good Corporate emissions and fugitive emissions, such as refrigerants. Citizenship tool in the U.K. allows organizations to evaluate their Scope 2 GHG emissions are indirect emissions from consumption position and determine where to invest efforts. of electricity, heat, or steam. These emissions typically are associ- GHG emissions, and the health impact of pollutants are, of ated with electricity that is purchased from, or that is generated at, a course, variable by country. The WBG report Geographic Hotspots power plant burning fossil fuel, such as coal or oil. It can also be emis- for World Bank Action on Climate Change and Health has roughly sions from purchased heating or cooling that might include steam characterized this impact and categorized countries at greatest and chilled or hot water. health risk from co-pollutants of GHG emissions consistent with Scope 3 GHG emissions are also indirect emissions, such as evaluations from the IHME Global Burden of Disease. As can be the production of purchased materials and fuels, transport-related seen in Figure 2.1, air pollution has widespread and immedi- activities in vehicles not owned or controlled by the reporting entity, ate health impacts that can further strengthen the case now for electricity-related transmission and distribution losses not covered in reducing emissions. Scope 2, as well as outsourced activities, waste disposal, etc. Low-Carbon Healthcare Interventions The Greenhouse Gas Protocol developed by World Resources There are multiple opportunities to contribute to low-carbon Institute and World Business Council on Sustainable Development healthcare development. This section summarizes low-emission represents a global standard for the measurement, management, interventions and solutions that are relevant to low- and middle- and reporting of greenhouse gas emissions. It provides organiza- income countries under the main headings of infrastructure tions and sectors guidance to support these calculations59 and development, operational delivery, models of care, and financial provides a benchmark so that comparisons can be made across considerations. The interventions described fall under the GHG countries and settings. Each standard outlines a basic approach emission reduction scopes, summarized in Table 2.3. for times when data is not as readily available, as may be the case in middle- and low-income countries. Infrastructure Development Pharmaceutical Products This section addresses the planning, design, and construction of More specific guidance for pharmaceutical products and medical spaces to deliver healthcare services. Most of the interventions devices also exists. Purchasing divisions of health systems or highlighted in this section apply to a wide range of care delivery ministries and companies can use this tool to identify the hotspots settings, from inpatient to ambulatory. There are some design within key purchasing categories. features, however, that are particularly important in patient care areas, such as providing access to daylight and views in patient International Healthcare Carbon Emissions rooms, which can lead to shorter patient stays.60 As such, these Reporting System features drive several design considerations that are especially As part of the 2020 Health Care Climate Challenge, Healthcare important in hospitals. Without Harm’s Global Green and Healthy Hospitals (GGHH) The constant high demand for heating energy, primarily for initiative has developed a carbon reporting tool for participants, heating water for sterilizers and domestic hot water, suggests the first such international carbon reporting system for health that thermal heating systems (e.g., combined heat and power facilities. It allows participants to assess their carbon footprint, and solar water heating) are likely to be even more beneficial to track and report on carbon reduction, resilience, and leadership, healthcare facilities. 15 c l im ate- s mar t he a lt hca r e Figure 2.1: Burden of disease attributable to ambient air pollution. Source: Geographic Hotspots for World Bank Action on Climate Change and Health (2016). Building and system design and construction (also Table 2.4). performance, moderate temperature changes, reducing the The design and architecture of buildings should incorporate need for mechanical heating and cooling and cutting energy low-carbon approaches61 by initially considering the siting and consumption. orientation of buildings to optimize solar shading and natural • Natural and mixed mode ventilation can produce higher air ventilation, which will help keep buildings comfortable. This is exchange rates than typical mechanical ventilation systems particularly important for in-patient bed unit areas. Configurations while reducing energy demands and their resulting greenhouse that feature narrow floor plates facilitate both daylighting and gas emissions. The use of natural ventilation can improve natural ventilation, and improve indoor environmental quality. reliability and resilience of health facilities, such as those The design of buildings should maximize the building envelope designed to treat multi-drug-resistant tuberculosis in South performance to avoid overheating in hot weather and heat loss Africa. WHO has produced guidelines for natural ventilation in cold weather. Incorporating high efficiency heating ventilation for infection prevention and control62 and published a design and air conditioning (HVAC) equipment, high-efficiency electric for natural ventilation model for healthcare centers.63 lighting, and energy-efficient equipment will further reduce energy consumption. Other specific considerations might include: • Preserving and enhancing the natural environment and veg- etation is particularly suited to warmer climates with higher • Passive solar heating and cooling strategies, such as over- hangs, shading devices and enhanced thermal envelope 16 De v e lopm e nt C ommu ni t y R ol e P r o mo ti ng Cli mat e- Smar t, L ow - Car b o n He althca r e  S olu tion s Table 2.3: Climate-smart interventions and the related for Healthcare, and the Green Building Council of Australia’s GHG scopes. Green Star–Healthcare. The latter two approaches were based upon the earlier Green Guide for Health Care. Interventions to reduce GHG emissions Scope 1 Scope 2 Scope 3 These tools have mostly been designed in a developed world Infrastructure development: context, yet have been deployed in numerous developing countries. While the principles of clean energy and the appropriate siting Buildings’ design and x x x of buildings remain, some features might need to be adjusted construction: new and retrofit to account for specific climate variations and extreme weather Operational delivery: vulnerabilities, and there are several examples of green building Energy including efficiency and x x in healthcare in low- and middle-income countries.64 renewables Waste disposal x Water x Case Study 1: Low-Carbon Transport and Travel including x x Building—India planning, own fleet and Kohinoor Hospital in Mumbai74 is committed to reducing its envi- tele-solutions ronmental impact while reducing costs to patients. The hospital Food including purchasing and x opened in 2009 and is LEED certified, relies on low-energy light waste reduction bulbs, uses photovoltaic power to heat its water, harvests rain- Procurement and supply chain x water, and treats its own sewage to reduce water use. Kohinoor engagement Hospital also installed high-efficiency wall and window systems and an air-­ conditioning plant, resulting in an energy use intensity of Pharmaceuticals x 166 kwh/m2/year (53 kBTU/ ft2/year). Waste anaesthetic gases and x health sector refrigerants Service delivery and low-carbon x x x models of care Case Study 2: Low-Carbon Building—Rwanda precipitations and will ensure more shade, and improved Butaro Hospital,65 a collaboration amongst Partners in Health, the Rwandan Ministry of Health, and MASS Design, reduces its energy rain-water management. consumption by using narrow floor plates, natural daylight, and natu- • Reducing water consumption in mechanical water treatment ral ventilation, along with high-volume, low-speed fans and germicidal and delivery saves water and energy as well. Reducing the UV lights to provide energy efficient ventilation while controlling the need for water, through native or drought tolerant planting, transmission of airborne diseases. Local materials from the nearby coupled with on-site rainwater harvesting and storm water Virunga Mountains were also used to decrease carbon footprint and management strategies that capture rainwater and recharge contribute to the local economy. The overall approach reduced the groundwater supplies, both reduce water consumption and facility’s price tag by 1/3, saving US$2 million while producing over enhance resilience to climate change. 4,000 jobs.* * Mass Design Group, The Butaro District Hospital. https://massdesigngroup • Building materials impact the health of building occupants .org/work/design/butaro-district-hospital, last accessed 17 January 2017. and the health of the workers who create the materials and use them to build facilities. Using local materials reduces the energy consumed to transport them and supports local While green building tools have not specifically addressed economies. Selecting materials that avoid the use of hazardous climate resilience, many sustainable building strategies—from substances (e.g., mercury, lead, and cadmium) will reduce energy and water demand reduction to daylighting, to reliance on exposure by building occupants. passive systems—enhance hospital and health sector resilience. • Green building design tools and accreditation mechanisms exist, including a few specific to healthcare buildings. Examples Building Retrofit include: EDGE certification system for hospitals, The Building Many of the strategies for new buildings can be applied to ret- Research Establishment Environmental Assessment Method, rofitting existing buildings, even though healthcare settings pose the Leadership in Energy and Environmental Design (LEED) challenges in terms of their technical requirements. Retrofits should 17 c l im ate- s mar t he a lt hca r e Table 2.4: Low-carbon building interventions and benefits. LOW-CARBON BUILDING DESIGN AND OPERATION CONSIDERATIONS Category Intervention Benefit Building Site and Climate zone and biome identification Energy savings by designing building to be responsive to specific local Context climate Site and orient building to maximize solar orientation and Reduces heat load and maximizing passive benefits of natural wind patterns ventilation Site planting and reflective paving Reduces heat island effect Preserve existing vegetation Maximizes shading from mature trees; stabilizes soil and preserves habitat Accommodations for public transportation, bicycles and Encourages active transportation and reduces transportation GHG walking emissions On-site renewable power generation Reduces GHG emissions and increase resilience to climate change Building Form Narrow floor plates Maximizes daylighting and natural ventilation* Building Exterior Enhanced building thermal envelope Reduces heating and cooling load* Reflective roofing Reduces solar heat load; reduces heat island impacts Renewable power generation Reduces GHG emissions and increase resilience to climate change Shading by overhangs or planting Reduces solar heat load Operable windows Enables natural ventilation Use of local materials Reduces energy to transport materials; supports local economies Space Heating and Natural ventilation Energy savings from passive heating and cooling Cooling Zone temperature control Reduces heating and cooling energy* Mixed mode ventilation Reduces heating and cooling energy* Partial air recirculation Reduces heating and cooling energy* Heat recovery Reduces heating and cooling energy* Variable flow systems Reduces fan energy Ground source heat pumps Reduces heating and cooling energy Combined heat and power Energy savings by using waste heat from power generation for thermal energy; reduces transmission losses for power; improves resilience Night or unoccupied setbacks Reduces heating and cooling energy Commissioning building systems Energy savings through more efficient systems operation Lighting Daylighting Energy savings by using passive illumination* Low energy light fixtures Reduces energy consumption Accessible lighting controls Reduces energy consumption Automated lighting controls Reduces energy consumption Water Heating Low-flow water fixtures Reduces use of hot water Cold water detergents in laundry facilities Reduces use of hot water Combined heat and power waste heat used to heat water Energy savings from using waste heat for hot water Solar water heating Reduces GHGs from heating water; energy savings from solar water heating 18 De v e lopm e nt C ommu ni t y R ol e P r o mo ti ng Cli mat e- Smar t, L ow - Car b o n He althca r e  S olu tion s LOW-CARBON BUILDING DESIGN AND OPERATION CONSIDERATIONS Category Intervention Benefit Equipment Include energy efficiency in equipment selection criteria Reduces energy consumption Implement sleep mode on computer equipment Reduces energy consumption Operations and Energy management systems Reduces energy consumption Controls Turning off lighting and equipment when not in use Reduces energy consumption *As there is a clinical benefit to providing access to daylight and views in patient rooms (studies have shown that high levels of daylight in patient rooms can lead to shorter patient stays67), daylighting gains added significance in a hospital setting. Similarly, healthcare’s need for heat create an opportunity for benefits from combined heat and power and solar water heating. These interventions drive design considerations that are especially important in hospitals. Source: Health Care Without Harm.68 begin with an energy audit to maximize the value of the ensu- Operational Delivery of Healthcare ing work.66 An energy audit highlights the building systems that Functions consume the most energy and can identify system deficiencies, such as leaks, that can generate energy savings and cost savings Low-carbon healthcare transcends all aspects of health sector through routine maintenance and repairs. Improving the controls delivery and so must include all operational aspects and subsequent of building systems through recommissioning, adding building impacts on energy, transport, and items purchased. energy management systems, occupancy sensors, and hospital staff initiatives to turn off lights and equipment can fine-tune Energy existing systems and reduce energy use. Building system innovation in recent years has focused on The healthcare sector is a major energy consumer. Many of its energy and water conservation, resulting in new high-efficiency buildings operate continuously and require energy intensive interior mechanical equipment. Replacing inefficient mechanical equip- climate and ventilation control for the safety and well-being of ment, such as old boilers, with high-efficiency substitutes can also patients and staff. As such, fostering more efficient and sustain- require significant capital outlays. Often hospitals begin retrofit able energy use is essential in low-carbon healthcare. efforts with incremental improvements, such as replacing existing Standard care delivery processes for most large hospitals lighting with high efficiency LED lighting before implementing require significant energy use (for heating water, temperature and more capital-intensive projects, using incremental savings to pay humidity controls for indoor air, lighting, ventilation and numer- for the additional efficiency measures. ous clinical processes) with associated significant financial cost and greenhouse gas emissions. For instance, in India a study of 140 hospitals found that multi-specialty facilities have an average Case Study 3: Building Retrofit— annual energy consumption of 378 kWh/m2 of built area, which South Africa is the most energy-intensive commercial sector in the country.68 Yet gains in energy efficiency can be made without sacrific- The Western Cape Government has eliminated the coal- and oil- ing the quality of care. Hospitals in Mexico and Brazil, India, fired boilers at nearly all its 53 hospitals. Annual savings from Len- and Poland have implemented basic measures to save money, tegur hospital’s laundry efficiency measures alone include more than strengthen facility resiliency, and reduce energy demand by 20 19 million liters of water, over 550 metric tons of CO2e, and at least to 30 percent.65 US$62,000 in costs. Extrapolating for all Western Cape Government Healthcare facilities can also significantly cut greenhouse gas hospitals, the savings would add up to US$3.3 million annually. emissions and energy costs over time by using alternative forms of clean and renewable energy, such as solar and wind energy, Augmenting existing systems with renewable sources, such as and biofuels that do not undermine local food production or com- solar water heating, reduces the amount of heat energy needed munity land tenure. from existing fossil fuel-based heating and cooling systems and Alternative energy sources can be used for lighting, heat reduces energy consumption. Changing processes can also reduce generation, and pumping and heating water. These can be either energy consumption, such as the use of cold-water detergents in standalone on-site installations or integrated with community-wide a hospital laundry facility to reduce energy consumption. renewable energy installations. 