Madagascar Climate Change and Health Diagnostic Risks and Opportunities for Climate-Smart Health and Nutrition Investment Investing in Climate Change and Health Series Madagascar Climate Change and Health Diagnostic Risks and Opportunities for Climate-Smart Health and Nutrition Investment Investing in Climate Change and Health Series ©2018 International Bank for Reconstruction and Development/The World Bank The World Bank 1818 H St. NW Washington, DC, 20433 Telephone: 202-473-1000 Internet: www.worldbank.org The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because the World Bank encourages dissemination of their knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H St. NW, Washington, DC, 20433, USA; fax: 202-522-2422; email: pubrights@worldbank.org. This document is part of the “Investing in Climate Change and Health” series, which aims to provide management and task teams with the tools and resources necessary to improve WBG action on climate change and health. Other documents published by the World Bank 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. • Methodological Guidance, Climate Change and Health Diagnostic: A Country-Based Approach for Assessing Risks and Investing in Climate-Smart Health Systems, 2018. Diagnostics for other countries will also become available as this program evolves.  Acknowledgments This work is a joint production of the World Bank Climate Change Group and Health, Nutrition, and Population Global Practice. The report was written by Timothy A. Bouley, Amelia Midgley, Joy Shumake-Guillemot (World Health Organization-World Meteorological Organization), Christopher D. Golden (Harvard University), and Kristie L. Ebi (University of Washington). Key support and advice was provided by Voahirana Rajoela, Jumana Qamruddin, Lisa Saldanha, Tazim Mawji, and Jakub Kakietek. The team is indebted to the support of Dr. Herlyne Ramihantaniarivo (Director General of Health, Madagascar) and Norohasina Rakotoarison (Ministry of Health, Madagascar). Considerable appreciation is also due to attendees of the two consultations held in Antananarivo, Madagascar, in particular, members of the Group de Travail de Santé et Changement Climatique (Annex 4). The team extends special thanks to Coralie Gevers and the Madagascar Country Office for their hospitality, insight, and collaboration. Catherine Lynch’s contribution for her work on the CityStrength Diagnostic, which was used as an early template of this work, is also well noted. The Nordic Development Fund (NDF) provided resources for the original climate change and health program, from which this report derives, and the team is indebted to the goodwill and support of the NDF team, particularly Pasi Hellman, Martina Jagerhorn, and Leena Klossner. Peer review was performed by Kazi Ahmed, Raul Alfaro- Pelico, John Balbus (US National Institutes of Health), Franck Berthe, Diarmid Campbell-Lendrum (World Health Organization), Brenden Jongman, Catherine Machalaba (EcoHealth Alliance), Nestor Mahazoasy (Office of Nutrition, Madagascar), Alice Mortlock, C. Jessica E. Metcalf (Princeton University), Tamer Rabie, Ando Rabearisoa (Conservation International Madagascar), Jules Rafalimanantsoa, (Office of Nutrition, Madagascar), Kanta Rigaud, Cecilia Sorenson (US National Institutes of Health), Nick Watts (UCL), Elena Villalobos (World Health Organization), and Ann Margaret Weber (Stanford University). Important contributions were also made by Patricia Braxton, Paula Garcia, Josh Karliner (Health Care Without Harm), Gary Kleiman, Barbara Machado, Montserrat Meiro-Lorenzo, Laura Robson (Blue Ventures), Hui Wang and Susan Wilburn (Health Care Without Harm). Overall guidance within the World Bank was provided by John Roome, Timothy Grant Evans, James Close, Olusoji Adeyi, Fadia Saadah, and Stephen Hammer. Damian Milverton of GlobalEditor.org performed the final edit and review. Formatting and graphic development were undertaken by Shepherd Incorporated. iii M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC How to use this document This report has been structured according to guidance presented in Methodological Guidance, Climate Change and Health Diagnostic: A Country-Based Approach for Assessing Risks and Investing in Climate-Smart Health Systems (World Bank 2018). It has been designed to provide direct guidance in assessing capacity to manage climate-sensitive health and multi-sector risks, to improve risk management, and to link with investment. The report can be read through or in parts: Section 1 provides an overview of methods for transparency and replicability; Section 2 establishes the climate change and health linkages in Madagascar; Section 3 serves as a review of the Mala- gasy health system; Section 4 describes interventions to address the climate-sensitive health risks; and Section 5 links the interventions to ongoing and pipeline investments. Intended audience This document is primarily directed to World Bank Group (WBG) staff working on health, nutrition, and population projects and pro- grams. Much of the content may also be useful to those inside or outside of this institution working on related issues in areas such as agriculture, environment and natural resources, water and sanitation, energy, transport, urban development, and others. As a cross- cutting discipline, climate change and health issues are germane to projects in many disciplines. Although some of the language in this document is specific to WBG policies and procedures (e.g., task team leaders, global practices, etc.), the document has value beyond this institution as other development banks, bilateral aid agencies, and communities are tackling common issues. Tools described here can be applied in many of these contexts. Policymakers and managers likely will find this document useful as it provides an assessment of climate change and health impacts and opportunities that may inform higher level dialogue and decision making. Operational teams should find value in the specific tools and approaches here that can be integrated within WBG lending programs. The examples should also provide useful context for all readers. iv Ma d a ga sc a r CLIM ATE CH AN GE AN D HEALTH D IAGNO STIC  Alignment with World Health Organization and World Meteorological Organization policy advice Alignment among international organizations and agencies is critical. No one has a monopoly on the resources necessary for operational success. In the case of climate change and health in Madagascar, the World Health Organization (WHO) and the World Meteorological Organization (WMO) are working with the government, supporting the interagency working group on climate change and health, and developing recommendations that align with and support government-identified priorities and needs. This document aims to build on this base of technical knowledge and government support to directly link much needed interventions to financial investment. Building on WHO precedent Beginning in 2015, the WHO began preparing climate change and health country profiles to raise awareness of the health impacts of climate change, support evidence-based decision making to strengthen the climate resilience of health systems, and promote actions that improve health while reducing carbon emissions. WHO prepared a profile for Madagascar that built on the government’s already considerable work (WHO 2016). The profile identified key climate change and health impacts and articulated opportunities for action. These are important in the context of this diagnostic because they implicate areas of alignment of WHO priorities with those prescribed by the government. Each of the WHO recommendations is being or has been addressed, indicating a strong commitment on the side of the Government of Madagascar (GoM) toward achieving established climate change and health targets. This World Bank Group work has also been developed to reinforce these recommendations and support the government in undertaking these initiatives. The following table presents how the WBG has worked in direct response to the WHO recommendations. WHO recommended activity WBG-supported response Adaptation Scale up the activities of the Malagasy interagency climate change and The WBG convened the interagency working group twice during the health working group. development of this report (June and October 2017). Additionally, the working group has provided consultation and review throughout, and directly influenced the recommended interventions. Strengthen the strategic alliance of the working group on health and Government partners in the interagency working group have participated climate change and mobilize resources for the implementation of the in WBG consultations, furthering strategic alliances. The interventions National Adaptation Plan on Health and Climate Change. described in this report are directly linked to WBG resources to support the achievement of improved and widespread climate-smart health outcomes. Implement activities to increase the climate resilience of health A recommended intervention of this report. infrastructure. Mitigation Develop a national strategy for climate change mitigation that considers A recommended intervention of this report. the health implications of climate change mitigation actions. Conduct a valuation of the health co-benefits of climate change A recommended intervention of this report. mitigation policies. v M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC WHO recommended activity WBG-supported response National Policy Implementation Mobilize authorities and development partners for the implementation of More than 75 representatives from government agencies and foreign policies and strategies integrating adaptation and mitigation measures development institutions participated in WBG consultations, highlighting for climate change. the links between development programs and opportunities for mutual support. Develop a normative, legal, and technical framework for the A recommended intervention of this report. implementation of interventions relating health sector adaptation to climate change and mitigation. Aligning with WMO priorities Since 2008 the WMO has supported the National Meteorological Agency (Direction Générale de la Météorologie à Madagascar [DGM]) to collaborate with the health sector by establishing a collaborative, interministerial working group on climate and health, which has since become a foundational institutional arrangement for the government. WMO’s policy priority is to support governments of all African nations to implement the five pillars of the Integrated African Strategy on Meteorology (Weather and Climate Services), aiming to correctly position weather and climate services as an essential component in national and regional development frameworks and sustainable development in Africa. The Strategy will ensure the implementation of a structured Global Framework for Climate Service (GFCS) in Africa toward promoting the production and incorporation of science- based weather and climate information and services into African development policy. The health sector is one of five priority sectors for the GFCS, and so the efforts outlined in this report directly respond to supporting this priority. Furthermore, implementation of the Madagascar National Framework for Climate Services, as prioritized in the Nationally Determined Contribution (NDC), includes support to the health sector. Pillars of the Integrated African Strategy on Meteorology (Weather and Climate Services) WBG-supported response Increase political support and recognition of NMHSs and related WMO A recommended intervention in this report. regional climate centers. Enhance the production and delivery of weather and climate services for A recommended intervention in this report and a common objective of sustainable development. the WBG PPCR program. Improve access to meteorological services, in particular for marine and Not directly recommended in this report, but noted. Madagascar’s most aviation sectors. vulnerable populations reside in coastal areas and depend on artisanal fishing which would benefit from enhanced marine services. Support the provision of weather and climate services for climate change A recommended intervention in this report. adaptation and mitigation. Strengthen partnerships with relevant institutions and funding WBG, in coordination with WMO and others, supports the Integrated mechanisms. Strategy, convened the Africa Hydromet Forum of AMCOMET in September 2017. Mobilize authorities and development partners for the implementation of More than 75 representatives from government agencies and foreign policies and strategies integrating adaptation and mitigation measures development institutions participated in WBG consultations, highlighting for climate change. the links between development programs and opportunities for mutual support. Develop a normative, legal, and technical framework for the A recommended intervention of this report. implementation of interventions relating health sector adaptation to climate change and mitigation. vi Contents Acknowledgments iii Executive Summary ix Introduction 1 Diagnostic Goal 2 Relevance to World Bank 2 Structure 2 Why Madagascar? 6 1. Methods 7 Stage 1: Pre-Diagnostic Desk and Data Review 7 Stage 2: Workshops and Meetings 7 Stage 3: Interviews and Site Visits 8 Stage 4: Developing Recommendations and Initiating Report Preparation 8 Stage 5: Presenting and Validating Report Findings and Recommendations 8 2. Climate Drivers, Impacts, and Vulnerable Populations 11 Climate in Madagascar 11 Climate Change in Madagascar 11 Observed Impacts of Climate Variability and Climate Change in Madagascar 13 Climate and Health Risks in Madagascar 14 Vulnerable Populations 17 3. Climate-Smart Healthcare Assessment 21 Health Sector Background 22 Climate-Related Health Sector Impacts 24 Current Low-Carbon and Sustainability Dimensions of the Healthcare Sector 26 Current Status of Health and Climate-Related Activities 26 4. Recommended Interventions 29 Resilience and Low-Carbon Interventions in the Health Sector 30 Resilience-Building Priority Interventions 30 Low-Carbon Priority Interventions 40 Relevant WBG Tools and Resources 42 vii M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC 5. Linking to Investment 45 Overview of WBG Lending in Madagascar 46 Madagascar Projects and Recommended Interventions 46 Trust Fund-Related Activities in Madagascar and Recommended Interventions 52 Annexes 55 Global Context of Climate Change and Health Impacts Annex 1:  55 Country-Identified Priority Actions for Climate Change and Health Annex 2:  59 Climate Change and Health Stakeholder Consultation Agendas Annex 3:  and Participant Lists 63 Overview of New World Bank Framework for Strengthening Systems Annex 4:  at the Human-Animal-Environment Interface (One Health Operational Framework) 71 Annex 5: References 75 viii Executive Summary In Madagascar, climate change is already impacting health, and this damage will continue. Without adequate investment in health sector resilience, recent development gains are likely to be reversed, with serious consequences for Madagascar’s people and environment. Even so, sustainable pathways to a resilient health sector are possible, despite growing evidence of climate change impacts across the country. What is needed is a clear understanding of these pathways to build resilience, taking into account robust projections of the country’s climate and development future. This report highlights the most prominent climate change impacts facing Madagascar, with a par- ticular emphasis on health, and provides investment relevant solutions to build resilience. Through the establishment of priority interventions to address the identified vulnerabilities, this report links evidence to opportunities for development actors, while providing specific input into the design of a World Bank investment. In doing so, the report builds momentum for the emerging climate and health activities in the country and seeks to facilitate multi-sector dialogue to enhance Madagascar’s policy planning. Climate Change and Its Impacts on Health Madagascar is distinctively susceptible to climate impacts and natural disasters given its extensive coastline and location in the Indian Ocean. The foremost climate change stressors in Madagascar can broadly be described as: (1) increased temperatures; (2) extended drought periods and increased vari- ability of rainfall; (3) intensification of cyclones and floods associated with cyclonic disturbances; and (4) climbing sea level and sea surface temperatures. They are projected to become more pronounced over time with a continued rise in global emissions. The cumulative impact of these climate stressors could drag many already vulnerable people back into extreme poverty, with much of this reversal attributable to negative impacts on health. There are many ways to categorize the impacts of climate change on human and environmental health. The Intergovernmental Panel on Climate Change (IPCC) provides one such approach; this describes three pathways through which climate impacts health: (1) a direct exposure; (2) indirect exposure (in which health impacts are mediated through environmental and ecosystem changes); and (3) another indirect pathway mediated through societal systems (e.g., food and water distribution systems). Applying the IPCC’s exposure framework as a lens to analyze climate impacts on health in Mada- gascar, the following key threats emerge: ix M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC Direct Impacts on Health including increases in patient numbers that arise during extreme weather events. Additionally, the urban concentration of health • Injuries, death, and diseases due to extreme weather and facilities relative to those available in rural areas, coupled with climate events inadequate transportation infrastructure, indicates a further pres- sure point regarding potential climate impacts on health. Climate • Heat-related mortality change is expected to harm poor people living in rural areas disproportionately, and currently the health sector is unprepared Natural System Mediated Impacts to respond to these expected impacts. • Infectious and vector-borne diseases, including helminthic, Key Health Risks water-borne and hygiene related diseases • Acute and chronic respiratory infections There are considerable health risks associated with environ- mental degradation and climate change in Madagascar. Many of Human System Mediated Impacts these impacts have already been felt in some ways. An analysis of climate impacts and projections on current health outcomes, • Chronic and acute undernutrition overlaid with an assessment of the country’s capacity to adapt and respond to these, points to key areas of climate-related health risk: • Poor mental health (1) nutrition; (2) waterborne disease; (3) vector-borne disease; • Any illness that requires professional medical care (4) disaster-related impacts on health outcomes and health-system functioning; and (5) air pollution. Climate-Smart Healthcare Assessment While none of these are new to the island, each stands to expand geographically and have greater impact in our new climate era. Climate-imposed health risks will play out in the context of Mada- gascar’s health sector capacity, exacerbating the existing health Recommended Climate-Smart challenges facing the country. The ability of the health system to Interventions manage potentially disruptive climate shocks and stresses is a fun- damental determinant of the country’s resilience and an important As opposed to most environmental health hazards, where exposures consideration in the assessment of its risks and vulnerabilities. can be reduced over time with improved control (e.g., exposure Madagascar did not achieve any of its Millennium Development to tobacco smoke or groundwater sources of arsenic), climate Goals (MDGs) by 2015. The country has a high communicable change will increase for several decades even after a reduction disease burden: almost 30 percent of all deaths are still attribut- in emissions. Vulnerabilities will also shift, reflecting changes in able to preventable and infectious and parasitic diseases, while climate and urbanization, technology, access to safe water and Madagascar has the fourth highest chronic malnutrition rate in improved sanitation, and factors associated with development the world. Climate is expected to act as a risk multiplier on these choices. Given that health risks from climate variability are, in already parlous statistics, exerting additional stress on its health general, not new, health systems have policies and programs to sector capacity. manage some climate-sensitive health outcomes. However, as Despite the 2009–2013 political crisis, there have been some these policies and programs were largely developed without tak- improvements in the country’s public health performance, par- ing significant climate changes into account, they will become ticularly in regard to improved access to drinking water, malaria increasingly less effective as climate change alters disease risk. pre-elimination efforts, and improved child immunization rates Further, because health risks vary spatially and temporally, the and health outcomes (WHO 2014a; World Bank 2015a). However, extent to which a particular program or intervention could be health coverage remains limited and the sector has generally affected by a particular hazard at a given time will depend on suffered from instability and turnover (World Bank 2015a). The local vulnerabilities and capacities. health sector has been constrained by a lack of financing, ineq- What is needed is a programmatic approach to increasing health uitable service delivery, and poor quality of service. In addition sector performance in the face of climate change. Modifying current to the comparatively low overall health budget, current health programs to manage each climate-related hazard separately may expenditure is highly inequitable between urban and rural areas. lead to inadequate preparation of health systems to manage multiple Low levels of access are a particular cause for concern with and synergistic exposures. A holistic approach that incorporates regard to the system’s ability to manage climate-related stresses, a range of interconnected climate-smart interventions, as well as x Ex e c u ti ve S u mm ary those that incorporate interventions outside of the health sector, iterative risk management; and add flexibility to current public should be adopted to meet climate-smart health system goals. health interventions, which can help them perform better under In addition to addressing vulnerability and risk, it is worth- a variety of climate scenarios. while to also consider low-carbon interventions. Mitigation and adaptation are truly two sides of the same climate change coin; Nutrition if extensive efforts are to be undertaken to adapt to the health- related impacts of climate change, one should also consider how to Undernutrition is widely recognized as the most critical human improve health-related systems so they contribute less to underly- health issue in Madagascar, and new climate stresses will only ing causes of the threats. New investments in any sector should worsen outcomes. Close to 50 percent of the population stunted and thus contribute to building resilience to climate change, while more than 40 percent of the population anemic, undernutrition is integrating low-carbon