19 c l im ate- s mar t he a lt hca r e Alternative clean, renewable energy makes both good envi- be easily shut down to be available when needed. More attention ronmental and economic sense, particularly when financing is required to improve the energy efficiency of major medical mechanisms are structured to support this shift. At the same time, equipment, along with the need for reliable functionality.71,72 given its formidable energy demands, health sector investment When selecting energy efficient equipment73, 74 it is important can play an important role in shifting the economies of scale and to assess the energy consumption of the equipment in standby and making alternative energy more economically viable for everyone. sleep mode, the heat output and the energy that will be needed For regions that have no access to reliable municipal electricity, to cool the space around the equipment, and the lifecycle of the alternative energy sources can fuel primary healthcare facilities in product (where and how it is manufactured, transported, used, even the most remote areas. In energy-poor settings, the use of low- and disposed of). The energy efficiency of medical equipment also energy and no-energy medical devices, together with deployment should be viewed alongside the need for reliable functionality.75, 76 of renewable energy sources, can improve access to basic health For example, among low-energy and carbon-neutral equipment, services. Finally, renewable energy sources give health facilities LED microscopes are more reliable and operate on daylight or an advantage in terms of disaster preparedness and resilience, low light77 and solar cold-chain refrigeration for medications and as on-site renewable energy sources are often less vulnerable to vaccines provides reliable temperature control.78, 79 damage and disruption than traditional grid-based power systems. Key steps for achieving energy efficiency in healthcare:70 1. Assess energy usage patterns and needs for the facility and Case Study 5: Energy Efficiency community; measure and benchmark energy performance. and Health Co-Benefits—Mexico 2. Develop an energy management plan. Torre de Especialidades in Mexico City reduces pollution by actively 3. Ensure equipment and systems are operating at peak perfor- removing smog from the surrounding air. The hospital is surrounded mance to optimize energy efficiency. by a giant, honeycomb-like screen that is coated with titanium diox- ide, which converts smog into benign chemicals upon contact. The 4. Minimize energy use in, heating (including water), cooling, screen also blocks sunlight, which reduces the amount of energy it ventilation, and equipment. takes to cool the air within the hospital. 5. Implement co-generation systems such as combined heat and power. On-site renewable energy can serve those areas without 6. Empower staff to reduce energy consumption (e.g., Case access and enable health facilities to operate out of daylight hours Study 4). and provide a wider range of services.80 On-site renewable energy 7. Conduct regular energy audits and use results to inform sources such as solar photovoltaics or wind for electricity, and awareness and retrofit programs. thermal solar energy for heating water provides a low-carbon and reliable form of energy for facilities in low-, middle-, and high- income settings alike.81, 82, 83 Case Study 4: Energy Efficiency— Small-scale hydroelectric power can also provide a source of South Africa renewable energy for health facilities in developing countries. For instance, a WHO and WBG report on energy in resource constrained Victoria Hospital, Cape Town empowered hospital workers through settings84 identified hospitals in Rwanda, Zambia, Uganda, and its “switch it off campaign.” Cleaners and housekeepers in this 180- the Democratic Republic of Congo (DRC) that use or have devel- bed secondary facility seek to ensure that unused lights and hospital oped hydropower facilities individually or in tandem with nearby equipment are switched off. This project resulted in the small but not communities. One example cited is in DRC where the Catholic insignificant saving of US$8,400 annually and boosted the morale of University of Graben-Butembo has invested heavily in solar and the cleaners and housekeepers, making them feel more recognized hydroelectric projects with support from USAID. within the hospital. Minimizing or eliminating the use of fossil fuels on-site by switching to renewable sources can reduce GHGs that contribute Energy Efficiency and Capital Intensive Medical to climate change and improve local air quality by eliminating air Equipment Provision and Replacement pollutants associated with burning fossil fuels. Where facilities Equipment such as X-Ray machines can be energy-intensive and are already supplied by centralized grid power systems, installing therefore costly to operate, and can generate significant heat while on-site renewables can yield significant operational cost savings as operating. Often the equipment is not in constant use, but cannot well as facility resilience in times of short-term grid disruption.85 20 De v e lopm e nt C ommu ni t y R ol e P r o mo ti ng Cli mat e- Smar t, L ow - Car b o n He althca r e  S olu tion s Co-generation, or combined heat and power (CHP), provides Waste Management immediate energy savings and improves operational resilience and reliability.86, 87 Hospitals and commercial building developers The health sector generates significant volumes of waste that in countries such as India, China, and Brazil, are exploring and must be safely disposed of, including infectious waste such as investing in CHP systems as either a primary or backup energy sharps and bandages, human tissue, and other hazardous waste source.88 including heavy metals, pharmaceuticals, and other chemicals. The WBG is actively partnering with the Sustainable Energy The UN Special Rapporteur has cited mismanagement of health- for ALL (SE4All) initiative,89 which calls on governments, busi- care waste as a violation of human rights in many countries.91 nesses, and civil society to increase access to electricity and clean A recent review concluded that approximately 50 percent of the household fuels and expand the use of renewable energy and world’s population is at risk from occupational, environmental, energy efficiency. These have a direct correlation to resilience in or public health threats from improperly treated medical waste.92 many countries because healthcare facilities can be energy self- The incineration of healthcare waste involves the generation sufficient. The WBG also has developed a toolkit for the deploy- of climate-relevant emissions, mainly CO2 and nitrogen oxides, a ment of renewable energy.90 range of volatile substances (metals, halogenic acids, products of incomplete combustion) and particulate matter, plus solid residues in the form of ashes.93 Small-scale incinerators, the most common treatment technology used in developing countries, emit greenhouse gases and other toxic pollutants such as dioxins and furans.94,95 Case Study 6: Renewable Energy— Under low-carbon healthcare, it is essential that healthcare waste Uganda management is conducted safely to protect patients, health workers and surrounding communities, as well as with minimal Uganda health centers with solar PV for lighting improved their night environmental impact. Waste minimization is the baseline point services, especially maternal care, and were better able to handle for effective waste management processes. emergencies due to more reliable electricity. Information and commu- A pilot project comparing cost and CO2 emissions from incinera- nication services improved, as members of staff could finally charge tion and outdoor burning of immunization waste compared with their mobile phones, and the health centers reduced their lighting treatment using an autoclave showed that autoclaves produced costs compared to the use of kerosene lamps. Benefits to health from less greenhouse gas emissions and were less expensive to oper- reduced air pollution, and to the quality of services through improved and more reliable lighting are significant co-­ benefits of installing on ate.96 Alternatives to incineration for healthcare waste treatment site renewable energy. have been recommended to reduce the emission of dioxins and furans required by the Stockholm Convention. Because less than 20 percent of waste in healthcare settings is hazardous,97 it is necessary to effectively segregate waste to ensure that only hazardous waste receives special treatment as required, while other wastes can be recycled or reprocessed as Case Study 7: Renewable Energy— in other industrial sectors. WHO has called for the phasing-out USA of incineration98 as a long-term strategy and, together with the UN Development Programme (UNDP) and Health Care Without Gundersen Health in the U.S. achieved energy independence by Harm, has modeled alternative technologies in seven countries in reducing energy consumption and using multiple renewable energy a project funded by the Global Environmental Facility. Additional generation systems. Its regional partnerships in energy creation research is needed in regards to the healthcare waste treatment include dairy digesters (renewable energy through manure/methane methods that mitigate climate change. use), turbines, and a landfill gas-to-energy initiative. Local projects also include geothermal energy and a biomass boiler. By integrating Anesthetic Waste Gases its energy systems with the local agricultural economy, Gundersen Controlling waste anesthetic gases can have a significant impact Health engaged with the community, contributed to the local econ- on a hospital’s overall greenhouse gas emissions. For example, omy, and converted its neighbor’s waste into energy for the hospital. the impact of Nitrous Oxide (N2O) on warming the atmosphere Gundersen’s accomplishments include improved energy efficiency of over 40 percent, resulting in annual savings of nearly US$2 million is almost 300 times that of CO2.99 Anesthetics, such as isoflurane, from conservation alone. Many of Gundersen’s strategies are readily desflurane, and sevoflurane, have been estimated to have a global applicable to low- and particularly to middle-income settings. warming potential 500 to 3,700 times that of equivalent amounts of CO2 over a 20-year period.100, 101, 102 A study by the NHS SDU103 21 c l im ate- s mar t he a lt hca r e in England found that, for acute care organizations such as hos- pitals, the global warming impact from waste anesthetic gases is Case Study 9: Low-Carbon Waste equivalent to around half the emissions used to heat buildings and Management—Nepal water. An anesthetic gases calculator tool is available to support calculations and establish a baseline from which to reduce GHGs. Bir Hospital in Kathmandu installed 248 solar panels with the sup- There are several practical carbon mitigation strategies related port of the World Bank, providing 60KVA of electricity for critical care to anesthetic gas use that can be adopted and included in profes- units. Bir Hospital also received international recognition for its waste sional anesthesiology training programs. These gases can be either reduction efforts, which are considered as much a humanitarian feat captured and reprocessed or substituted for alternatives such as total as an environmental one. The hospital cut its medical waste in half and now recycles 55 percent of all waste, which provides income intravenous anesthesia, as well as neuraxial or peripheral nerve to the hospital. Bir uses autoclaves to treat its infectious waste, blocks, which have much lower carbon footprints. For instance, including sharps, reducing emissions from small-scale incinerators. desflurane and N2O can be restricted to cases where they may The hospital is experimenting with new methods to reduce waste reduce morbidity and mortality over alternative drugs. Clinicians further, including vermicomposting and a biogas system that turns can avoid unnecessarily high fresh gas flow rates for all inhaled food waste into biogas is generating 1KW of electricity for cooking drugs. There are also waste anesthetic gas capturing systems.104 in the hospital kitchen. All contribute to reducing carbon emissions, as less waste needs to be incinerated, and rely on alternative forms of energy. Case Study 8: Anesthetic Gas Waste—Brazil damage water treatment and conveyance infrastructure. Access In 2012, Sao Paulo’s Albert Einstein Hospital conducted a study that to potable water can be interrupted, causing public health crises. identified that N2O contributed to more than 50 percent of the GHG Designing redundancy and reserve storage capacity into the supply emissions it was tracking (7,220 tCO2e out of a total of 12,998 tCO2e). and disposal systems to enable continued delivery of healthcare Research shows that these gases accumulate in the atmosphere and services during a water supply crisis is a key element of quality contribute to climate change. The hospital created an interdisciplinary healthcare delivery.106 team to increase awareness of the issue, and reduced its use of N2O for anesthetic procedures by 23 percent. Case Study 10: Transportation— Water Tunisia Water use and its treatment can be energy intensive, carrying a The Kasserine region of Tunisia piloted an approach to increase the carbon and financial cost that can be minimized through low- energy efficiency of the distribution of vaccines and temperature- carbon, water-efficient strategies. The wide variation of uses sensitive drugs. The existing distribution system was modified to throughout a typical hospital offers many opportunities for water store vaccines and medicines in the same buildings and to trans- consumption management, engaging all departments and person- port them along prescheduled and optimized delivery circuits. Elec- nel. Depending on the climatic zone and availability of water as tric utility vehicles, dedicated to the integrated delivery of vaccines a natural resource, it also presents an opportunity to manage the and medicines, improved the regularity and reliability of the supply use of water to ensure access to reliable potable water, water con- chains. Solar energy, linked to the electricity grid at regional and dis- servation, and the sound management of wastewater discharge. trict stores, supplied over 100 percent of consumption, meeting all Water efficiencies can be achieved through technology such as energy needs for storage, cooling, and transportation. Supply trips rainwater harvesting, grey water reuse, air conditioning conden- were scheduled, integrated, and reliable. Energy consumption was reduced. sate capture, water-saving faucets, low-flow sanitary fixtures, and This initiative cut the recurrent cost of electricity and reduced the water efficient equipment and systems. Additionally, optimizing release of carbon to the atmosphere. Such an approach could be cooling tower water consumption by eliminating once-through particularly relevant in countries where energy costs threaten the main- cooling, and behavior change (e.g., timely repair of leaks and use tenance of public health services in areas of low population density. In management) also can have an impact.105 these countries where the mobility of health staff and the timely arrival Another key factor is the resilience of water management sys- of supplies is at risk, there is considerable potential to reduce energy tems in times of emergency, both climate-induced and otherwise. costs and release recurrent budgets to other service needs while also Floods can overwhelm municipal potable water delivery. Droughts improving the effectiveness of the supply chain. can challenge the reliability of water supply. Seismic events can 22 De v e lopm e nt C ommu ni t y R ol e P r o mo ti ng Cli mat e- Smar t, L ow - Car b o n He althca r e  S olu tion s Transport and Travel Implementation of low-carbon travel and transport strategies is Case Study 11: Low-Carbon Food— a key component of low-carbon healthcare and can also have a Taiwan co-beneficial significant impact in terms of reducing air pollution and its associated health impacts. The following are three key Tzu Chi Hospital, Taiwan is a Buddhist hospital that provides veg- strategies to foster low-carbon transport and travel: etarian food only. The hospital’s cafeteria is supplied by an organic farm within the compound which is also used as horticultural therapy • Transportation planning. Promote integrated travel planning for patients with mental health challenges. The Hospital is proud to with municipal agencies so patients and staff can access services be reducing carbon emissions, promoting a healthy diet, promot- easily and, wherever feasible, reduce the reliance on roads. ing a natural and healing environment as well as encouraging more Health facility planning with access to public transportation well-being in staff and patients. The hospital calculates during the improves access to facilities for patients and health workers.107 period of 2010–2014 they saved over 2,000 tons of carbon emis- For instance, a new health facility might be sited close to a sions through serving over 2 million vegetarian meals in their cafeteria main bus terminal or with an easy pedestrian link from the and food court. Cultural differences mean that this approach may railway station. be harder to translate to other countries, however in many