interventions. Investment in low-carbon pointedly suspected as being the underlying driver. Inadequate food healthcare systems can foster clean and independent energy, safe access and borderline famine conditions in some regions, inacces- water, clean transport, and clean waste disposal mechanisms. sible infrastructure to transport food nationally, and very low-input, low-tech agricultural production systems clearly illustrate the entire Resilience Interventions Malagasy food system’s dependence on climate. Extreme weather events like droughts, flooding, and cyclones will lead to shocks in food Action that addresses the five core climate change risks to production. Increasing temperatures and carbon dioxide will cause the health sector is key in building a resilient health sector in crop failure and reduced nutritional quality in food crops in some Madagascar, supported by a range of crosscutting, policy driven regions. Maintaining ecological integrity and appropriate land-use recommendations aimed to strengthen its ability to respond to planning will enable Malagasy populations that are heavily reliant climate risks. on natural resources to continue to seek out such a livelihood in The interventions outlined in Figure ES.1 are illustrative of the the face of climate change. Strategic interventions designed to build types of actions that can be taken, but are not comprehensive given resilient and climate-smart food systems will enable sustainable the expectation that others will emerge with implementation and as nutrition flows throughout the country. Specifically, these include: the full scope of needs becomes apparent. Broadly, recommended Education/Communication: interventions aim to: improve understanding and monitoring of health vulnerability and the relationship to the environment and • Integrate climate considerations into mass media and com- climate; anticipate and prepare for changing risks over different munity awareness campaigns for nutrition and health. spatial and temporal scales; promote multi-dimensional and Figure ES.1: Climate-related health priorities in Madagascar and areas of investment intervention. CLIMATE-RELATED HEALTH PRIORITIES 1 2 3 4 5 Water-related Extreme weather Vector-borne Nutrition Air pollution illness events diseases CROSS-CUTTING SYSTEM SUPPORT INTERVENTIONS Governance, Policy, and Coordination Human Resources and Capacity Development Research Data, Mapping, and Information Systems Information Infrastructure xi M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC • Promote education and training in meal preparation and choice are resilient will have significant public health consequences. for balanced and diverse meal consumption. Measures include: Capacity/Training: Knowledge gaps: • Integrate water and sanitation education into health worker • Conduct climate- and nutrition-focused research to inform training and activities, including household water treatment projects and investment and translate research findings for and medical waste management. the public (see Section 5 for further elaboration). • Train health and nutrition workers to anticipate and activate • Analyze nutrient value of food products to inform appropriate prevention measures to minimize increases in diarrheal disease dietary recommendations. following flooding, drought, and other extreme weather events. Monitoring: Education/Communication: • Assess dietary intake patterns and establish nutritional surveil- • Integrate water and sanitation education in primary school lance monitoring to pre-position aid and support for climate- education programs. related food shortages and undernutrition. • Develop a strategy to monitor changing food production, Knowledge gaps: quality, and safety in relation to changing climate conditions. • Improve the knowledge base and mapping of existing water and sanitation infrastructure and enhance prevailing practices, Policy/Planning: including location of medical waste facilities. • Align and integrate nutrition sensitive climate-smart agriculture • Determine risks and susceptibility of water and sanitation approaches with the development of (i) multi-hazard disaster infrastructure and practices to sea level rise, cyclonic disrup- protocols and risk management protocols for the health sec- tion, etc., and develop appropriate planning that accommodates tor, and (ii) multi-sector guidance on norms and standards long-term change. for enhancing nutritional outcomes through sustainable land use, soil conservation, marine spatial planning, and resource • Identify major regional gaps in infrastructure and then rank management. areas most likely to be affected by climate-induced increases in diarrheal disease. Water and Sanitation • Conduct anthropological studies on water and sanitation prac- tices in the targeted regions to improve intervention design. Water- and sanitation-related illnesses are still a major driver of disease in Madagascar; less than 14 percent of the population Monitoring: had access to safe sanitation in 2012 (WSP 2012). Madagascar’s • Develop integrated meteorological and water and sanitation economy loses US$103 million each year due to poor sanitation disease surveillance to help predict risk areas and to pre- (World Bank 2012). The precarious water supply and sanitation position aid and support to at-risk areas. systems in Madagascar are already highly vulnerable to present- day climate variability and are expected to worsen with climate Policy/Planning: change. Extended dry periods may deplete water sources or make • Develop climate-smart water and sanitation infrastructure them intermittent, reduce good hygiene practices, and accelerate in high-risk regions, accompanied by an iterative climate airborne fecal dust in open defecation zones, all while reducing risk management plan to maintain and improve services as the performance of sewers (where they do exist). Extreme weather the climate changes. Interventions would need to be context events may damage water- and sanitation-related infrastructure, specific but should include interventions in ‘safe’ water and while flooding may result in the contamination of water supplies. sanitation supply resources, including improved water sup- Sea level rise is expected to compromise water sources in some ply sources, such as hand pumps, or improved latrines (the coastal regions through a range of impact pathways. Strategic UNICEF and Global Water Partnership’s report WASH: Climate interventions designed to build climate-smart water and sanitation Resilient Development provides a useful approach for preparing infrastructure will minimize the risk of an accelerating burden such interventions). of diarrheal disease by minimizing contaminant exposures and ensuring sustainable infrastructure. Failure to ensure that services • Align agricultural, livestock, and forestry land-use planning to minimize downstream water contamination. xii Ex e c u ti ve S u mm ary Disasters and Extreme Weather facilities and development of health services that can withstand flood, drought, temperature extremes, and cyclones (including Madagascar is expected to experience greater variability in pre- ambulatory and health logistics transport, communication and cipitation and increases in temperature, sea level, sea surface information and technology infrastructure, and water and sanita- temperature, and cyclonic activity and intensity. Each of these tion infrastructure). Create government-led mandatory norms. climate-related environmental changes is expected to magnify • Leverage humanitarian aid to raise awareness of specific direct health impacts (drownings, physical trauma, forced migra- climate-related health concerns and advocate for inter-sector tion), indirect health impacts (diarrheal disease, vector-borne coordination and risk management. disease, etc.) and direct impacts on health system infrastructure • Establish a clear partnership with neighboring facilities that will and health-care delivery. Ultimately, all will exacerbate the disease support the sharing of resources in a disaster, including financial burden in Madagascar. Strategic interventions are needed to link recoupment. This is something that can be performed immedi- disaster relief operations to health operations and to improve ately given the existing disaster response work in the country. disaster preparedness, to build climate-smart health infrastructure, to develop climate-smart healthcare delivery, and to develop land- • Invest in measures to improve water and energy security of use planning protocols that create ecosystem resilience against health facilities in regions prone to droughts, cyclones, and likely climate change impacts. Targeting should be conducted floods (e.g., solar/turbines and independent water sources) nationwide but particularly in areas prone to drought, cyclones, as well as disaster proof medical waste management facilities. and flooding. Interventions should encompass: Capacity/Training: Vector-Borne Disease • Train and mobilize health workers in climate-related disaster Madagascar is likely to experience an increase in vector-borne preparedness, response, and case detection for disaster-related disease for a number of reasons. Climate change is expected to outbreaks. increase temperatures and precipitation, creating conditions that Education/Communication: are ripe for the biological proliferation of vector-borne diseases. Climate influences virtually all components of disease systems • Develop and deploy community awareness campaigns and sea- (Figure 4.4): the pathogen (for instance, influencing the devel- sonal disaster preparedness programming for floods, cyclones, opment rate or survival outside the host or vector), the host and droughts; promote advisory and outreach services (using (through the immune response or changes in host distribution), severe weather forecasting) via risk communication technolo- and the vectors (arthropod vector development is tightly linked gies to alert at-risk populations. to climatic parameters such as temperature and humidity). Key Knowledge gaps: areas of focus include strategic interventions that link weather and disease surveillance to contribute to early warning systems and • Map and audit the safety and preparedness of health infra- risk mapping, and aligning the livestock, forestry, agriculture, and structures and update flood, drought, and cyclone risk map- land-use sectors for integrated vector management: ping nationally. Knowledge gaps: Monitoring: • Create population-based and geographically specific risk maps • Create a systematic and coherent registry to track health facil- for vector-borne diseases, and conduct operational and social ity damages, economic costs, and human impacts of extreme science research on effective behaviors and control measures. weather events. Monitoring: • Enhance hydrometeorological systems by strengthening and • Locate, collate, ‘clean’, and digitize paper records to improve tailoring multi-hazard early warning systems for cyclones, datasets for disease data, vectors, meteorological conditions, floods, and droughts for health decision making, while creating and environmental indicators (e.g., percentage of forest fires, more direct links to public health surveillance and monitoring percentage and locations of ecological zones, etc.). Improve systems (including air quality, harmful algal blooms, water ability to access and use remote sensing data of proxy variables quality, etc.). for environmental conditions (e.g., land use). Once existing Policy/Planning: data are understood, invest in hardware and software to carry out skill-based training to improve data collection, manage- • Provide operational guidance including norms and standards ment, and analysis. (i.e., protocols) to guide investments for the construction of xiii M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC Policy/Planning: Policy/Planning: • Develop an integrated health and environmental surveillance • Scale up clean cookstove programs and coordinate across system that includes, at a minimum, meteorological and health ministries. data for use as an early warning system. • Develop and adopt a city-wide plan to reduce transport-related • Strengthen integrated vector management approaches and air pollution in Antananarivo. align timing and location of activities with potential climate- In many ways, sector and health outcome focused interven- induced shifts in disease burden. tions are impossible without the necessary crosscutting systemic • Align agricultural, livestock, and forestry land-use planning support and enabling functions of: (i) governance, policy and to minimize disease transmission. coordination; (ii) human resources and capacity development; (iii) research; (iv) data, mapping, and information systems; and • Adopt a government-wide ‘One Health’ approach (see page 4 (v) information infrastructure. Recommendations in each of these for more) to manage zoonotic disease risks. areas are described on page 38. Air Pollution Low-Carbon Interventions The emissions that drive climate change are largely co-emitted Low-Carbon interventions primarily work toward decreasing by the same sources that are responsible for air pollution. WHO pollution and limiting greenhouse gas emissions, resulting in has recognized the large and significant role that ambient air pol- health benefits for cardiovascular and respiratory health, while lution (AAP) and household air pollution (HAP), particularly in also providing an opportunity to strengthen local economies, the developing world, play in increasing morbidity and mortality employment, and infrastructure provision. Given Madagascar’s (WHO 2014b). The most recent Global Burden of Disease report progress on the climate and health agenda, it is well positioned estimates suggest that AAP and HAP combined were killing more to become a leader in the new field of climate-smart healthcare, than 5.5 million people annually by 2013 (GBD 2013; Risk Fac- which combines low-carbon and resilience approaches into a new tors Collaborators 2015), more deaths than those attributable to practice that maximizes benefits for people and the planet. Key malaria or tuberculosis. Tens of millions more suffer from related, elements of low-carbon healthcare include: preventable diseases, including pneumonia (which predominantly affects children), lung cancer, cardiovascular disease, stroke, and • Low carbon health system design and models of care based chronic obstructive pulmonary disease, which includes emphysema on climate-smart technology, coordinated care, emphasis on and bronchitis (WHO 2014b). Both AAP and HAP pose significant local providers, and driven by public health needs risks in Madagascar, with the effects of AAP felt in cities and in • Building design and construction based on low-carbon approaches areas with certain types of industry, and HAP in rural areas where • Investment programs in renewable energy and energy efficiency families are reliant upon cookstoves. Specific measures can include: • Waste minimization and sustainable healthcare waste Capacity/Training: management • Train healthcare workers about pollution avoidance techniques • Sustainable transport and water consumption policies that can be communicated to local patient populations. • Low-carbon procurement policies for pharmaceuticals, medical Education/Communication: devices, food, and other products • Educate urban populations and rural populations about dangers • Resilience strategies to withstand extreme weather events of prolonged exposure to harmful air, specific to their region. Using these as high-level principles and in consultation with Knowledge gaps: government partners, specific low-carbon interventions have been recommended for Madagascar that build on current programming • Establish a database and registers of pollution sensitive diseases, and optimize for current capacity within the health system to: mapped to case incidences in cities and regions. 1. Develop a low-carbon strategy for the health sector Monitoring: 2. Scale up community small and medium enterprise (SME) • Identify concentration and types of pollutants in major cities programming and markets around efficient and clean cook- using local sensors and satellite remote sensing data. stoves, solar lamps, and communal energy charging activities xiv Ex e c u ti ve S u mm ary 3. Scale up waste management programs, particularly existing facilities and solar batteries in data collection tablets used during pilot projects using autoclaves surveillance and research. It connects climate and health risks to disaster protocols, highlighting climate change in nutrition mass 4. Scale up the Green Hospitals initiative media campaigns and research. The consideration of climate- 5. Promote water use efficiency through multiple use (i.e., grey sensitive health threats occurs throughout all project phases and water recycling) approaches as a result of this diagnostic, recommendations have been included 6. Establish training programs to educate health policy decision- in the Project Appraisal Document (PAD). makers in the value of low-carbon interventions 7. Conduct health system-wide cost-benefit economic analyses Conclusion to assess the value of decarbonizing the health sector This report serves as the first application of the WBG’s Climate Change and Health Diagnostic Tool. Madagascar was chosen both Linking with Investment due to its susceptibility to climate change and as it provided an opportunity to embed climate considerations in the design of an Informed by this knowledge, these recommendations are useful imminent WBG health investment. During the process, the WBG tools to enhance climate-smart health outcomes in Madagascar. worked closely with the Government of Madagascar, which exhib- While targeted to a forthcoming World Bank lending program ited significant leadership in addressing climate and health risks. (Improving Nutrition Outcomes using the Multiphase Program- Piloting the diagnostic tool in Madagascar demonstrated (i) its matic Approach Project, see page 4 for further details), the recom- usefulness as a tool to collect and catalogue existing climate mendations should be taken as resources for any project type in change and health resources in the chosen country; (ii) its ability Madagascar working to improve overall health, environment, or to inform the development of a set of concrete recommendations resilience outcomes. They could be introduced at any point dur- that can be considered in the context of shaping future WBG ing the project cycle—from preparation through implementation involvement in the country vis-à-vis the WBG’s Climate Action and evaluation. The best approach, however, is to align project Plan and climate targets; and (iii) its usefulness as a stand-alone design with resilience measures (as was the case with Improving project that can shape priorities of the country itself (and other Nutrition Outcomes) so that climate and health can be included interested stakeholders). Having proved a successful exercise from an early stage. In short, it is never too early nor too late to in project quality enhancement, and given that there is now a enhance project design and implementation by integrating climate set of lessons learned from the pilot study, it is expected that its change and health considerations. application elsewhere will be able to realize similar value in other The Improving Nutrition Outcomes lending program includes countries, particularly those facing accelerated climate risks in the a mixture of low-carbon and resilience interventions. Specifically, face of already vulnerable health systems. these are: climate change education for healthcare workers and communities; the scaling up of solar refrigerators in healthcare xv Introduction The World Bank Group (WBG) is committed to pursuing an end to extreme poverty and to build shared prosperity. This commitment includes improving health outcomes and achieving universal health cov- erage (UHC) while also mitigating and adapting to climate change. The compounded effect of climate change on health will jeopardize these core WBG objectives and undermine the viability of its invest- ments, which rank among the largest of any development institution in the world. The WBG has recently established an “Approach and Action Plan for Climate Change and Health” delineating institutional targets, geographies, and approaches to mainstreaming climate-smart healthcare and other climate-sensitive health considerations across the institution. One commitment focuses on country-level engagement and, more particularly, on undertaking climate change and health diagnostics. These aim to assess overall health system and health outcome sensitivity to climate and environmental change, while identifying opportunities for investment and intervention to build climate-smart health systems. The team has established a global methodology for conducting such assessments (i.e., an approach that can be applied across countries, regardless of the types of risks and vulnerabilities)1 and is working with task teams across the institution, as well as engaging with countries to implement the diagnostic. This report is the first WBG climate and health diagnostic in any country. It aims to provide develop- ment lending entry points for enhancing Madagascar’s readiness to manage current and future climate risks to health with particular focus on WBG investments. Although constructed to provide an overview of risks and opportunities for lending, the diagnostic has been conducted to directly inform the develop- ment of a new World Bank nutrition investment (Improving Nutrition Outcomes Using the Multiphase Programmatic Approach, P160848 as described on page 4). The aim is to both ensure immediate uptake of climate considerations into a major health investment and maintain ongoing dialogue with a lending task team to guarantee that the approach and recommendations are operationally relevant. To promote understanding of potential future climate resilience, the Climate Change and Health Diagnostic was developed to help technical staff at the WBG and other development institutions facili- tate an action-focused dialogue among stakeholders (e.g., government and civil society) about risks, resilience, and the performance of sectors and systems. The diagnostic identifies priority actions and investments that can enhance a health system’s resilience (and that of other related systems), reduce greenhouse gas emissions, and increase the climate-smart potential of ongoing or future projects. 1  World Bank 2017. 