contexts, steps towards a more balanced and less meat-orientated diet is • Tele-health. Many forms of service delivery can be achieved beneficial. through tele-health strategies that provide quality healthcare and reduce transportation emissions. Tele-health offers the ability to make the health sector more resilient, smaller, less methane (a GHG 72 times more powerful than CO2) than other resource-intensive, and more cost-effective. For instance, livestock.110 Even eliminating meat for one day each week, where telemedicine services can reduce demands on space in often culturally feasible and without reducing the nutritious value of crowded healthcare facilities. Cost savings realized also free the diet, can help reduce emissions. A healthy, balanced, and low- up resources for delivery of more healthcare services. carbon diet can be beneficial to health by reducing risk factors for diseases such as diabetes, cardiovascular disease, and hypertension. • Low-emission vehicles. Health service fleets could be migrated Purchase sustainably-grown foods: The manufacture and to low-emission type vehicles such as electric cars, with re- use of nitrogen fertilizers is the second-highest source of GHGs charging located in the hospital grounds. In some circumstances, from food production. N2O is released into the atmosphere when bicycles or motorcycles might be more effective in delivering nitrogen fertilizers are manufactured and applied to fields. Agri- the required service, due to traffic congestion, for example. culture is responsible for 60 percent of global N2O emissions.111 Healthcare facilities can reduce their climate impact while support- Food ing local economies by purchasing local food that is organically Food is not only a pillar to good health, but is also provided in or sustainably grown. many healthcare settings. Low-carbon healthcare considers both Reduce food waste: Preventing food waste and diverting the nutritious value of food and the ways in which carbon impact unused food from landfills is another powerful way to reduce of food manufacture, delivery, and waste can be reduced. climate impact. If it were a country, food waste would be the The IPCC estimates that agriculture and land use change are third largest source of GHG emissions globally.112 When food is responsible for 24 percent of global emissions, greater than emis- discarded, the waste embodies all the associated emissions from sions from industry and more than the combined emissions of its production and it generates significant quantities of methane transportation and buildings.108 Health systems in many countries when decomposing in landfills. Halving wasted food globally purchase significant amounts of food and can help to reduce the by 2050 could reduce emissions by an estimated 4.5 Gigatons climate impact from agriculture by purchasing and serving foods (Gt).113 Healthcare facilities can work to prevent food waste by that are produced less carbon-intensively. conducting an audit to identify reduction opportunities. In cases There are four key purchasing and operational strategies for where waste cannot be avoided, it can be diverted from landfills healthcare to reduce its climate impact from food service: for use in animal feed, composting, or generation of biogas (see Reduce the use of meat and cheese: Livestock production Case Study 9 from Nepal). contributes 14.5 percent of the world’s GHG emissions.109 Beef Use energy-efficient technologies for cooking and dishwash- and cheese have the highest climate impact of all foods as cows ing (see preceding section on energy). consume more feed, and their digestive system produces more 23 c l im ate- s mar t he a lt hca r e products, as part of any contract. Identifying an organization’s Case Study 12: Less Meat, Fewer top 10 suppliers is a useful starting point to discuss its approach Emissions—USA to climate change mitigation and to integrate requirements into contractual clauses. For instance, suppliers could be asked to reduce The University of Washington Medical Center in Seattle has used sev- packaging and make it more reusable, to consolidate supplies eral strategies to reduce the amount of meat it purchases and serves for ease of transportation, to consider using more local produce, including hosting “Meatless Mondays,” increasing vegetarian options, and to reduce the carbon footprint of manufacturing. Small- and reducing meat portion sizes, and focusing more on vegetables and medium-sized enterprises (SMEs) might require support given other forms of protein, such as fish and beans. The facility’s efforts their smaller size, though they are generally well placed to help have cut food consumption-related GHG emissions in the facility by encourage local economies. The U.K.’s Procuring for Carbon Reduc- 11.8 percent. tion tools116 provide a framework to estimate the carbon footprint of procurement activities and guidance to establish an approach going forward. The Sustainable UN initiative (SUN, also known as Procurement and Supply Chain ‘greening the blue’)117 also has a variety of procurement tools avail- Supply chain-related emissions accounts for at least 65 percent able, including criteria for shipping and freight to reduce carbon. of the carbon footprint of England’s National Health Service and 82 percent of the carbon footprint of UNDP-administered Global Pharmaceuticals Fund for HIV/AIDS and Tuberculosis projects in Tajikistan.114,115 It The carbon footprint of pharmaceuticals is estimated at 21 percent may be extrapolated that proportions are similar in other health of the overall footprint of the health sector in England,118 a signifi- settings and, as such, procurement represents a major potentially cant number that is viewed as a conservative estimate.119 Work significant contributor to low-carbon healthcare. A large percent- is underway to identify the relative difference between product age of NHS England’s procurement carbon footprint rests with categories, including a report detailing the top 10 most relevant pharmaceuticals (21 percent) and medical devices (11 percent). drugs used in the NHS.120 Propellant N2O inhalers, for instance, By engaging with its supply chain to stimulate changes across represent 4.3 percent of the carbon footprint in the health sector industrial sectors, healthcare can support the development of low- in England.121 These products are most often manufactured in carbon products and innovative solutions in these areas and others. emerging economies where their production has environmental health impacts on those communities. Encouraging innovation for safe, low-carbon pharmaceutical production and the development Case Study 13: Procurement—UN of ‘green pharmaceuticals’122 is crucial across the sector. At the same time, the health sector has a responsibility to minimize the The UN interagency initiative on sustainable procurement in the use and waste of pharmaceutical products, ensuring that they are health sector counts 10 members (UNDP, UN Environment Pro- gramme, UN Population Fund, UN Refugee Agency, UNICEF, UN prescribed and utilized as effectively and efficiently as possible. Office for Project Services, WHO, Gavi, the Vaccine Alliance, the Improved management and sustainable procurement processes Global Fund to Fight AIDS, Tuberculosis and Malaria, and the UNI- for pharmaceuticals can reduce the overall quantity of products TAID initiative). They are committed to establishing sustainable manufactured and purchased. This would lead to reduced emis- practices in the procurement of health sector products and ser- sions from waste disposal, particularly of hazardous waste, and vices. Its focus includes GHG emissions, resource depletion (water, cut the energy required for waste disposal due to reduction and energy and material consumption), and chemical pollution. These substitution of toxic chemicals. It would also diminish the energy UN agencies have developed a joint strategy to engage system- footprint of production of unused/expired pharmaceuticals and atically with suppliers and manufacturers and expect to establish products, and their transport. For instance, reducing pharmaceuti- evidence-based standards, implement environmental product cal use by 2.5 percent was identified as the highest-impact carbon specifications and criteria, and engage with supply chain and global reduction intervention in a study in England.123 health financing groups. The health sector’s influence on the use and disposal of pharmaceuticals can lead to strategies that will reduce the carbon Within the WBG itself, procurement is a critical phase of a footprint and improve the efficiency of services by: project and ensuring that it is sustainable can have considerable • Establishing clear prescribing practices and only prescribing impact over the lifecycle of a project. A first step in this direction medicines when necessary. This is a driver for many other could be for health systems or for financers, like the WBG, to health improvement and medicine optimization initiatives.124 require suppliers to estimate their carbon footprint, and of their 24 De v e lopm e nt C ommu ni t y R ol e P r o mo ti ng Cli mat e- Smar t, L ow - Car b o n He althca r e  S olu tion s • Encouraging early patient diagnosis and management/inter- of health conditions, including diabetes, mental health, high-risk vention and supporting patient compliance that will promote pregnancy monitoring, heart failure, cardiac disease, lung disease, longer, healthier living and reduce GHG emissions.125 orthopaedic conditions, and chronic wounds.131, 132 Low-carbon models of care that naturally utilize less resources • Reducing and greening the packaging of pharmaceuticals. and focus on improving health in communities are closely aligned Pharmaceutical packaging is a US$20-billion industry, expected with models being developed in low- and middle-income countries, to grow to US$78 billion by 2018.126, 127 Most pharmaceutical particularly in rural and remote areas. These models provide a packaging is destined for landfill or incineration, presenting useful approach that could be adopted worldwide.133 a significant opportunity for greening this segment of the healthcare supply chain. Financial Considerations • Minimizing wastage in medicine usage. The NHS estimates that £300 million a year is wasted in prescribed medicines and Low-carbon healthcare can bring multiple benefits to societies has identified ways of addressing this through waste reduction where access to clean energy, safe water, clean transportation campaigns, support to care homes and repeat prescription and clean waste management are far from universal. The effect of management approaches.128 these measures can save lives, protect public health, and support • Ensuring low-carbon product manufacture, transport, and local economic growth. delivery through systematic engagement with the supply chain Many initiatives can save money over the short, medium and (see Case Study 13 on UN procurement). long term. Greater impact can be realized through better calcula- tion of the indirect financial returns, such as improved health Health sector refrigerants: Hydroflourocarbons (HFCs) are (from reduced pollution), improved resilience through renewable man-made greenhouse gases used in air conditioning, refrigeration, energy, improved supply chain management, and stimulation of and other applications. Many HFCs are short-lived climate pollut- local economies. ants, remaining in the atmosphere for less than 15 years. Though The NHS Sustainable Development Unit (SDU) in the UK has they represent a small fraction of the current total greenhouse gases shown that it is possible to calculate returns in terms of social, (less than 1 percent), their warming impact is particularly strong economic, and environmental benefits. It has estimated healthcare and, if left unchecked, HFCs could account for nearly 20 percent savings totaling £5.1 million through tele-health and tele-care of climate pollution by 2050.129 WHO is proposing that future services for people with long-term health conditions, while also specifications require that healthcare refrigerants with a high global yielding a reduction of 67,000 tons of CO2 and an improvement warming potential, such as HFCs, be phased out over 2 years.130 of 5,671 Quality Adjusted Life Years (QALY).134 A study published by the US Commonwealth Fund examines Service Delivery and Models of Care data from selected hospitals that have implemented programs to reduce energy use and waste and achieve operating room sup- Every aspect of health sector delivery comprises opportunities ply efficiencies. After standardizing metrics across the hospitals for climate-smart approaches. Many of these can be considered studied and generalizing results to hospitals nationwide, the by delivering healthcare through less infrastructure-intensive analysis found that savings achievable through these interven- mechanisms; for instance, through telemedicine and the use of tions could exceed US$5.4 billion over 5 years and US$15 billion mobile technology and applications. Support for chronic disease over 10 years. Given the return on investment, the authors rec- management can often be more effective through mobile phone ommended that all hospitals adopt such programs and, in cases apps and telemedicine can provide alternative ways of providing where capital investments could be financially burdensome, that expert support to rural facilities. public funds be used to provide loans or grants, particularly to Clinics can also be brought closer to communities by utilizing ‘safety-net hospitals.’135 local facilities such as schools, libraries or town halls, and by pro- While to date no such study has been carried out focused viding support for care to be provided at home. Likewise, clinics on developing country health systems, a series of case studies within communities can provide other services: local farming, water produced by the Global Green and Healthy Hospitals Network, treatment, composting of community food waste, and essential some of which are cited in this paper, provide anecdotal evidence public health infrastructure, and health management support. With for a series of economic benefits related to implementing environ- appropriate local backing, many hospitalizations can be avoided. mental sustainability initiatives in health facilities in a diversity These approaches, while fostering better health outcomes, are also of economic settings.136 This is clearly worth exploring further to low-carbon. Studies on tele-health, tele-care and home monitoring develop a systematic evidence base. methods have documented improved outcomes for a wide range 25 c l im ate- s mar t he a lt hca r e Calculating return on investment Immediate Gains, Co-Benefits, and Return There are tools for calculating the best returns for reducing emis- on Investment sions in the health sector. These are based on standard return Many processes and interventions can begin at a local level and on investment (ROI) calculations, linked to carbon emissions bring swift financial returns, principally through efficiency savings reductions on a yearly basis. The NHS marginal abatement cost (e.g., by closing doors in a colder climate, and switching off lights curve (MACC)137 (Figure 2.2) lists several health-related carbon and computers). These require attention to the education, involve- interventions that showed returns in fewer than 5 years. Most ment, and sense of ownership among staff.143 The costs of such interventions it identified saved money and carbon. The curve education can be recouped within less than a year.144 Approaches has been recently updated and identified yearly savings of £414m that support changes in behavior (e.g., in reduced air conditioning, and 1MT CO2 by 2020 through changes that also benefit people’s improved waste segregation and better water conservation) can be health.138 Other examples of this include: a UNDP-developed implemented immediately, with the promise of financial returns marginal abatement cost curve for global health fund projects through lower costs (see Case Study 4 from South Africa). The in Montenegro and Tajikistan139 as well as the WBG EDGE Tool, Carbon Trust has developed a calculator to help calculate potential which can provide ROI estimates for hospitals. savings through such behavioral change. The main investment is Some interventions require upfront investment, such as the capacity building through time, communication to raise aware- installation of renewable energy. However, such investments ness, and the resourcefulness to advance these types of projects. fuel economic growth, create new employment opportunities, enhance human welfare, contribute to a climate-safe future, and Monitoring the Economic Benefits yeld economic returns in the medium term.140 of Lowering Emissions Increasingly, power purchase agreements in some countries The WBG developed and published a model in the Climate-Smart enable institutions such as hospitals to contract for renewable Development Report145 to calculate the benefits of climate-smart energy without needing to provide the initial funding for the capital developments by quantifying the lives saved, jobs created, crops investment in the applied renewable technology.141 The Interna- protected, energy saved, GDP gains, and reduced emissions. tional Renewable Energy Agency provides assessments as to the This approach could easily be applied to low-carbon healthcare renewable energy development potential in several countries.142 and provide valuable and much-needed additional information to support its implementation. Additionally, the World Health Organization announced at the 2nd Global Conference on Climate and Health (July 2016) the formation of a working group on the Case Study 14: Renewable Energy— economics of health and climate change to explore related issues Zimbabwe and which is likely to generate further resources that could be used in understanding and advocating for health sector interventions A UNDP pilot study on renewable energy planning for rural health centers and clinics in Zimbabwe found that a power source using a around climate change. hybrid system based on PV panels brings significant carbon savings compared to the business as usual (BAU) solution of burning fossil fuel derived diesel. The carbon payback of the system was deter- mined at less than 2 years, with it being cost-neutral compared to the BAU system in only 4 years. 26 Figure 2.2: NHS marginal abatement cost curve (MACC) with interventions. 100 £ cost per tonne of CO2 Increasing 50 Costs CO2 Savings 0 (tCO2) in 2015) 100,000 200,000 300,000 400,000 500,000 600,000 700,000 800,000 –50 –100 Increasing Savings –150 –200 –2,000 –4,000 –40,000 3 2 1 5 8 9 10 13 14 18 23 25 26 27 29 (£/tCO2)— CO2 £000 This table illustrates just some of the carbon saving measures that the NHS could implement. Not all Savings + Savings Savings are numbered above. Some CO2 savings are too small to depict on this scale of graph. Costs (tCO2/yr) (£000/yr)  1 Packaging of medical equipment –40,299 2 +81  2 Reduce drug wastage –3,987 22,430 +89,428  3 Teleconferencing to replace 5% of business miles –2,038 6,827 +13,913  4 Decentralisation of hot water boilers in non-acute/PCT –240 10,612 +2,547  5 Combined heat and power installed in acute trusts –213 232,331 +49,487  6 Variable speed drives –168 5,508 +925  7 Introduce hiberation system for ambulance stations –135 1,096 +148  8 Improve heating controls –134 26,551 +3,558  9 Improve lighting controls –127 29,686 +3,770 10  Energy efficient lighting –91 30,140 +2,743 11 Voltage optimisation –75 29,364 +2,202 12 Improve the efficiency of chillers –71 7,313 +519 13 Roof insulation –65 25,928 +1,685 14  Energy awareness campaign –61 92,549 +5,645 15  Building management system optimisation –56 20,610 +1,154 16 Improve insulation to pipework, and/in boiler house –55 11,195 +616 17 Install high efficiency lighting/controls—ambulance trusts –55 2,999 +165 18  1 degree C reduction in thermostat temperature –53 49,144 +2,605 19 Improve the efficiency of steam plant or hot water boiler plant –52 8,933 +465 20 Upgrade garage and workshop heating –49 214 +10 21  Boiler replacement/optimisation for HQ/control centres –12 171 +2 22 Improve building insulation levels in ambulance trusts –12 951 +11 23  Wall insulation –8 25,928 +207 24 Office electrical equipment improvements –4 7,957 +32 25 Travel planning 0 81,524 0 26 Insulation—window glazing and draught proofing +6 25,928 –156 27  Electric vehicles +19 36,969 –702 28  Wind turbine +25 245 –6 29  Biomass boiler +35 30,533 –1,069 Total 823,638 179,987 27 Chapter 3 Development Community Role Promoting Climate-Smart Resilience in Healthcare This section reviews the current state of climate change resilience, adaptation planning and implemen- tation in the health sector, with a focus on low- and middle-income countries and identified climate/ health impact hotspots. Various tools are listed, as are approaches to integrating these into development operations. Ultimately, this section describes how health lending and investment can build resilience and adaptive capacity in response to climate change. Diagnostic Tools That Can Help Assess the Impact of Climate on Health Building resilience to the health impacts of climate change is largely about risk reduction. It is widely understood and accepted that climate change will have broad impacts on human health and that it will be the poorest and most vulnerable that feel the full force of impact. Though it may not be possible to diminish this risk of health impact to zero, more can be done to predict and prevent impacts, and build resilient health systems that will be sturdy in the face of future threats, whether pandemic outbreak, economic collapse, or global environmental change. It is also important to note that health risks from climate change vary in both their nature as well as the type of climate risk that precipitates them. So far, there has been considerable discussion of the types of health impact: infectious disease, undernutrition, heat stress, and so on. The magnitude and pattern of risks from climate change, however, are also important and are due to: the characteristics of the hazards created by changing weather patterns; the extent of exposure of human and natural systems to the hazard; the susceptibility of those systems to harm; and their ability to cope with and recover from exposure. To establish truly resilient systems, each of these components should be consid- ered individually. In doing so, it should become clear that the starting point for efficient and effective resilience strategies and adaptation must encompass: the vulnerability of a community; the capacity of health systems to prepare for, cope with, respond to, and recover from exposure to a hazard; or the hazards created by a changing climate. Each of these categories highlights important areas for adapta- tion and resilience planning. Simply focusing only on climate change is too broad a frame, and makes assumptions about the roles of vulnerability and exposure that could prevent effective action. Improving understanding of the discrete and varied risks that climate change poses for health allow for concentration on the most vulnerable populations and the most susceptible regions. Development lending must target the correct geographies, populations, and causal factors. Awareness of potential climate-related risks is also important to ensure that a project is not derailed during implementation. As awareness of the linkages between climate and health has grown, so too has the number of information sources and diagnostic tools that quantify impacts to support improved decision making. Information sources and tools can be characterized in multiple ways but for the purposes of this exercise it will be most helpful to consider two: global and national. 29 c l im ate- s mar t he a lt hca r e Global Resources and Tools to Assess to derive estimates of local climatic conditions through a combi- nation of observations, modeled information, and technologies the Impact of Climate on Health (such as remotely sensed data from satellites).146 Each of these Many tools and resources available globally can be useful for have different operational utility (Table 3.1). Snapshots and those understanding a country’s climate change/health links. Some of that provide data are perhaps most useful during early phases of those might be specific to health, others to climate information, project development or anytime later when it is important to make and others yet that combine health and climate information. Drill- a case for climate and health investment, while also providing ing further into this framework, it can be helpful to characterize important background information. Those that provide step-by- tools in three ways: (i) those that provide a snapshot of the climate step processes, conversely, may be most useful in project design and health situation in a country; (ii) those that offer a step-by- as unique tools are necessary to inform different components and step process related to climate change and health; and (iii) those stages of investment. that provide access to data and analytical tools that can be used Table 3.1: Examples of tools relevant to assessing climate and health impacts. Source Tool (& Link) Type Description147 Health and Climate World Health Snap shot “Relevant and reliable country-specific information about the current and future Profiles Organization impacts of climate change on human health, the opportunities for health benefits from climate mitigation actions, and current policy responses at country level” Climate Change World Bank Group Snap shot “A quick reference source for development practitioners to better integrate Knowledge Portal climate resilience into planning and operations . . . a common platform to access, synthesize, and analyze the most relevant data and information for disaster risk reduction and adaptation to climate change” Protecting Health World Health Step-by-step process “Guidance on conducting a national or subnational assessment of current and from Climate Organization future vulnerability (i.e., the susceptibility of a population or region to harm) to Change: Vulnerability the health risks of climate change, and of policies and programmes that could and Adaptation increase resilience, taking into account the multiple determinants of climate- Assessment sensitive health outcomes” Climate screening World Bank Group Step-by-step process “A systematic way to undertake due diligence and flag potential risks for tools (including one projects in the health sector” specifically for health) Building Resilience U.S. Centers for Step-by-step process “Five-step process that allows health officials to develop strategies and Against Climate Disease Control and programs to help communities prepare for the health effects of climate Effects (BRACE) Prevention change” (US-focused but with approaches that are applicable elsewhere) Framework Climate Data Library International Research Data/analytical tool “Online data repository and analysis tool that allows a user to view, analyze, Institute for Climate and download hundreds of terabytes of climate-related data” and Society (Earth Institute, Columbia University) Forecasts in Context International Data/analytical tool “Information [about rainfall patterns and forecasts] that can be used for Federation of Red humanitarian decision making around the world . . . It also provides information Cross and Red on the types of early action that can be taken based on these maps” Crescent Societies Global Risk Data UNEP/UNISDR Data/analytical tool “Spatial data information on global risk from natural hazards . . . visualise, Platform download or extract data on past hazardous events, human and economical hazard exposure and risk from natural hazards” 30 De v e l op m e nt C ommu ni t y R o l e Pr o mo ti ng C li mat e- Smar t Res i li e n c e i n He a lthca r e National Sources of Climate Information use of improved climate data at a relevant scale for health decision making, provide innovative opportunities for evidence-based policy for Health Decision Making and practice. The meteorological services have been charged with While the global resources provide a starting point for assessments serving the health community, in particular, as one of five priority of major climate impacts on health, information on local climate areas advanced by the Global Framework for Climate Services.150 conditions is often typically available at the national level for health Engagement of meteorological services provides a primed entry decision making and planning. Understanding environmental point for national climate and health policy issues and provides drivers (changing sea levels, storms, heat) and the varied health a central coordinating mechanism with other sectors, as well impacts, when taken with population vulnerability, establishes as tapping the most relevant source of country-owned climate an important nexus of factors to consider in resilience planning. information. National meteorological services are critical sources of infor- It is worth highlighting that weather station coverage is a mation. As the mandated focal point for national climate data challenge, particularly in Africa and in parts of Latin America.151 and services, they are crucial to supporting rigorous adaptation The distribution of existing stations is often uneven, concentrated planning and should be engaged as a key ally for health and cross- along major roads and in urban areas. Where station records exist, sector investments in resiliency. Some development institutions, they are often of poor quality, with significant data gaps. In some like the WBG, are already prioritizing engagement of national countries, capacity constraints and restrictive policies make what meteorological services through global investments in observational little data that does exist hard to access. networks and infrastructure148 and these can be further leveraged so that improved national climate data can be accessed by the Case Study 15: Improving Malaria health community and other sectoral stakeholders, overcoming Evaluation and Planning—East Africa significant traditional policy and technical constraints, especially in low- and middle-income countries.149 Changes in climate influence patterns of malaria transmission. Cli- Institutional partnerships between ministries of health and mate services that can follow malaria trends and help predict the meteorological services, along with collaborations to support the impact of climate variability on malaria transmission are becom- ing critically important in allocating malaria control and elimination Table 3.2: Tools for development of climate health resources. assessments, early warning, resilience, etc. National meteorological agencies and national malaria control programs in East Africa are developing tools and partnerships to uti- Africa Real Time Environmental Monitoring System (ARTEMIS) lize climate data to inform public health decision making, particularly Climate Hazards Group InfraRed Precipitation with Station data (CHIRPS) on malaria impact assessments and other areas of malaria plan- ning. The Ethiopian National Meteorology Agency and the Tanzanian Committee on Earth Observation Satellites (CEOS) Meteorological Agency—with technical support from the Institute for Emergency Prevention System (EMPRES) for Transboundary Animal and Climate and Society, the Columbia Global Centers/Africa, the Roll Plant Pests and Diseases Back Malaria Partnership, and the US President’s Malaria Initiative— European Space Agency data sets have launched the Enhancing National Climate Services (ENACTS) Initiative. This is improving the availability and relevance of climate Food and Agricultural Organization (FAO) GeoNetwork information to serve the needs of decision makers around malaria Global Risk Identification Programme programming. In consultation with national malaria control programs, Group on Earth Observation (GEO) the initiative is developing high-resolution data and tools for mapping International Research Institute for Climate and Society malaria high-risk areas, determining seasonality and best timing of malaria interventions, investigating trends over time, and putting in Goddard Spaceflight Center (US National Aeronautics and Space place resources for early preparedness. By integrating all ground- Administration) based observations with proxy satellite and other data, ENACTS’ RVF Activity Database (Kenya, Zimbabwe) products overcome issues of data access and quality, introducing SERVIR Regional Visualization and Monitoring System rigorous and spatially complete data services that serve national stakeholder needs. US Department of Defense Global Emerging Infections Surveillance In 2014, these ENACTS products were used by national malaria Program control programs in Ethiopia and Tanzania to monitor and prepare for US National Oceanic and Atmospheric Climate Prediction Center (including the forecasted El Nino and the potential for increased malaria trans- ANHRR) mission, including map rooms and other data visualization tools that have supported historical impact assessments. World Animal Health Information Database (WAHID) 31 c l im ate- s mar t he a lt hca r e The Enhancing National Climate Service (ENACTS) initiative is very ground upon which hospitals are built. Adaptive manage- one innovative approach to expanding access to climate informa- ment throughout the course of project implementation therefore tion national decision making and has been backed by the Weather is also necessary, as climate change can easily disrupt a project, and Climate Information and Services for Africa under the UK’s regardless of the quality of project design during the development Department for International Development (DFID). Other deci- of a Project Appraisal Document. sion making tools and information systems that leverage national Second, the adoption of a mixed health systems approach in climate information are featured in the forthcoming WMO/WHO development projects takes on increasing importance. Taking again publication Climate Services for Health: Global Case Studies of the example of the WBG, in most countries in which it works, Enhancing Decision Support for Climate Risk Management and private sector and civil society organizations (including faith-based Adaptation (other are referenced in Table 3.2).152 Central to these organizations) deliver a considerable fraction of healthcare. These efforts is the need to support national climate observation systems, nonstate actors can provide an important element of redundancy in addition to strengthened national health information systems. in the health system, which is particularly important given the stresses that climate change can exact on the system. The service Climate Change and Health Approaches, provision by nonstate actors can contribute significantly to building Interventions