1 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC states are most at risk. These significant majorities underscore an Box I.1: Defining Components absolute need for further engagement on the health and climate of a World Bank Climate Change agenda and implicate a need for prioritization in future investment. and Health Diagnostic Addressing climate change and health inherently demands solutions across sectors. The WBG has a comparative advantage in aligning analytic and operational expertise across health, climate, • Identifies climate-related events and conditions that stress and shock health systems economics, environmental management, and other core areas to address integrated development threats. The WBG’s disaster risk • Identifies climate-related events and conditions in non- management interventions, for example, often implicitly incorpo- health sectors that can negatively impact public health or health systems rate improvements in health, but do not explicitly measure these. Working at a system level, the WBG is especially well placed to • Prioritizes interventions that address these shocks and help clients embed an integrated approach in planning. Deep stresses implementation expertise can then support countries in effectively • Provides information useful in establishing climate-smart, executing programs and interventions, establishing a platform or health-related interventions standard upon which other development institutions can build. • Directly links to an active lending portfolio WBG research and economic analysis can also help countries establish financial baselines that can be useful in government- Diagnostic Goal wide planning beyond merely the health and environment sectors. Regionally, climate and health work stands to add considerable The overall goal of conducting a climate change and health value to development investments, with minimal additional effort diagnostic is to link knowledge to investment. It aims to identify undertaken by country teams. The case for WBG involvement events and conditions where climate stresses and shocks under- has been articulated and validated by international experts and mine the effectiveness of health systems (at local or national partners. WBG has identified key geographies of impact (as well scales), increasing morbidity and mortality. The diagnostic uses as methods of assessing subnational impact), developed climate- these insights to prioritize interventions toward establishing smart health tools that can readily be built into investments, and climate-smart health systems that both increase resilience and it can draw on an international community of climate and health reduce climate forcing emissions. The diagnostic also identifies experts to perform relevant country- and project-specific analyses. shocks and stresses in other sectors that could have negative Integrating climate and health considerations into current and consequences for public health in general or health systems upcoming investments presents a straightforward approach to help in particular. This diagnostic has been conducted within the development lending teams and countries meet overall climate context of an active lending portfolio so that recommendations commitments while aligning with country demands to address can be directly integrated into investment. climate and environmental impacts on health. Relevance to World Bank Structure Many WBG client countries—and especially their poor populations—­ One of the first steps in any new climate-smart strategy is the are disproportionately affected by the negative impact of climate creation of baselines and identification of opportunities. For cli- on human health. According to a new WBG analysis, 79 percent mate and health considerations, this means conducting a health of countries supported by the International Development Asso- and climate assessment which explores risks, capacities, and ciation (IDA) are among the most at-risk countries for negative opportunities and which has specific utility for institutions or health outcomes associated with climate change (for either health governments. There are established models for performing climate impacts caused by climate change, health impacts associated with and health assessments that have primarily been developed by the climate change-causing emissions, or both). Half are in Africa WHO and partner governments. These assessments are broadly (World Bank 2017). Madagascar is categorized as both an IDA relevant to the development community and have been used to and fragile, conflict-affected or violent state.2 The same analysis help countries formulate climate and health action plans that are indicates that 86 percent of fragile, conflict-affected, or violent specific to unique geographic and systemic needs. In the context of the WBG, country-specific climate and health diagnostics using the World Bank method (World Bank 2017) expand upon these 2  Harmonized List of Fragile Situations FY 2017, found at: http://www.worldbank assessments to make them relevant for development operations .org/en/topic/fragilityconflictviolence/brief/harmonized-list-of-fragile-situations and necessary to inform investment. Methods developed here may 2 I nt ro duc tion also be useful for other development institutions and investors scientific in nature, this section has been prepared with a general endeavoring to undertake similar analyses. policy audience in mind. Overall, this work seeks to stimulate and support greater integration of health and climate considerations across the insti- Section 3 serves as an assessment of the health sector in tution; both within the Health, Nutrition, and Population (HNP) Madagascar, providing relevant facts and figures to inform climate Global Practice and in other sectors. As part of corporate climate and health decision making, while also exploring dimensions of commitments, the WBG has established a target of ensuring the sector to determine the degree to which it is climate-smart. 28 percent of its portfolio generates climate co-benefits by 2020. This is important to identify pressure points in the health system Individual WBG global practices have their own targets to support where interventions may be most useful. this broader goal; for example, HNP aims to ensure 20 percent of new operations are climate considerate by 2020. Doing so requires Section 4 describes the interventions. This includes: what can considerably broader recognition of climate change implications be done, both in terms of resilience and low-carbon or co-benefit within all departments, particularly HNP where there is at present opportunities for the health sector; what can be done in other little climate engagement. sectors; and what has previously been recommended by both This diagnostic is organized as follows: international and local experts. This information should be broadly useful to anyone working on climate and health in Madagascar. Section 1 presents the methods used in conducting the analysis Section 5 links these interventions to specific WBG projects to (i) ensure transparency of approach and (ii) illustrate the use and and opportunities, identifying entry points and making recommen- adaptation of the approach outlined in Methodological Guidance, dations for inclusion. In the case of the primary project to which Climate Change and Health Diagnostic: A Country-Based Approach this diagnostic is linked (Improving Nutrition Outcomes Using for Assessing Risks and Investing in Climate-Smart Health Systems the Multiphase Programmatic Approach, P160848), an overview (World Bank 2017). The diagnostic guidelines were developed to of all recommendations has been provided given many of the establish a template for replicability, though with flexibility for recommendations are already integrated into project documents. country-specific adaptation, as was the case in Madagascar. Annexes provide detailed information on certain aspects Section 2 provides an overview of climate and health impacts highlighted in previous sections (such as in-depth climate change and drivers in Madagascar. This section provides a go-to resource projections, listings of relevant partners, reference documents, and for those wishing to understand the scope and magnitude of other resources) that may be interesting to certain audiences, but climate-related impacts and risks. It includes data on, and discus- that are beyond the immediate scope of this report. sion of, both climate change and climate health risks. Although 3 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC Why Madagascar? malnutrition. In the last three years alone, the WBG has prepared two emergency IDA3 financing operations that include support to Madagascar was chosen as the subject of the WBG’s first climate delivering WBG HNP interventions as a direct response to climate- change and health diagnostic based on several considerations: related event impacts. Looking to the future, climate change poses (i) Madagascar, geographically, is particularly susceptible to climate a continued, critical threat. change; (ii) there are relevant World Bank health investments in In a country where over 50 percent of children suffer from project phases that align with the timing of this project such that chronic malnutrition (a figure that is projected to increase without they are well positioned to integrate novel climate- and health- intervention), there is considerable need to develop multi-sector related recommendations; (iii) the government of Madagascar solutions for reliable, affordable, and climate-smart access to has shown significant leadership on the climate and health issue, food. Conducting a climate change and health diagnostic during having maintained an interagency working group on climate preparation of the project Improving Nutrition Outcomes Using and health for 10 years; and (iv) the country has benefited from the Multiphase Programmatic Approach (P160848, see box below) capacity building of the WHO and WMO in preparing a related benefits this project with direct recommendations and climate- national assessment and prioritized action plan. Many living in smart enhancements, while establishing baseline knowledge and Madagascar are also poor, with nearly 77 percent of the population opportunities for intervention in future projects. living in extreme poverty (World Bank, 2012). Poverty compounds vulnerability and there are many in Madagascar who will likely be impacted by the health impacts of climate change. Extreme weather conditions have already impacted health and nutrition outcomes in Madagascar. These are expected to 3  International Development Agency (the arm of the WBG focusing on the world’s worsen in the future with a growing number of infectious diseases, poorest countries, providing concessional finance with low or no interest credits and deteriorating mental health, and exacerbated food insecurity and with repayments of up to 40 years). Improving Nutrition Outcomes Using the Multiphase Programmatic Approach (P160848) The “Improving Nutrition Outcomes Using the Multiphase Programmatic Approach” Program, approved by the World Bank Board in Decem- ber 2017, is envisioned as a 10 year, estimated US$200 million-dollar IDA investment with an overall program development objective “to reduce stunting prevalence in children under 2 years of age in targeted regions.” The program includes three phases to be implemented over five, five, and four years, respectively. The first phase is a five-year US$90 million-dollar investment (including US$10 million in co-financing from Scaling Up Nutrition) that will be operational in spring 2018. This first phase operation aims “to increase utilization of a package of reproductive, maternal, and child health and nutrition interventions and improve key nutrition behaviors known to reduce stunting in targeted regions.” There will also be analytical and technical assistance to inform the government on the more complex and longer-term institutional, financing, and policy reforms required to achieve and sustain results over time. 4 I nt ro duc tion Box I.2: Connecting Climate Change and Health with “One Health,” “Planetary Health” and the Sustainable Development Goals Public health challenges stemming from environmental factors inherently span multiple sectors, and warrant holistic, society-level solutions. “One Health” (humans-environment-animals) and “Planetary Health” (earth systems and health) are related approaches that recognize the connections between humans and environment and that promote coordination to better manage risks and improve health. The intention of this climate change and