Viable for Health Sector resilience and to ensuring the continuity of services in the event of a natural disaster or a pandemic.153 Finance Climate-smart activities can be included in development lending Health System Responses to Build in the form of a project component (or subcomponent) that is Resilience, Adapt to Climate Change flagged specifically for climate change and health. It may be that a project component is designed specifically to match a climate Development finance for health goes to a variety of areas. At the WBG, and health opportunity—or is rather part of a broader project this includes issues such as child health, HIV/AIDS, tuberculosis, design that has not explicitly considered climate. For example, nutrition, injuries, and non-communicable diseases. However, the early warning systems are useful for pandemics, but also have largest single area of lending does not have a programmatic-specific utility for climate and weather impact. Expanding the scope of one focus but is directed to multifaceted strengthening of health systems such project component to include climate can both enhance the strengthening: almost exactly half of the WBG’s HNP commitments impact of a project and enable involvement in other areas (e.g., have been for improving health systems performance over the past meteorological services) and establish new avenues for access to decade, totaling nearly US$12 billion.154 With the WBG’s strong funding, such as climate finance. emphasis on universal health coverage, the focus on health systems The ultimate success of development work on climate change is likely to be maintained or increased in the coming years. and health will vary by institution. Within the WBG, this relies on As noted above, climate change and its spectrum of hazard- integrating climate as a transversal element into the routine work related impacts poses multiple threats to health systems. The of HNP, informing and shaping components that are not specific WBG’s (and other institution’s) emphasis on health systems to climate change and health, including infrastructure and human strengthening means that a considerable share of the overall port- resources investments. This would mean that, for example, an folio is vulnerable to disruption due to climate change. However, analysis of the effects of climate change on medium-term changes there are also key opportunities for development. The WBG, for to disease dynamics and the implications for the population catch- example, is currently placing considerable emphasis on emergency ment area should be undertaken before a new hospital receives preparedness and rapid response in the health sector (e.g., in the financing. It should also be taken in tandem with an assessment form of the Pandemic Emergency Facility). Integrating climate of low-carbon options as described in Section 2. considerations in this work is an important way to ensure that Considering climate change as a transversal element that affects these investments are more effectively able to address the threats all health operations requires recognizing the unique challenges faced by client countries. posed by climate change and its related impacts. First, climate Investing in health systems strengthening to improve resil- change increases uncertainty across several domains that influ- ience and build capacity to adapt to climate change can also be ence both the supply of, and the demand for, health services and understood as assisting health systems in five areas, which are that unpredictability requires integrating response flexibility into defined in the US Department of Health and Human Services’ development operations. Storms can threaten basic infrastructure. Sustainable and Climate Resilient Healthcare Infrastructure Toolkit. Heat can undermine energy grids and prove fatal for nonclimate Understanding the unique role that healthcare plays during and controlled hospital rooms. And rising sea levels can erode the following extreme weather events, the vulnerabilities that may 32 De v e l op m e nt C ommu ni t y R o l e Pr o mo ti ng C li mat e- Smar t Res i li e n c e i n He a lthca r e exist to providing uninterrupted care, and the investments that are required to improve health system resilience must consider all Case Study 17: Resilience to Grid these factors, many of which have been discussed in the earlier Power Cuts, Renewable Energy— sections of this document, including: Nepal • Understanding climate risk and community vulnerabilities In response to unpredictable power cuts from the energy grid, • Land use, building design, and regulatory context Nepal’s Gunjaman Singh Hospital switched to solar power with • Infrastructure protection and resilience planning backup batteries. The solar panels power the hospital and the doc- tors’ quarters, including power for the x-ray machine and the waste • Essential clinical care service delivery planning autoclave. • Environmental protection and ecosystem adaptation Infrastructure and Supply Chains in WBG HNP Case Study 16: Resilient Passive Lending Energy—Sudan Infrastructure has diminished as a share of the HNP portfolio but Salam Centre for Cardiac Surgery is resilient to the harsh climate the WBG continues to lend for the construction or refurbishment and sand storms of the desert. The hospital reduces mechani- of hospitals, health centers, and other health facilities. It also cal cooling demands through passive technologies, such as thick makes investments in strengthening supply chains for health com- masonry walls with extensive insulation, deep overhangs, and high- modities and medical equipment, which are weak in many of the performance windows. To alleviate the significant dust infiltration countries in which the WBG operates. There are three key ways in from dust storms, a thermal labyrinth filters and precools outdoor which WBG investments must adapt in preparation and response air, reducing the demand on the solar-powered water heating and to climate change and which hold lessons for other development chilling equipment. institutions aiming to do similar. First, the Increased Risk of Extreme Weather Events These can be thought of as two primary dimensions to devel- Should Be Factored into Construction Planning opment engagement in strengthening health system resilience: The risks of heat waves, extreme precipitation, and coastal flood- Ensuring that the type of health systems strengthening that the ing increase as temperatures warm.155 Many of these require shifts institutions routinely finance better incorporates climate change in construction approaches to place an increased emphasis on adaptation, and consideration of the type of new investments to materials and techniques that can withstand extreme weather improve its support to the health sector in light of climate change. events that were previously too rare to be factored into facility The work that development institutions perform in both areas design. Additionally, extreme events can disrupt the supply of should draw to the greatest extent possible on existing national- water, sanitation, and electricity services to health facilities, which level agreements on priorities for the intersection of climate and necessitates planning for, and possibly investing in, backup options, health issues. UNFCC National Adaptation Plans described below and ensuring that the infrastructure is located out of harm’s way. are an important source of these agreements and can be useful A number of these systems have the benefit of also contributing starting points for understanding what can be done around cli- to climate change mitigation (e.g., installing solar panels or wind mate and health. turbines to provide a locally-controlled energy supply may be valu- able from the perspective of ensuring the continuity of services Making Approaches to Investing and may also contribute to reducing a facility’s carbon emissions). in Health Systems Climate Resilient A generalized risk of increased extreme events is insufficient for planning purposes, as not all areas are equally at risk, even At the WBG, HNP lending has increasingly shifted from input-based within one country. This means that potential climatic shifts at the financing (through investment project financing) to results-based local level and the impact on frequency, intensity, and duration financing (either through the Programs for Results or through of extreme weather events should be assessed and factored into investment financing tied to the results at the facility level). How- the facility design before major investments are made. There are ever, the WBG still makes considerable investments in key health tools for this purpose in high-income settings156 but these are not systems inputs. The areas that are most relevant for adaptation to yet widely available for low- or middle-income countries, though climate change are infrastructure and supply chains, and human many of the approaches used are generally applicable. resources for health. 33 c l im ate- s mar t he a lt hca r e In the absence of specific tools, a potential avenue involves of the likely impact of climate change on the populations to be partnering with national meteorological services or efforts that work served and the disease profile of the population. with local climate data (e.g., the ENACTS initiative) to quantify risks associated with climate change. Even short of having access The Third Important Shift Is an Embrace to good quality local data, there are practical steps that can be of Redundancy in the Supply Chain System taken (Table 3.3). Redundancy is a useful feature of resilient health systems as it enables service provision to continue unabated in the event of an extreme event that renders part of a health system inoperable. Case Study 18: Adapting Services in One way to do this without causing significant inefficiencies is to ensure that there are multiple systems coexisting in one country, Nonclimate Controlled Healthcare with private sector supply chains operating as a complement to Settings—India central medical stores run by the public sector. This approach has been adopted in several African countries, even without consider- Healthcare infrastructure without air conditioning in urban areas is ation of climate change (especially for products that have stringent of high concern given the effects of the urban heat island. There is increasing evidence that newborns and pregnant women are par- dosing requirements, such as antiretrovirals, or strict cold chain ticularly vulnerable to extreme heat. During the 2010 heat wave in needs, such as some immunizations) but it becomes even more Ahmedabad, India, when temperatures reached as high as 46.8°C, important in a context of increased extreme events. a retrospective review of hospital records at the city’s SCL General The implication for development financing is that supply chains Hospital found that neonatal intensive care unit (NICU) admissions could be assessed for their ability to withstand extreme events and, increased dramatically. if deficiencies are identified, projects should consider investing in During 2010, the maternity ward was located on the top floor of alternative supply chains. This could either take the form of investing the non–air-conditioned hospital and under a dark tar roof, making directly in the development of an alternative system outside the central it the hottest area in the building. As a response to the high rate of medical store (e.g., such as by using performance-based financing admissions and neonatal mortality in 2010, the maternity ward was mechanisms to support facilities to purchase quality products on the moved to the ground floor in 2012. It was found that, at 42°C, there market) or it could focus on improving the quality of existing private was a 64 percent reduction in heat-related admissions to the NICU sector supply chains. This latter option is particularly important in after moving the ward to a lower, cooler floor. contexts in which a robust private sector already provides some redundancy but where there are concerns about the quality of the The Second Way in Which Climate Change Affects products found in the private sector. In this case, investments could Investments in Health Infrastructure Is Around the be in the form of strengthening regulatory systems to ensure that Location of New Facilities poor quality products do not end up in facilities. Planning for new hospitals and health centers is typically done based Given these considerations, before embarking upon significant on existing catchment areas (and occasionally disease profiles) investments in major infrastructure, project teams should seek to or on demographic projections based on current populations and answer three central questions: trends in fertility and disease trends. Climate change affects both • Do the assumptions (e.g., on utilization rates) that underpin by shifting the patterns of disease transmission (which can result the economic modeling associated with the investment reflect in, for example, the spread of a pathogen to areas in which it was possible shifts in disease patterns related to climate change? not previously present) and by shifting populations themselves, • What impact will climate change have on the catchment area due to factors such as increasing desertification or increasing for the facility being built or renovated? Will climatic shifts, urbanization as a result of increased food insecurity. Although these particularly in rural areas, result in catchment reductions shifts often unfold over a relatively long time horizon (>10 years), agriculture is increasingly difficult in the area? Will climate major health infrastructure investments such as new hospitals are change increase the pace of urbanization? planned for even longer timeframes and so decisions about where to locate new facilities should systematically factor in assessments • Has the construction plan considered the possibility of increased frequency, intensity, and duration of extreme weather events? 34 Table 3.3: Resilient building design considerations. Category Intervention Benefit Building Site and Context Climate zone identification Understand extreme weather risks and long-term climate stressors and impacts on population health Site and orient building to maximize solar orientation and wind Buildings remains habitable if and when mechanical systems patterns are inoperable Implement site landscaping, planting and reflective paving Reduces heat island effect; reduces indoor temperatures; stabilizes soil Multiple access points Connection to two or more roads provides redundancy to road damage/blockage following event Ensure storm water management systems function; use Reduces impacts from flood events; provides safe routes for permeable paving in wet climates water flow Building Form Narrow floor plates Maximizes daylighting and natural ventilation; building remains habitable when systems fail Location of critical clinical services above flood levels or out of Ensures that critical clinical services can continue harm’s way uninterrupted during and after weather events Include provisions for patient surge during and following an Locating emergency services to allow for rapid expansion of event treatment area during or after an event improves ability to care for patients Building Exterior Enhanced building thermal envelope; reflective roofing Reduces heating and cooling load, allowing building to operate longer on a fixed thermal energy supply, or reduces the size of installed renewable energy sources Renewable power generation Reduces or eliminates dependence on utility grid; improves reliability Stronger exterior walls and roofs; wind and water resistant Enables building to withstand damage from extreme wind and exterior rain events Use of local materials Reduces length of time hospital is disrupted if damaged from weather event Space Heating and Cooling Natural ventilation Reduces dependence on mechanical systems; maintains habitable conditions Combined heat and power On-site electrical generation reduces dependence on utility grid; less likely to be damaged or interrupted by weather event Location of critical energy plant Locate critical energy and utility services above flood level and out of harm’s way Lighting Daylighting Maintains habitable conditions without need for energy systems Low-energy light fixtures Reduces energy consumption; allows building to operate longer on a fixed supply of fuel Water Supply and Heating Develop two independent water sources; municipal, on-site Redundancy in water sources improves ability to operate well, on-site bottled or potable water storage when one source is lost Low-flow water fixtures Reduces amount of water that requires heating Solar water heating Reduces GHGs from heating water; Improves likelihood of maintaining hot water if utility services are disrupted Sewage Treatment Backup or on-site sewage treatment If municipal sewage system is damaged or lost, hospital can remain safely operational Supply Chain Designate areas for additional clinical/ food supplies If transportation systems are disrupted, facility can continue to function 35 c l im ate- s mar t he a lt hca r e Human Resources for Health consequences of climate change.157 A key issue is building capacity to anticipate and prepare for risks and to manage complex emer- Climate change and associated hazards affect demand for health gencies. Building resilience in the health workforce is challenging services both by increasing (and occasionally decreasing) the bur- and demands a long-term view and investment that could exceed den of disease and by influencing the movement of people. This the duration of a typical development project.158 means that the need for both general health staff and specialized Community engagement is also critical, both in emergency expertise will shift and that health outcomes will suffer if this is preparedness and in responses to the aftermath of an extreme not properly factored into planning efforts. weather event or a pandemic. Investment to strengthen commu- For example, the spread of malaria to a higher elevation means nity capacities is essential for building resilience of the system that health workers who have not historically needed to treat the and avoiding some of these many negative consequences of a disease will need to be trained in its management, and the overall changing climate.159 burden of disease may also increase, necessitating redeployment of staff. Projections of the ways in which climate change affects Potential Areas for Develoment future needs must inform the investment decision making process. Investment in Resilience and Adaptive The planning of investments in human resources for health— Capacity in particular longer-term financing for large-scale capacity development—should be based on rigorous assessment of future ­ needs, rather than simply relying on historical data. Case Study 20: Innovative Heat Wave Extreme weather events can disrupt transport and travel, Early Warning System and Action inflicting significant damages on homes of healthcare workers. Plan—India Hospitals in vulnerable locations must often shelter not only many healthcare workers during and after events, but their extended Ahmedabad is a growing urban center of 7 million people in Gujarat families as well. Accordingly, investments in human resources for state, western India. During an extreme heat wave in 2010, the city health may also need to anticipate such circumstances. registered 1,344 additional deaths. Following this event, the Ahmed- abad Municipal Corporation and a coalition of national and interna- Additionally, financing should shift to focus more heavily on tional experts came together in 2013 to develop and implement an the development of institutional capacities, which is critically early warning system and the first Heat Action Plan (HAP) for a city in important for assisting countries to cope with the unpredictable India. Updated in 2016, the Ahmedabad HAP utilizes best practices on early warning systems and heat adaptation by focusing on four key strategies: • Building public awareness and community outreach (com- munication) using traditional (pamphlets, advertisements, radio, Case Study 19: Resilience etc.) and new media tools (SMS, WhatsApp, etc.) to commu- to Increased Weather Events— nicate the risks of heat waves as well as what to do to avoid St. Vincent and the Grenadines heat-related illness and death. • Initiating an early warning system and interagency coordina- Georgetown Hospital participated in the PAHO Smart Hospital ini- tion that put in place formal communication channels to alert tiative and was refurbished to be resilient to hurricanes, as well as government agencies, hospitals, community groups and the pub- to ash from a neighboring volcano. The hospital strengthened its lic about predicted extreme temperatures. roof, installed a water storage system and solar panels to generate • Capacity building among healthcare professionals based electricity, and took other energy efficiency measures that reduced upon training to recognize and respond to heat-related illnesses. energy consumption by over 60 percent. After a hurricane struck • Reducing heat exposure and promoting adaptive measures St. Vincent, the hospital remained operational and had a working by mapping high-risk areas to increase outreach and prevention supply of water that supported the hospital and neighboring com- activities, such as providing cooling spaces and drinking water on munities. Some members of the community who worked on the extreme heat days. construction of the hospital recognized the advantages of solar Based on positive initial results that show reductions in heat- power and added solar panels to their homes, reducing their energy related morbidity and mortality in the city, several other cities and costs and making their homes more resilient to the impacts of regions in India are developing HAPs based on the Ahmedabad hurricanes. model. 36 De v e l op m e nt C ommu ni t y R o l e Pr o mo ti ng C li mat e- Smar t Res i li e n c e i n He a lthca r e Early Warning Systems Few low- or middle-income countries have scaled up early warning systems to the national level. This creates a significant Early warning systems represent a growing field of interventions investment opportunity for development institutions, which can leveraging climate information to improve health outcomes that pass along the lessons from past efforts to create such systems to shift the focus from surveillance and response to prediction, inform this kind of scaling up.163 preparedness, and prevention.160 Recent investments in early For example, successful early warning systems depend on warning systems have provided case studies for both disease and early action actually being taken and the response component of hazard early warning systems, from the forecasting and control of this type of intervention should be considered at the outset. The meningococcal meningitis epidemics in West Africa to heat wave International Federation of Red Cross and Red Crescent (IFRC) early action plans in India.10 Climate Centre has invested heavily in its ”Early Warning>Early Early warning systems can address specific disease burdens Action” campaign164 and in 2012 piloted a health risk manage- (malaria, dengue, cholera, meningitis, etc.), specific hazards or ment project that focused on deploying early warning systems multi-hazard frameworks (heat waves, floods, cyclones, hurricanes, to reduce the burden of diarrheal disease in Kenya and Tanzania droughts, fires, pollution, etc.) or specific lead times (e.g., from and dengue fever in Indonesia and Vietnam.165 In addition to short-term planning around extreme weather events to medium- early warning system design, it prioritized education campaigns, term planning around seasonal or decadal forecasts). Investments improved coordination for early detection through local com- in early warning systems can also provide value added to existing mittees, climate-informed contingency planning, best practices funding for health systems strengthening and overall emergency for disease prevention in communities at risk, and strengthened response preparedness.161 institutional partnerships. The cornerstones of early warning systems are risk models built on climatic and health information. There are some tools Disaster Preparedness Systems available globally to assist with this, such as those contained in the IRI Climate Data Library (see, for example, the Malaria Early Disaster risk reduction has emerged as a unique field of its own, Warning System,) and the US Geological Survey’s Early Warning with multiple internationally agreed frameworks for action, a UN and Environmental Monitoring Program. Many of the existing early body devoted to the area (the UN Office for Disease Risk Reduc- warning systems have developed customized risk models for the tion), and a global partnership managed by the WBG (the Global local conditions162 and some of the tools exist to assist with this Facility for Disaster Risk Reduction), among other initiatives. process are listed in Table 3.4. Table 3.4: Select early warning risk management tools. General or health Tool Source sector-specific Year Heatwaves and Health: Guidance on Warning-System World Meteorological Organization and World Health Health 2015 Development Organization Using Climate to Predict Infectious Disease Epidemics World Health Organization Health 2005 Developing Early Warning Systems: A Checklist United Nations International Strategy for Disaster General 2006 Reduction Guidelines on Early Warning Systems and Application of World Meteorological Organization General 2010 Nowcasting and Operation Warnings Implementing Hazard Early Warning Systems Global Framework for Disaster Risk Reduction General 2011 Climate Information and Early Warning Systems United Nations Development Programme General 2016 Communications Toolkit 37 c l im ate- s mar t he a lt hca r e A full survey of this area and the ways that it can apply to Potential Programmatic Responses the health sector is beyond the scope of this paper, but there are to Climate Change several tools that WHO has developed that are specific to the health sector and that are useful resources in specific situations: Although health systems strengthening is the largest single area • The WHO Hospital Safety Index166 is used to assess a hospi- of HNP investment for the WBG, considerable resources are still tal’s capacity to function in the event of a major disaster or directed to programmatic areas. Other development institutions emergency. This tool could be applied in the context of an have different priorities, though many also have discrete realms HNP investment in a health facility in an area that is prone of programmatic investment. The areas that are most directly to disasters, to determine actions to be taken to strengthen impacted by climate change are malaria and other vector-borne its disaster preparedness. diseases, food- and waterborne diseases, and nutrition. • The PAHO Health Sector Self-Assessment Tool for Disaster Adapting Approaches to Vector-, Food-, Risk Reduction167 identifies weakness in a health system with and Waterborne Diseases in Response regard to disaster preparedness. This tool is particularly useful to Climate Change in the context of project preparations in a setting in which a government is seeking WBG support in this area. The approaches to controlling malaria, most other vector-borne diseases, and most food- and waterborne diseases are well estab- Using Climate Information to Strengthen lished: protocols for prevention and treatment already exist for Health Preparedness malaria, schistosomiasis, cholera, and other diseases. Shifting away from a culture of response and relief to disaster Climate change will not affect this, and so will not change what preparedness (and in some cases prevention) requires new frame- types of services are supported in certain investments: malaria works for the integration of climate information derived from control in the context of climate change still involves long-lasting probabilistic forecasts. The International Federation of Red Cross insecticide treated bednets, artemisinin-containing combination and Red Crescent Societies reported in 2013, for example, that it therapies, and indoor residual spraying, just as it does in the used seasonal forecasts to act prior to flooding events in the Sahel, absence of climate change. stocking and pre-positioning emergency relief items in several It is where these are to be provided that is most affected by West African countries.168 These efforts required international climate change. Climatic changes are shifting the geographical dis- assistance and community engagement that could be mobilized tribution and/or seasonality of several vectors for disease. Diseases based on likely, though not certain, information and leveraged likely to be impacted by the changing climate include malaria, institutional learning around regional flooding events in 2008.169 dengue fever, chikungunya, schistosomiasis, African trypanoso- miasis, West Nile virus, Hanta virus, Japanese encephalitis, Rift Valley Fever, and Lyme disease. Climate change is also increasing Case Study 21: Cholera Treatment the risk of many food- and waterborne diseases. Diseases such as Center in Port au Prince—Haiti cholera become more common as a result of warmer temperatures and of extreme weather events (e.g., flooding). Following the 2010 Haiti earthquake, cholera, a disease that had not existed in the country for more than a century, proliferated. WHO has attempted to quantify the impact of climate change Weak public systems were powerless to protect against a chain on three key climate-sensitive causes of morbidity and mortality: of events triggered by the environmental shock, and thousands malaria, dengue fever, and diarrheal diseases, outlined in Table 3.5.170 became ill and perished. In response, public health officials and The implication for development investments is that climate doctors at Les Centres GHESKIO teamed up with architects and change increases the importance of having good access to data: designers at MASS Design Group to build a state-of-the-art treat- historical predictions become less accurate as a result of climate ment center that would enable responders to treat the ill while also change, increasing the risk that programmatic responses will be preventing recontamination of water. The facility also incorporated misaligned with disease patterns. This requires the use of the elements of sustainable design to minimize energy use and envi- diagnostic tools covered earlier to analyze the seasonality and ronmental impact. timing of interventions, map populations at risk, and monitor These efforts illustrate the critical links between mitigation trends. This also highlights the potential value of investing in and adaptation. New facilities and interventions are necessary to early warning systems. respond to emerging climate-related health impacts. There is also considerable opportunity to integrate low-carbon and environmen- This increased need for climate data can be built directly into tally friendly strategies, enabling a truly climate-smart approach. health sector programming. For example, the US President’s Malaria 38 De v e l op m e nt C ommu ni t y R o l e Pr o mo ti ng C li mat e- Smar t Res i li e n c e i n He a lthca r e Table 3.5: WHO assessment of potential impact of climate change on three significant diseases. Mechanism of action and predicted impact Disease Pathogen Vector of climate change Malaria Plasmodium falciparum Various Anopheles Influenced by both temperature and rainfall, so complex and nonlinear (also mosquitoes (particularly strongly related to economic growth): expansions to some new geographies A. gambiae) likely (particularly in Asia and South America) but transmission declines in hotter temperatures Dengue fever Dengue virus (flavovirus) Primarily Aedes aegypti Likely expansion of geographical range, particularly in Sub-Saharan Africa and Aedes albopictus (although also strongly related to economic growth) mosquitoes Diarrheal diseases Multiple (e.g., E. coli, Multiple Limited data make predictions challenging but likely temperature-related rotavirus, salmonella) increase in mortality, particularly in South Asia and Sub-Saharan Africa the setting of populations that are already struggling with chronic Case Study 22: Malaria in Ethiopia food insecurity and by those who are newly confronted with nutrition-related challenges as a result of extreme events. Poor and Malaria is a major public health problem in Ethiopia, although its disadvantaged populations—especially women and children—are mountainous terrain reduces the risk of infection among the greater likely to bear the brunt of the effects of climate change on nutri- population. As part of a broader effect to scale up the malaria tion, which calls for programmatic responses that are tailored response in the country, the Federal Ministry of Health collaborated to the specific needs of those who cannot afford basic nutrition. with the National Meteorological Agency, with financial backing from The implications are significant for the development commu- the Global Fund to Fight AIDS, Tuberculosis and Malaria. nity and particularly the WBG given their emphasis on stunting: The National Meteorological Agency focused on supporting modeling of the impact of climate change on nutrition suggests decision making in malaria programming through forecasting tools based on rainfall and temperature patterns. Both the National Meteo- that in 2030 the number of moderately stunted children could rological Agency and the Federal Ministry of Health concentrated on increase by approximately 3.6 million and the number of severely providing regular communications to the subnational level to assist stunted children could increase by 3.9 million.172 This suggests regional program managers. that WBG targets on stunting will be harder to reach, requiring increased investments in nutrition. As with vector-, food-, and waterborne diseases, the effect on Initiative funded a national climate analysis in Tanzania in 2012, individual nutrition project is manifold. It is altering distribution, leveraging historical climate data to better evaluate the impact while not necessarily requiring a fundamentally new nutritional of its malaria control interventions over the preceding decade.18 approach (though does increase the importance of improving infor- mation systems to anticipate climate-related shifts). Additionally, Climate Change Implications for Development CO2 is changing the concentration of proteins and micronutrients Approaches to Nutrition in many cereal crops. This can have significant impact on those communities already facing nutrition stresses, highlighting a greater Climate change has significant effects on both the quantity and imperative to diversify food sources and prepare for climate shocks. quality of food production, resulting in higher food prices and The second effect is to increase the importance of multi-sector reduced caloric intake, increasing the risk of undernutrition and responses to nutrition challenges, as it will not be possible to stunting, particularly in children. Additionally, climate change address all of the nutrition-related challenges posed by climate influences the composition of diets, with reduced consumption change within the health sector. Collaboration with the agricul- of fruits and vegetables expected to be a major risk factor for ill ture sector will be critical, given the long-run effects of climate health. One recent study found that mortality related to these change on food security. The social protection sector is another effects far exceeded the estimated deaths from undernutrition.171 important partner, particularly given the disproportionate effect These shifts have two primary impacts on financing for nutri- on poor women and children. tion. The first is to increase demand for nutrition services, both in 39 c l im ate- s mar t he a lt hca r e Cross-sector collaboration is often challenging, but the represented but should be embedded within the basic approach Investing in the Early Years initiative, for example, is creating an of the initiative. For example, analysis of the projected impact important opportunity to strengthen engagement between Global of climate change on stunting patterns should be systematically Practices. The climate change perspective is not yet sufficiently included in action plans. 