health diagnostic firmly aligns with the goals and ethos of One Health and can be considered a tool employed under the broader One Health umbrella. Climate and health interactions fit clearly within the spheres of “human health systems” and “environmental health and management” below. Utilizing the “One Health” title is important because many countries implementing the legally binding International Health Regulations, including Madagascar, are taking measures to develop One Health coordination mecha- nisms, particularly for the control of zoonotic diseases. Human Health Systems Animal Health Environmental Systems Health and Management Systems One Health model, as used within the World Bank The World Bank has worked for over a decade to promote and operationalize One Health, supported by country partners, technical institutions, international organizations, and other development funders. This has included the generation of a considerable knowledge base on the topic, with reports and studies addressing various One Health dimensions, such as People, Pathogens, and Our Planet, Investing in Climate Change and Health series, and an extensive portfolio on antimicrobial resistance. This research has underpinned country opera- tions, like the Global Program for Avian Influenza and Human Pandemic Preparedness and Response, and the Regional Disease Surveillance Systems Enhancement program. At present, an Operational Framework for Strengthening Public Health Systems at the Human-Animal- Environment Interface (also referred to as the One Health Operational Framework—see Annex 2) is in development and will soon be able to offer further tools toward the achievement of more sustainable health and environmental systems in and among many countries with which the WBG is engaged. In recent years, support for a related framing has emerged. Planetary Health characterizes public health risks associated with rapidly accelerating, anthropogenic environmental change. There are a range of changes with the potential to significantly impact human health: climate change, biodiversity loss, fishery collapse, land-use change, urbanization, ocean acidification, sea temperature and level increases, and freshwater scarcity. Accordingly, holistic interventions are required to safeguard the future health of both people and planet (Rockefeller Foundation-Lancet Commission Report on Planetary Health 2016). This framework is particularly useful for Madagascar, which has experi- enced a rapid and massive ecosystem transformation from the time of human settlement several thousand years ago. The trajectories of mass deforestation, biodiversity loss, runoff and soil nutrient leaching, and climate-related impacts all point to the relevance of the Planetary Health framework in Madagascar and are important to understand in the context of this diagnostic. 5 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC Genetic Climate change diversity Biosphere integrity Novel entities Functional diversity ? ? Land-system Stratospheric ozone depletion change ? Atmospheric aerosol loading Freshwater use Phosphorus Ocean acidification Biochemical flows Nitrogen Beyond zone of uncertainty (high risk) Below boundary (safe) In zone of uncertainty (increasing risk) Boundary not yet quantified Planetary boundaries, as defined by Steffen et al., 2015. The post-2015 sustainable development agenda currently includes 17 Sustainable Development Goals (SDGs). Goal 13 calls for urgent action to combat climate change and its impacts, while goal 3 aims to ensure healthy lives and promote well-being. Virtually every other goal includes some dimension that touches upon health and/or climate, underscoring the relevance of integrated systems perspective across environmental and health spheres, which is at the heart of the One Health and Planetary Health approaches. Fundamentally, each of the goals is linked; progress in any one of these areas can lead to collective achievement toward improved development and a more sustainable future. 6 SECTION 1 Methods The approach to this diagnostic was modeled on the five-step process described in Methodological Guidance, Climate Change and Health Diagnostic: A Country-Based Approach for Assessing Risks and Investing in Climate-Smart Health Systems (World Bank 2017). Each step is detailed below (and in Fig- ure 1.1), including variances and specific dates and duration, so as to be most useful to both previous participants and those who may wish to replicate the process for other countries. Stage 1: Pre-Diagnostic Desk and Data Review May 16–June 3, 2017 (2.5 weeks) This stage focused on collecting information and leveraging efforts already undertaken, particularly health Vulnerability, Capacity, and Adaptation Assessments (V&As) and climate-related planning documents. The latter include works that assess recent climate-related shocks and stresses, and the effectiveness of the health system. Stocktaking was achieved through literature searches, discussions with development partners, researchers, and government contacts. The process identified several dozen relevant studies, reports, and plans developed by the government, WBG, WHO, other development partners, and aca- demics. Each document was then uploaded to a file-sharing site and made available to the diagnostic team. These documents were analyzed for relevant information that was flagged for future use. Key stakeholders were mapped through a similar process. Contacts and organizations were compiled in a spreadsheet and reviewed by the team to determine if there was appropriate coverage across gov- ernment agencies and nongovernment entities. In-country relationships and personal contacts proved essential to both the stakeholder mapping process and in achieving buy-in throughout the project. The contact list was then made available for subsequent phases. The core diagnostic team, as well as the extended HNP lending team to which this project is most closely aligned, met several times during this stage. Discussions focused on three topics: (i) resource sharing, including the latest documents, data, and stakeholder contact details; (ii) briefing one another on new information learned; and (iii) preparing for subsequent work stages. Stage 2: Workshops and Meetings June 4–June 10, 2017 (1 week) The purpose here was to assess and verify the information collected during Stage 1 with in-country partners, confirm initial thinking and directions, and identify additional resources and stakeholders that should be part of the overall assessment. The team found this time useful to listen to partners and learn from in-country experiences after having explained the project’s context with stakeholders. Bilateral meetings were arranged and held with a number of government and nongovernment partners (including WBG staff) drawing upon the previously established contact list. Calling upon the 7 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC influence and expertise of the Ministry of Health, an invitation to recommendations for actions and investments (or line items in a one-day consultation was sent to relevant personnel. In parallel, projects). It seeks to incorporate factors such as the eminence of the team prepared the workshop agenda, which was reviewed the threats, competing demands, windows of opportunity based by the Ministry of Health. More than 75 individuals from across on current and planned projects and investments, and stakeholder government, civil society, and international institutions attended concerns and preferences. The final draft was prepared for cir- the workshop (agenda and participant list provided in Annex 3). culation to the consultative group in Madagascar for review and The day included framing presentations by the WBG climate and revision. After completion of Stage 5 (final workshop), the report health team, technical presentations from country staff, comments was sent to an international team of reviewers comprising expertise and reactions from international partners, and several hours of in climate and health, environmental health in Madagascar, and working sessions with the interagency working group for climate country-level assessments. The report was then finalized and key and health, which helped to refine messages from the earlier recommendations delivered to development partners and WBG presentations. Notes were taken and circulated to all participants. lending staff (who also maintained an active role incorporating inputs during the development lending project preparation phase). Stage 3: Interviews and Site Visits Stage 5: Presenting and Validating Concurrent with Stage 2 Report Findings and Recommendations The purpose of this stage was to better understand the challenges and opportunities of communities and health systems, and to quali- October 1–October 7, 2017 (1 week) tatively assess the extent to which current policies and programs To ensure the diagnostic would be valued by WBG lending teams, could manage the associated risks. Unfortunately, time constraints as well as government and other international partners, in-country did not allow for visits beyond those that were held in relation staff received the findings and recommendations to provide feed- to Stage 2. The team was reliant upon the first-hand experiences back through bilateral meetings and a workshop. The report was of the experts on the core team with long-standing experience in circulated one week in advance of the workshop to ensure time Madagascar, and those with whom they met in bilateral meetings for review and comment. A one-day workshop was held 4 October and those who attended the workshop. with more than 25 participants from the Groupe de Travail—Santé et Changement Climatique. Overall report findings were presented Stage 4: Developing Recommendations and working groups created to discuss and review interventions and Initiating Report Preparation throughout. At completion, the participants had reviewed all the report’s recommended interventions and, based on their feedback, June 11–September 30, 2017 (16 weeks) the WBG team discarded some of the original interventions and This stage presented an overview of climate and health impacts added new measures, while many others were modified. The final and opportunities in Madagascar in the format of a five-part report report was amended to include all the day’s inputs, and it was (this document). Additional technical information was supplied in circulated for review among country and international partners annexes for further reading. This report aims to be a comprehensive as well as relevant WBG staff. account of the latest climate and health information in Madagas- car, detailing impacts, opportunities, a systems assessment, and 8 M etho ds Figure 1.1: Climate and health diagnostic staging. Stage 1: Pre-diagnostic Stage 2: Workshop to Stage 3: Interviews Stage 4: Stage 5: Validating date and document launch the climate and site visits Recommendations and report findings and review change and health initiating summary recommendations diagnostic report Review existing studies, Host review meeting Plan for Conduct Develop reports, and plans, and 2nd stakeholders the workshop interviews recommendations and interviews consultation Conduct the Prepare a Finalize Map the stakeholders Visit sites workshop summary report the report Identify priority climate- Make the findings sensitive health impacts public Set the path for Prepare the briefing note future engagement Train the task team 9 SECTION 2 Climate Drivers, Impacts, and Vulnerable Populations Climate in Madagascar Due to the geography, microhabitats, and weather patterns of the island, the climate of Madagascar varies by region, within region by month, and across region by year. This variability