40 Chapter 4 Policy and Partnership Development institutions can engage at the national level around climate change and health policy along two distinct paths: (i) the focused inclusion of a climate perspective in health dialogue between development actors and government counterparts, particularly ministries of health and of finance; and (ii) the participation of development staff in broader climate policy fora. The Climate Perspective in Ongoing Health Policy Dialogue Staff of the WBG, like many other development institutions, are constantly engaged in policy dialogue with client governments. Diving deeper into these interactions within the WBG may shed light on relevant processes at other development institutions and illuminate clearer paths forward for all. For example, the Country Partnership Framework (CPF) used within the WBG provides a framework by articulating how the WBG will support a country’s national development plan while advancing the WBG’s twin goals of ending extreme poverty and promoting shared prosperity. Given its impact on the economic development prospects of many countries, climate change should increasingly feature in Country Partnership Frameworks (CPFs) and in the analytical work that precedes it (particularly the Systematic Country Diagnostic). The connection between climate change and health should emerge as part of this process. The WBG should be conducting focused analytical work into the ways climate change is affecting health (and the pathways through which this contributes to dampening economic development) and how the health sector can both mitigate and adapt to climate change to further emphasize the links between climate change and health. Analytical work in this area can also enrich policy dialogue with both ministries of health and of finance. While important for defining priorities for operational lending, it is an important means for the WBG and other development institutions to play a thought-leadership role, helping governments identify emerging issues for the health sector. There is considerable scope for increasing the extent to which the development community addresses climate change in this dialogue. A more systemic approach to commissioning analytical work on the links between climate change and health at the national level would be a first step, with the results of this work influencing the process of identifying key priorities in the health sector. A second key area in which the development institutions can play an important role in policy dialogue is around financing for climate and health work. Considerable investment in climate change is occurring; a partial estimate put total private and public international financing at US$391 billion in 2014.173 The majority of finance is for mitigation (particularly renewable energy), while US$25 billion was provided from public sources174 for adaptation, particularly in East Asia and the Pacific (46 percent), Sub-Saharan Africa (13 percent), and Latin America and the Caribbean (12 percent). The health sector has been excluded from this financing despite the opportunities that abound for health sector mitigation via low-carbon healthcare strategies and the sector’s significant and rising costs related to adaptation. Accordingly, the costs associated with health sector adaptation to climate change or the implemen- tation of low-carbon strategies are borne almost exclusively by traditional sources of financing for the 41 c l im ate- s mar t he a lt hca r e sector (e.g., ministry of health budgets, out-of-pocket payments, The WBG, and other similarly engaged institutions, are posi- insurance mechanisms, development assistance for health). There is tioned to discuss approaches to climate change with governments an untapped opportunity to help countries access climate financing and ministries by: for health, a topic that government officials repeatedly raised at • Encouraging health ministries to develop a carbon baseline for the Second Global Conference on Health and Climate in July 2016. their sector, identify carbon reduction targets where appropri- There are several global climate financing mechanisms that can ate, and develop low carbon health sector development provide resources for climate change and health work, including175 The Global Environment Facility, The Green Climate Fund, The • Stimulating health ministries to develop resilience and adap- Adaptation Fund, and The Least Developed Country Fund. There tive strategies both for new health system infrastructure and are also some programs with development and aid agencies, such disease-specific impacts as DFID, the Nordic Development Fund, USAID, and others that • Advocating for the introduction of low-carbon, carbon reduc- may fund climate and health initiatives. tion and health creating investment schemes Development institutions have significant expertise partner- • Calling for iterative risk assessments that qualify and quantify ing with climate funds176 but this has not been a focus within the health related climate hazards health sector to date and there is considerable scope for develop- ment staff to play a more active role in supporting governments • Catalyzing health sector investment in renewable energy, accessing these funds. energy efficiency, local transport systems, sustainable and safe Development institutions often have one other important com- water use, safe waste disposal, and the purchase of locally- and parative advantage in policy dialogue: they can bring a multi-sector sustainably-produced food where appropriate perspective to looking at health outcomes. This is particularly • Encouraging the health sector to develop partnerships with important because of the key roles the water and sanitation and meteorological agencies and climate information service pro- the agriculture sectors (which are themselves sensitive to chang- viders to prepare and plan for health-related climate hazards ing climatic conditions) play in determining health outcomes. The • Encouraging industries in the healthcare supply chain to develop WBG, in particular, also has significant investments in other areas low carbon and environmentally sustainable manufacturing that influence health, including transportation, urbanization, and and distribution practices social protection. Recognizing these links and broadening policy dialogue on health to encompass these sectors can further boost • Stimulating innovative solutions in all aspects of climate development community contributions. mitigation, low carbon development, and resilient health strengthening approaches Engagement with Governments Helping ministries of health in tackling climate change mitiga- and Other Stakeholders tion and adaptation can be a means of strengthening local capacity and supporting better health in communities. Development leaders Many countries have outlined their approaches to climate change can foster discussions that can help remove barriers in the system through Nationally Determined Contributions (NDCs), National and generate further momentum across the sector. Adaptation Plans (NAPs), or fully-developed strategies.177, 178 Several Engaging with the private sector and international agencies health ministries have also developed adaptation plans to respond to support the health sector in low- and middle-income countries to climate change and established extreme weather event response can foster joint initiatives for integrating climate-smart healthcare mechanisms.179 Yet, so far, few health ministries have developed into their core goals. This would parallel a similar effort through national climate mitigation or low-carbon healthcare approaches. ministries of health and development, such as that the UNDP is The WBG has been involved in development of green build- developing with several other UN agencies.180 ing codes for 10 countries, which includes minimum energy and water saving requirements for health care projects. This initiative, Participation of Health-Focused which establishes mandatory guidelines, was implemented in Development Staff in Broader Climate collaboration with local governments. These codes are devel- Policy Fora oped with extensive local market study and public consultation, and they consider the costs and returns of each of the proposed The landscape for national climate policy is often complex. Gov- requirements under code. ernance varies among countries, with different modes of engage- ment: national task forces, interagency working groups; elevated bureaus; appointed focal points under executive branches; and the 42 P o li cy a nd Pa r tne rship vertical programming of climate policy within sector and impact Adaptation Programs of Action (NAPAs; see Box 6), introduced areas. However, there are good examples of national governance in 2001 to address the most urgent and immediate national adap- of climate processes generating concrete action to combat the tation needs.185 The initial NAPAs, while primarily championed drivers of climate change and adaptation to climate impacts.181 by ministries of environment and their partners, resulted in an Existing avenues of engagement on climate policy should be pri- unprecedented country-led cataloging and ranking of proposed oritized across low- and middle-income countries: the NAP and activities across sectors in the NAPA priorities database.186 NDC processes as well as improved coordination with national While the NAP process provides a key entry point for national meteorological services (around available information and tools climate policy dialogue and country-led adaptation priorities, the relevant to stakeholders and decision making at the national level). health sector has historically been underrepresented in this process. While past performance has been weak, the active engagement of In 2010, WHO evaluated the inclusion of health within the first the health sector and the integration of health priorities through generation NAPAs and concluded that only 11 percent of the 459 these governance mechanisms and institutional partnerships priority projects focused on health explicitly. Only 4 percent of the provide critical opportunities for overall adaptation planning and portfolio of the Least Developed Country Fund had been applied policy, in addition to health-sector driven approaches.182 to health adaptation, despite 95 percent of the NAPAs identifying In 2010, the 16th Conference of Parties (COP 16) to the UN health as a priority sector.187 Over time, health has been more rec- Framework Convention on Climate Change (UNFCCC) established ognized, to some degree. A recent study found that of 184 NDCs, a process to support least-developed countries in identifying and 65.8 percent make mention of health, with 74.4 percent of those implementing NAPs, specifically to address medium- and long- referring to it in the context of adaptation and 23.1 percent with term adaptation needs.183 This process built on almost a decade of regard to mitigation.188 Nevertheless, these inclusions are rarely experience gained by least-developed countries through the National more than passing mentions and the international climate com- munity still has work to do to fully integrate health. Climate-sensitive sectors, such as agriculture, water, and Box 6: The National Adaptation Plan energy have more successfully accessed climate-related funding Process184 and Nationally Determined and have engaged in national climate policy, suggesting there is Contributions considerable scope for further engagement by the health sector in international climate processes. Development institutions have The National Adaptation Plan (NAP) process was established in 2010 several avenues available in emphasizing health within the inter- by the COP under the Cancun Adaptation Framework. Accord- national climate discourse, including policy dialogue with ministers ing to the UNFCC, under the NAP, least-developed countries “are of environment, health, and finance, stakeholder engagement on invited to identify their medium- and long-term adaptation needs and the periphery of the international climate negotiation process, and develop and implement strategies and programs to address these participation in civil society and policy-oriented events aimed at needs, building upon their experience in preparing and implementing influencing climate policies. National Adaptation Programs of Action (NAPAs).” Development institutions also have a range of significant The objectives of the NAP process are: to reduce vulnerability technical resources that can augment the political dialogue by to the impacts of climate change, by building adaptive capacity and identifying national goals for health adaptation and mitigation resilience; and facilitate the integration of climate change adaptation, planning, while positioning health as integral to stronger socie- in a coherent manner into relevant new and existing policies, pro- grams and activities (particularly development planning processes ties and the transition to a low-carbon economy. For instance, and strategies) within all relevant sectors and at different levels, as the 2014 WHO Guidance to Protect Health from Climate Change appropriate. Through Health Adaptation Planning189 serves as a robust and The COP also mandated the Least Developed Countries Expert tailored resource for national governments and partners in the Group to deliver technical support and the Global Environment Facil- health community seeking to align health adaptation planning to ity to provide financial support to those countries preparing NAPs. the NAP process (see Box 7). In anticipation of an historic international climate agreement at the December 2015 UNFCCC Conference of Parties in Paris, many Potential Partners for Health countries described climate actions they intended to take after 2020. Such statements came to be known as Intended Nationally and Climate Projects Determined Contributions, pairing national policy with the global framework. The use of “intended” ceased following ratification of the Academic work highlighting the impact of the climate on health has Paris Agreement, and these declarations are now called Nationally been available for decades, yet most countries and international Determined Contributions (NDCs). organizations have placed little emphasis on the intersection of 43 c l im ate- s mar t he a lt hca r e climate and health. One consequence is that many countries have Box 7: Recommended Steps in capacity constraints in this area, with limited technical expertise Health National Adaptation Planning to access climate information and use it to shape health program- (HNAP) (WHO, 2014) ming, despite some notable efforts at the political level.190 There are few sources of technical assistance and financing in 1. Align the health adaptation planning process with the national this area. WHO is a key technical partner in most countries as it process for developing a National Adaptation Plan has the longest and most sustained history of climate and health 2. Take stock of available information work among international organizations. It has also produced a 3. Identify approaches to address capacity gaps and weaknesses range of global publications and materials191 and been involved in in undertaking the HNAP several climate change and health projects at the country level.192 4. Conduct a health vulnerability and adaptation assessment, Other institutions running and advising climate and health including short- to long-term adaptation needs in the context of projects in multiple countries include UNDP (which has generally development priorities worked closely with WHO), the Center for Health and the Global 5. Review implications of climate change on health-related devel- Environment at the University of Washington, the International opment goals, legislation, strategies, policies and plans Research Institute for Climate and Society at Columbia University, 6. Develop a national health adaptation strategy that identifies priority adaptation options the World Meteorological Organization, USAID, Germany’s Deutsche 7. Develop an implementation strategy for operationalizing HNAPs Gesellschaft für Internationale Zusammenarbeit (GIZ), and the and integrating climate change adaptation into health-related Red Cross/Red Crescent Climate Centre. Given confluence with planning processes at all levels, including enhancing the capac- the other climate agendas, the much larger set of actors working ity for conducting future HNAPs on mitigation, resilience, and disaster risk reduction represent 8. Promote coordination and synergy with the NAP process, par- important sources of technical expertise. ticularly with sectors that can affect health, and with multilateral Finally, it is important to highlight institutional internal capac- environmental agreements ity that can be used to strengthen the climate sensitivity of health 9. Monitor and review the HNAP to assess progress, effective- programming. Within the WBG, for example, relevant technical ness and gaps expertise can be found in the Climate Change Group, at the IFC, 10. Update the health component of the National Adaptation Plans and in global practices such as Environment and Natural Resources, in an iterative manner Energy, Transport, and Urban Global Practices. 