manifests important differences in the types of risks experienced throughout the country, as the climate moves from tropical to temperate to arid. It also drives the need for local-to-regional approaches that are appropriate to the ecological and climatic profile of that particular area. Microclimates prevail in Madagascar (Figure 2.1), with broad patterns of hot, humid rainforest on the east coast, dry deciduous forest on the west coast, a water-deprived spiny desert in the south- west, and the High Plateau, which is characterized by a mountain chain running down the spine of the country (highest point, nearly 2,900 meters). Rainfall can vary from a few hundred millimeters of rain per year to well over 5 meters of rain per year, depending on the location. Similarly, temperature extremes can range from –10°C to 44°C, although the average is from 14°C to 32°C, depending on the location and season. The southeastern trade winds originate in the Indian Ocean anticyclone, where high atmospheric pressure builds and can generate cyclones that frequently bombard the eastern coast. As these winds move from east to west, they become drier, explaining the higher frequency of cyclones in the east versus the west. Although there are regional nuances, the dry season lasts from May until October, and the rainy season spans November to April. The east coast is persistently wet throughout the year. In the high plateau, arid south, and west coast, all of the rain falls from November to April. The rest of the coun- try can generally be divided into four seasons: Cold/Wet (June–August, called Rirignina), Hot/Dry (September–November, called Lohataona), Hot/Wet (November–January, called Taona) and Cyclone Season (February–May, called Fahavaratra). Climatologically, the cyclone season in the southwestern Indian ocean runs from November 1 until April 30. Climate Change in Madagascar Madagascar is uniquely susceptible to climate impacts and natural disasters, given its extensive coastline and location in the Indian Ocean. The hot, rainy season (November to April) can often bring destruc- tive tropical cyclones. Drought conditions are ever present in certain southern regions. The north and northeast are often affected by flooding and rainfall variability. Climate risks like these are expected to worsen with climate change. Madagascar’s mean annual temperature is projected to rise anywhere from 1–4°C by 2100. There have been significant temperature increases throughout Madagascar from 1961 to 2005, particularly in the country’s south. Average minimum temperature increased across all seasons in 67 percent of the 21 observation stations across Madagascar, and maximum temperatures increased 11 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC Figure 2.1: Climate zones and population centers in Madagascar. Subarid Dry Humid Subhumid Montane Source: Socioeconomic Data and Applications Center, Columbia University, accessed at http://www.efloras.org/web_page .aspx?flora_id=12&page_id=1204 across all seasons at 63 percent of all observation stations, with Assessment Report (IPCC AR5; Smith et al., 2014). For tempera- only one station (Maevatanana, in the Northwest) showing a ture specifically, depending on whether we model moderately significant decrease in temperature (Tadross et al., 2007). There low (Representative Concentration Pathways (RCP) 4.5) or high do not appear to be significant trends in precipitation based on (RCP 8.5) greenhouse gas emission pathways, the lowest and rainfall records from 1901 to 2000; however, there is a correlation highest bounds of the temperature envelope could see increases between increasing temperatures in northern Madagascar relat- between 2.0–6.5°C by 2100, with higher temperatures projected ing to reduced rainfall, and increasing temperatures in southern in the south (Tadross et al., 2008). With regard to projecting the Madagascar relating to increased rainfall (Tadross et al., 2008). future incidence of cyclones between 2060–2100, Tadross et al., Downscaling trends and using global climate models (GCMs), 2008 generated downscaled calculations of the “Genesis Potential” Tadross et al. (2007) produced a series of projections using the (an approximate measure of frequency of cyclones) and maximum scenarios of the International Panel on Climate Change, 5th “Potential Intensity” (an approximate measure of the destructive 12 Clim ate Driv er s, I mpa ct s, and V ulnera ble Populations power of cyclones). The models suggest inconsistent projections for the connections between climate, environment, and society. Impacts, the current cyclone seasons in Madagascar, but a likely reduction drawn from the NDC and other sources, can be broadly connected in cyclones during the current “non-cyclone season.” Far greater to: (1) increased temperatures; (2) extended drought periods and clarity is projected with regard to the potential intensity of future increased variability of rainfall; (3) intensification of cyclones and cyclones where all four GCMs predict increases in the destructive floods associated with cyclonic disturbances; and (4) increasing sea power of cyclones by 2–17 percent (Tadross et al., 2008). This level and sea-surface temperatures. A brief outline of each of these has obvious and significant implications for future infrastructure follows, and further impacts are contained in Table 2.1. development, as well as health risk management. 1. Increased temperatures and carbon dioxide • Extreme temperature events will impact plant development Observed Impacts of Climate Variability and productivity, leading to changes in the flowering, fruit- and Climate Change in Madagascar ing, and pollination of important food crops. The impact of extreme temperature events will have synergies with water Madagascar’s Nationally Determined Contribution4 report provides availability and lead to risks to food security. many tangible examples of the impacts of climate change already observed in Madagascar, all of which have indirect but systemic • Human labor, primarily outdoors in Madagascar (where influences on the determinants of public well-being and health (to 74.5 percent of the population works as agriculturalists) be discussed in further detail in the next section). It is worth first will stagnate as heat increases, leading to reduced agricul- understanding these before proceeding to health impacts to emphasize tural productivity and increases in heat stress and stroke. • Rising levels of carbon dioxide (CO2) will lead to reduced 4  See Box 4.1 in Section 4 for detail regarding the origins and nature of Nationally micronutrient contents in staple crop foods, thus driving Determined Contributions. increased micronutrient deficiencies. Table 2.1: Climate changes and associated environmental impacts in Madagascar. Climate element Current climate experiences Future impacts Increased temperatures Between 1961 and 2005, statistically significant Disruption to unique and critical microclimates increases in daily minimum temperatures were lead to significant changes in local farming observed across most of the country systems, with implications for food security Extended drought periods and increased Droughts: Between 1980 and 2009, five major Decreasing production yields and soil fertility variability of rainfall droughts occurred, with large impacts on loss; water stress (irregular rainfall patterns, agriculture and food security drought, and deficit in some areas) Floods: Over 30 floods or heavy rainfall events affected Madagascar in the past 30 years, killing hundreds of people and affecting thousands Intensification of cyclones and floods Madagascar has one of the highest cyclone Critical risk to the productive and social sectors associated with cyclonic disturbances risks among African countries, with an average of the economy, destroying key infrastructure of 3–4 cyclones affecting the country every year and livelihoods; there are also indirect costs to the economy for the duration of the time that these assets cannot be used Cyclones threaten life-sustaining ecosystems Increasing sea level and temperature increase Shoreline erosion caused by sea level rise Threat to coastal infrastructure, including poses a significant problem to the coastal ports houses, roads, and ports, as well as negatively and beaches of Madagascar; coastal erosion— impacting underground freshwater resources, as measured in 1997—was between 5.7 and agriculturally rich areas, changing the ecology 6.5 meters of coastal regions, and threatening biodiversity 13 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC • Seventy-eight percent of all recorded cyclones have occurred Box 2.1: Ocean Health within the last 30 years (OFDA/CRED 2011). • Social infrastructure (schools, health centers, nurseries) is Ocean impacts are a critical consideration. The ocean is as important often destroyed by cyclones. to Madagascar as any terrestrial asset and is under at least as much stress—both from climate change and insufficient global environmen- • Mangrove forests can be destroyed by flooding. tal management. The Ocean Health Index (http://www • Coral reefs, habitats, and associated species (fishes, arthro- .oceanhealthindex.org/) ranks Madagascar’s ocean health as 162nd pods, sea grass, etc.) can be impacted or destroyed by storm out of 221,5 with declining Ocean Health that is expected to deterio- surges, recessions, and debris. rate by 4% in the near future.6 According to Smith et al., 2014, global sea surface temperatures are expected to rise by approximately • Crops and fields are susceptible to destruction following 0.4–1.1°C by 2025. For Madagascar specifically, these increases heavy rains, floods, and severe winds. in sea temperature will be linked to an approximate 1–20 percent decline in catch potential for fish in or near coastal waters as fisheries 4. Increasing sea level and rising sea-surface temperature migrate pole-wards (IPCC 2014). This impact will be compounded by • Average sea level rise of 7–8 mm per year has resulted in signifi- the rising sea temperature also causing coral bleaching events. This cant coastal erosion and the progression of receding shorelines. large decline in available fish will have significant downstream effects on the local population’s ability to obtain adequate animal-source • Increasing dinoflagellate algae accumulation in fish, asso- foods for nutrition, especially in the context of limited aquaculture ciated with a rise in sea-surface temperature, has resulted directed for subsistence use (Golden 2016 et al., 2017). in illness and death. • Reduction in marine life leads to reduction in catch potential that impacts livelihoods and health. 2. Extended drought periods and increased variability of rainfall • In 2016, the El Nino effect caused rainfall to drop 75 percent Climate and Health Risks in Madagascar compared to the past 20-year average in the southern part of the country, causing soil infertility and harvest losses of This section provides an overview of the key climate-sensitive up to 95 percent, and forcing more than 1 million people health risks in Madagascar, as identified by the IPCC, peer-reviewed to become food insecure. 