11. Outreach on the HNAP process, including reporting on prog- ress and effectiveness 44 Chapter 5 Conclusion The health sector contributes significant emissions worldwide through energy use, transport, and through products manufactured, used, and disposed of. It is also at the forefront of the response to climate impacts, preventing and diminishing human casualties. Climate mitigation, adaptation, and low-carbon and resilient health development strategies reduce emissions, build healthcare climate resilience, and yield significant health and economic co-benefits. Climate-smart healthcare will strengthen the health sector and communities by ensuring access to clean and independent energy, safe water, clean transport, and clean waste disposal mechanisms. It will also stimulate the development and supply of sustainable products, while preparing the sector for a future of known and unknown health-related climate hazards. Fundamentally, climate-smart solutions can be a cornerstone of universal healthcare and sustain- able development. By integrating climate-smart principles into health sector strategies, development institutions can establish low-carbon, resilient, and adaptive programs that set precedents for other sectors, while sharply responding to pressing climate needs. The authors of this document have drawn on the resources of many other institutions and experts, and hope that others will use this work in their own efforts to amplify and accelerate the rate of posi- tive change toward more sustainable climate and health futures. 45 APPENDIX 1 Climate Change Glossary CO2: Carbon dioxide is the most prevalent greenhouse gas. CO2 emissions result from the combustion of fuel, from land use changes and from some industrial processes. CO2e: Carbon Dioxide Equivalent. There are six main greenhouse gases, which cause climate change and are tar- geted by the Paris Agreement. Each gas has a different global warming potential. For simplicity of reporting, the amount of each gas emitted is commonly translated into a carbon dioxide equivalent (CO2e) amount so that the total impact from all sources can be summed to one figure. GHG: Greenhouse gases (GHG) include carbon dioxide, nitrous oxide, methane, hydro fluorocarbons, per fluoro- carbons and sulphur hexafluoride. They trap heat in the earth’s atmosphere, such that a rise in levels of GHG increases temperature—the so-called greenhouse effect. GHG Categories include direct or Scope 1 emissions, which are emissions directly controlled by an organization (mostly through the burning of fossil fuels). Scope 2 relates to indirect emissions from electricity, heat and steam purchased elsewhere but consumed and managed on-site, and Scope 3, which forms the bulk of indirect emissions, relate to the extraction, production and transportation of purchased materials and services procured. GHG Protocol: The Greenhouse Gas Protocol (GHG Protocol) is the most widely used international accounting tool for government and business leaders to understand, quantify, and manage greenhouse gas emissions.193 Direct Carbon Emissions: Emissions resulting from on-site combustion of fuels which produce CO2 emissions, for example, the fossil fuel burned to heat water for a hospital. In addition, some processes emit other greenhouse gases. For instance, the production of certain chemicals produces methane (CH4) and the use of anesthetic gasses leads to nitrous oxide (N2O) emissions. Indirect Carbon Emissions: Emissions that are a consequence of an organization’s activities but occur off-site. For example, a medication or appliance dispensed by a healthcare provider has emissions produced during its manu- facture, transportation, usage and disposal. These are counted as indirect emissions of the healthcare provider. 47 annex 1A Carbon Emission Hotspots Across the Health Sector in England by Setting An illustration of a carbon hotspot analysis. The pattern will vary across countries and settings and can help identify focus areas. Size of dots corresponds to impact in each sector. Color corresponds to type of hotspot. Yellow: travel ad transport; green: energy; light blue: pharmaceuticals, medical devices and gases; dark blue: commissioned services. Adult social care Dept. and ALBs Mental health Public health Community Ambulance Specialist Dentist Acute CCG GP Service user travel Visitor travel Staff travel Business travel Electricity Gas Oil Coal Renewables Pharmaceuticals excluding inhalers Meter dose inhalers Medical instruments/equipment Freight transport Business services Paper products Other manufactured products Manufactured fuels, chemicals and gases Food and catering Construction Information and communication technologies Water and sanitation Waste products and recycling Other procurement Anaesthetic gases Commissioned health and social care service 49 annex 1B U.S. Healthcare GHG Emissions Absolute U.S. healthcare greenhouse gas emissions (MtCO2-e) by national health expenditure category and U.S. total for 2003–2013. Expenditure category/year 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Hospital care 184 188 195 200 206 210 218 222 226 233 238 Physician and clinical 57 60 62 65 65 68 69 70 72 74 77 services Other professional 7 8 8 8 8 8 9 9 9 10 10 services Dental services 11 12 12 12 12 12 12 12 12 12 11 Other health, residential, 20 21 22 22 23 23 24 25 25 25 26 and personal care Home healthcare 9 10 11 12 13 13 14 15 15 16 17 Nursing care facilities 35 36 37 37 38 39 39 39 40 40 41 and continuing care retirement communities Prescription drugs 59 63 65 68 71 71 72 69 68 67 68 Durable medical 12 13 14 15 16 16 16 16 17 17 18 equipment Other nondurable 11 11 12 12 13 13 13 13 14 15 15 medical products Government 13 13 14 14 13 13 13 13 14 14 15 administration Net cost of health 7 7 7 8 8 8 8 8 8 8 9 insurance Government public 28 28 28 28 29 30 31 31 29 29 29 health activities Research 12 12 13 12 12 12 12 13 12 12 11 Structures and 45 47 50 51 57 62 59 60 65 70 71 equipment Healthcare total 511 529 547 563 584 600 608 615 626 643 655 U.S. total a 7073 7208 7245 7182 7308 7096 6636 6849 6727 6502 6673 Healthcare % of U.S. 7.2% 7.3% 7.6% 7.8% 8.0% 8.5% 9.2% 9.0% 9.3% 9.9% 9.8% GHG emissions US national emissions are from the annual US Greenhouse Gas Emissions Inventory conducted by the USEPA. a Eckelman MJ, Sherman J (2016) Environmental Impacts of the U.S. Healthcare System and Effects on Public Health. PLoS ONE 11(6): e0157014. doi:10.1371/journal.pone.0157014 http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal .pone.0157014 51 annex 1C Environmental/Health Impacts of U.S. Healthcare Activities Products/ Govt./ Hospitals Prof. services Other care supplies insurance Investmt. HH non-cancer 690 Mt toluene e HH cancer 250,000 t benzene e Ecotoxicity 69,000 t 2,4-D e Smog formation 40 Mt O3 e Ozone depletion 731 t CFC-11 e Eutrophication 94,000 t N e PM emissions 1.0 Mt PM10 e Acidification 3.1 Mt SO2 e GHG emissions 655 Mt CO2 e 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Eckelman MJ, Sherman J (2016) Environmental Impacts of the U.S. Healthcare System and Effects on Pub- lic Health. PLoS ONE 11(6): e0157014. doi:10.1371/journal.pone.0157014. http://journals.plos.org/plosone/ article?id=info:doi/10.1371/journal.pone.0157014 53 annex 2 Community Health and Safety Safeguard In August, 2016, the World Bank Board of Directors approved a review and update of World Bank Safe- guard policies. These are salient in many ways to this work. Relevant excerpts that deal with health are listed below. Excerpts: ESS4: Community Health and Safety 101. ESS4 consolidates into one standard the existing practices related to the impacts of projects on communities. It incorporates OP/BP 4.37, Safety of Dams, and also captures many of the World Bank’s provisions regarding the design and safety aspects of infrastructure, equipment, products, services, traffic, and hazardous materials. It requires borrowers to develop and implement measures to address possible community exposure to disease as a consequence of project activities and to address emergencies through contingency planning. ESS4 includes requirements on security personnel (both government and private) that are similar to the provisions of some other MDBs. 49. Many of the investment projects the World Bank supports advance the realization of human rights expressed in the Universal Declaration of Human Rights, including through better healthcare, education, and social protection, and better access to such services. 57. Climate change is among the most pressing development issues of this generation. The World Bank recognizes the fundamental importance of this issue and has developed an institution-wide strategy to address it. The proposed ESF includes a range of climate change considerations, including GHG emission estimation in the proposed ESS3: Resource Efficiency and Pollution Prevention and Management, and climate change adaptation in ESS4: Community Health and Safety. 153. Additional resources would be needed for the new steady state to cover, in particular, the fixed costs associated with hiring additional staff for new areas covered by the ESF, as well as variable and overhead costs required to deliver project support across the Bank’s IPF pipeline and portfolio. Incremental costs would be associated with: a) Broader scope of practice due to new topic areas (labor, community health and safety, stakeholder engagement), new processes (ESCP, risk classification, social assessment), and the assessment of borrowers’ ES frameworks. . . 55 References 1 United Nations (2015). Sustainable Development Goals. Available at: http://www.un.org/sustainabledevelopment/ sustainable-development-goals/ [Accessed on 24/05/16] 2 WHO (2016). Address to the 69th World Health Assembly by the Director General, Geneva, Switzerland on 23rd May 2016. 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Hospital Safety Index. http://www.who.int/hac/techguidance/ Publications, Washington DC. safehospitals/en/ 146 While globally available products can often provide open-source and 167 PAHO. Health Sector Self-Assessment Tool for Disaster Risk Reduction. web-based platforms for decision-making, with information appro- http://www.paho.org/disasters/index.php?option=com_content& priate to large-scale assessments of climate impacts on health, they view=article&id=1375%3Ahealth-sector-self-assessment-tool-for- frequently do not fully access climate data available at the country level disaster-risk-reduction&catid=895%3Abooks&Itemid=924&lang that may be the most relevant to national and subnational planning. =en 147 All quotes taken from the website for the tool. 168 IFRC. 2013. Red cross responds as severe flooding takes its toll in the Sahel. 148 Saghir, J. 2015. Transforming weather, climate and hydrological ser- (http://www.ifrc.org/en/news-and-media/news-stories/africa/mali/ vices in Africa. Speech delivered at Launch of conference ‘Strength- red-cross-responds-as-severe-flooding-takes-its-toll-in-the-sahel-63090/). ening Climate and Disaster Resilience in Sub-Saharan Africa,’ 169 Tall A et al. 2012. “Using Seasonal Climate Forecasts to Guide Disas- Geneva. (http://www.worldbank.org/en/news/speech/2015/06/02/ ter Management: The Red Cross Experience during the 2008 West transforming-weather-climate-and-hydrological-services-in-africa). Africa Floods,” International Journal of Geophysics (http://dx.doi 149 International Research Institute for Climate and Society (IRI). 2006. A .org/10.1155/2012/986016). Gap Analysis for the Implementation of the Global Climate Observ- 170 World Health Organization. 2014. Quantitative risk assessment of the ing System Programme in Africa. New York. (http://hdl.handle effects of climate change on selected causes of death, 2030s and 2050s. .net/10022/AC:P:8898). 171 Springman, M et al. 2016. Global and regional health effects of 150 Global Framework for Climate Services website. (http://www.wmo future food production under climate change: a modelling study. .int/gfcs/). The Lancet (http://www.thelancet.com/journals/lancet/article/ 151 World Meteorological Organization (WMO). 2015. Status of the Global PIIS0140-6736(15)01156-3/fulltext). Observing System for Climate. Geneva. 172 World Health Organization. 2014. Quantitative risk assessment of the 152 WHO-WMO Joint Office for Climate and Health. 2016. Climate Services effects of climate change on selected causes of death, 2030s and 2050s. for Health: Improving Public Health Decision-making in a New Cli- 173 Climate Policy Institute. 2015. Global Landscape of Climate mate, case studies. Finance 2015. (http://climatepolicyinitiative.org/publication/ 153 See, for example, Kruk 2015 (op. cit.), for an example of this in the global-landscape-of-climate-finance-2015/). context of Ebola. 174 This includes “governments, bilateral aid agencies, Climate Funds, 154 Authors’ calculations from data available at http://datatopics.worldbank multilateral, bilateral and national Development Finance Institu- .org/hnp/worldbanklending (accessed 26 March 2016). tions.” Ibid, p. 3. 61 c l im ate- s mar t he a lt hca r e 175 See Climate Funds Update website for an easy-to-use resource on climate 185 UNFCCC. 2002. Report of the Conference of the Parties on its Sev- funds: (http://www.climatefundsupdate.org/). enth Session. Bonn. (http://unfccc.int/resource/docs/cop7/13a01 176 See in particular section 4 (“Mobilizing Other Resources for Climate .pdf#page=32). Action”) of World Bank; 2015 “Finance for Climate Action: A Snapshot 186 UNFCCC. 2013. NAPA Priorities Database. Bonn. (http://unfccc.int/ of the World Bank Group’s Climate Work”. Washington, DC. adaptation/workstreams/national_adaptation_programmes_of_action/ 177 World Resources Institute (2015). Blog available online at: http:// items/4583.php). www.wri.org/blog/2015/10/national-climate-plans-indcs-numbers. 187 WHO. 2014. WHO Guidance to Protect Health from Climate Change [Accessed on 25/05/16] Through Health Adaptation Planning. (http://www.who.int/phe/ 178 Partnership for European Environmental Research (PEER, 2009). Europe Health_in_NAPAs_final.pdf). Adapts to Climate Change: Comparing National Adaptation Strategies. 188 https://www.mcgill.ca/epi-biostat-occh/files/epi-biostat-occh/analysis_ PEER, Helsinki, Finland. of_indcs_1.pdf 179 The African Development Bank (2011). The African Plan of Action for 189 WHO. 2014. (http://apps.who.int/iris/bitstream/10665/137383/1/ Public Health Adaptation to climate change 2012-2016. Available online 9789241508001_eng.pdf). at: http://www.afdb.org/fr/cop/cop17-africa-pavilion/programme/ 190 For example, African ministers of health and of the environment prepared the-african-plan-of-action-for-public-health-adaptation-to-climate- the “Libreville Declaration on Health and the Environment in Africa” change-2012-2016/ [Accessed on 25/05/16] in 2008 (see http://www.afro.who.int/en/clusters-a-programmes/ 180 Sustainable Procurement in the Health Sector (2012). UN Informal hpr/protection-of-the-human-environment/highlights/2418-first-inter- Interagency Task Team. Available online at: http://iiattsphs.org ministerial-conference-on-health-and-environment-in-africa.html) and [Accessed on 25/05/2016] held a follow-up in 2010 (http://www.unep.org/roa/hesa/Events/2nd 181 Climate Policy Institute, 2013. The Policy Climate. London. (http:// InterMinisterialConference/tabid/6011/Default.aspx). climatepolicyinitiative.org/wp-content/uploads/2013/04/The-Policy- 191 WHO. Climate change and global health: publications (http://www Climate.pdf). .who.int/globalchange/publications/en/). 182 WHO. 2014. WHO Guidance to Protect Health from Climate Change 192 WHO. Climate change and global health: projects: (http://www.who through Health Adaptation Planning. (http://apps.who.int/iris/ .int/globalchange/projects/en/). bitstream/10665/137383/1/9789241508001_eng.pdf). 193 Greenhouse Gas Protocol (2012). Calculation Tools. Available online at: 183 UNFCCC. 2011. Cancun Adaptation Framework. Bonn (http://unfccc http://www.ghgprotocol.org/calculation-tools [Accessed on 26/05/16] .int/adaptation/items/5852.php). 184 UNFCC. National Adaptation Plans website: (http://unfccc.int/adaptation/ workstreams/national_adaptation_plans/items/6057.php). 62 WORLD BANK REPORT NUMBER 113572-GLB