5 6 literature, national evaluations, and expert opinion. This includes health risks exacerbated by extreme weather and longer term climate • At the time of writing, 30–60 percent of the population of change, as well as the health and development risks associated southern Madagascar was suffering from food insecurity with the emission of short-lived climate pollutants. due to drought periods. There are many ways to categorize the health impacts of climate • Water stress attributed to irregular rainfall patterns, drought, change. One approach focuses on identifying discrete impacts and deficits in some areas will lead to inadequate sources (Figure A1.1), which represents a useful framework in clarifying for drinking water and challenges to crop irrigation. challenges and conveying the scope of potential risk. Another construct was created by the IPCC to highlight intermediate drivers 3. Intensification of cyclones and floods associated with cyclonic (Figure 2.2). This is important when thinking about approaches disturbances to intervention, and so it is included here as it is particularly • From 1976 to 2011, at least 46 national disasters (floods, relevant for country operations. Three typologies of impact are drought, and cyclones) were reported in Madagascar, affect- outlined: (1) direct impacts of climate change on human health; ing more than 11 million people and causing an estimated (2) natural system mediated impacts; and (3) human institution US$1 billion in damages (UNHCHR 2011; Clayton 2012). mediated impacts (Smith et al., 2014). (Co-emitted air pollution is • Around 14 percent of Madagascar’s population is particularly treated separately to better account for the health impacts associ- vulnerable to natural disasters, with 10 percent specifically ated with the drivers of climate change and is classified in terms vulnerable to cyclones (UNISDR 2009). of sources that contribute to ambient air pollution versus those that contribute to household air pollution.) The term “direct impacts” encompasses illness and death due 5  According to analysis by Exclusive Economic Zone; a band extending from coast- line to 200 miles offshore, for which a country has exclusive rights and domain. to exposure to extreme weather and climate events in which climate 6  The Ocean Health Index is measured as a composite score of biodiversity, clean change may play a role. These include effects of high heat (including waters, food provision, artisanal fishing opportunities, natural products, carbon stor- heat exhaustion and heat waves), floods, storms, air quality, etc. Natural age, coastal protection, coastal livelihoods and economies, tourism and recreation, and a sense of place. 14 Clim ate Driv er s, I mpa ct s, and V ulnera ble Populations Figure 2.2: Discrete health impacts of climate change. Mediating Factors Environmental Social Infrastructure Public Health Capability Conditions and Adaptation Direct exposures • Geography • Warning systems • Flood damage • Baseline weather • Socioeconomic • Storm vulnerability status • Soil/dust • Heat stress • Health and nutrition • Vegetation CLIMATE CHANGE status HEALTH IMPACTS • Baseline air/water Indirect exposures quality • Primary healthcare • Precipitation Mediated through • Undernutrition natural systems: • Heat • Drowning • Floods • Allergens • Heart disease • Storms • Disease vectors • Malaria • Increased water/air pollution Via economic and social disruption • Food production/ distribution • Mental stress *The light blue box indicates the moderating influences of local environmental conditions on climate change exposure pathways in a particular population. The gray box indicates the extent to which factors such as background public health and socioeconomic conditions and adaptation measures moderate the actual health burden produced by the three categories of exposure. The solid black arrows at the bottom indicate that there may be feedback mechanisms—positive or negative—between societal infrastructure, public health, and adaptation measures and climate change itself. system-mediated impacts applies to illnesses and deaths due to events useful in discerning interventions. It is important to note that these such as shifts in patterns of disease-carrying mosquitoes and ticks, or impacts will play out in a country where the healthcare system increases in waterborne diseases caused by warmer conditions and is already severely constrained. These constraints, discussed in increased precipitation and runoff. It also includes worsening air quality Section 3 in more detail, include a history of weak health service in general, and increased air pollution in particular, due to temperature provision, limited budgets, and low capacity. increases. Human institution-mediated impacts include morbidity and Direct impacts on health mortality from altered systems created by humans. Impacts include Injuries, death and diseases due to extreme weather and climate malnutrition associated with agricultural production losses, diseases events and poor health outcomes related to failure of built environments (cities, roads, hospitals), stress and undernutrition following violent conflict, • The intensity of heavy precipitation events and cyclones has and widespread impacts that result from market and economic losses. already increased as a result of climate change in Madagascar. Climate change in Madagascar is anticipated to correlate with Increases in the intensity, duration, and frequency of such events health impacts across each of these impact pathways, as described have increasingly severe impacts on human health, and it is below. Although each has been inserted into a category, health expected that as climate change becomes more pronounced, impacts do not exist in a vacuum; being afflicted by a single impact so too will these impacts on health. Cyclones and floods are (such as malnutrition) may result in increased vulnerability to some of the deadliest of all weather-related hazards, accounting another (infectious disease). The categorization simply serves to for many deaths per year, mostly due to drowning. In addition highlight primary drivers and pathways of impact which may be 15 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC to these immediate health hazards, other hazards can often flood season. With anticipated rapid increases in urbanization, appear once a storm has passed, as is discussed below under coupled with flooding due to climate change, these are likely natural system-mediated impacts. to put increasing strain on the health system. • Drought also poses risks to public health and safety. Drought • Increases in malaria are anticipated throughout the country in conditions may increase a range of health impacts, including the future (as is the current trend), particularly in the Menabe wildfires, degraded water quality, and reduced quantity. and Nosy Be regions. This will be driven by a broadening of the temperature envelope which has, historically, limited malaria • While it is hard to estimate the exact number of deaths or in these areas, increased flooding (which leads to increased public health incidences attributed to direct climate impacts on mosquito larvae), and increased human displacement, which health, previous estimates give an indication of their potential also leads to more malaria. impact. Between 1990–2011, more than 2,000 deaths were attributed directly to cyclones, not counting the lagged deaths Acute and chronic respiratory infections from compromised water sources or changes in vector-borne • Climate change is projected to impact human health by increas- disease burden or food insecurity. ing ground-level ozone and/or particulate matter air pollution. Heat-related mortality Such pollutants are associated with a range of health problems and increases in premature deaths (CDC 2017). • Heat-related mortality, along with other impacts on the gen- eral health and productivity of the population, is expected to • While on the one hand, air pollution—a determinant of climate worsen as temperatures increase in Madagascar. While not change—is damaging to human (and ecological) health, climate specific to Madagascar, under a high greenhouse gas emis- change, through increasing temperatures, more frequent and sions scenario, heat-related deaths among the elderly (65 years intense wildfires, etc., is projected to increase concentrations and older) are projected to increase to about 50 deaths per of air pollution. It is estimated that approximately half of all 100,000 by 2080 compared to the estimated baseline of just deaths of ischaemic heart disease are attributed to the use of over 1 death per 100,000 annually between 1961 and 1990. A solid fuels in the country, used by more than 95 percent of rapid reduction in global emissions could limit heat-related the population, and which contribute to approximately 30,000 deaths among the elderly to about 10 deaths per 100,000 in deaths per year. This type of fuel burning contributes to emis- 2080 (Honda et al., 2015). sions and is destructive to population health (WHO 2015). Natural system-mediated impacts Human system-mediated impacts Infectious and vector-borne diseases, including helminthic, water- Chronic and acute undernutrition borne and hygiene-related diseases • In 2016, the El Nino weather phenomenon caused a 75 per- • Climate change is expected to alter the distribution of diseases cent drop in rainfall compared to a 20-year average. In turn, borne by vectors such as ticks, fleas, and mosquitoes. Climate this prompted harvest losses of up to 95 percent, brought is expected to impact these through geographic and seasonal food insecurity to more than 1 million people, forced 35,000 changes, which will influence all parts of a disease lifecycle children under 5 to suffer from moderate acute malnutrition from incubation through transmission (CDC 2017). and another 12,000 from severe acute malnutrition. • By 2070, under a high emissions scenario, about 46 million • Given that undernutrition has such a multifactorial etiology, people are projected to be at risk of malaria in country (also projections of increased risk of undernutrition are difficult. partly reflecting population growth). A low emissions scenario However, it is clear climate change will increase the stress could slightly reduce the population at risk toward 2070. on food systems that are already very vulnerable to shocks. Population growth can also cause increases in the population Damage to cropland, collapse of fisheries, CO2 impacts in at risk in areas where malaria presence is static in the future reducing the micronutrient content of food crops, deforestation (Rocklov et al., 2015). and unsustainable hunting leading to reduced access to wild • Diarrheal deaths are expected to decline due to improvements foods, among other events, will all destabilize food security in Water, Sanitation, and Hygiene (WASH). While not specific to and increase undernutrition. Madagascar, literature suggests that those attributed to climate • The 2008 cyclone season resulted in damages to an estimated change will increase by 12 percent (Lloyd, et al., 2015). Urban 1,255 community nutrition sites, primarily in the regions of areas are particularly at risk: current inadequate hygiene, and Analanjirofo (where 196 were completely destroyed), Atsina- drainage and waste infrastructure in urban areas are currently nana, and Atsimo-Atsinanana. Damages were estimated at leading to outbreaks of various diseases, especially in the Ar. 1,314.3 million (US$800,000). Losses, calculated through 16 Clim ate Driv er s, I mpa ct s, and V ulnera ble Populations Box 2.2: Locust Crises Box 2.3: Discerning Climate Change in Madagascar Risks from Environmental Change Risks In addition to being prone to natural disasters, Madagascar also faces locust plagues that further threaten food and nutrition In light of the holistic approaches of One Health and Planetary security. It was estimated that the food security of 13 million Health, it is necessary to recognize that climate change is not people, or 60 percent of the population, were affected in the the only environmentally related risk factor to human health. In locust plague of 2013, of whom 9 million earned a living from preparing a national action plan for adapting the health sector to agriculture (FAO 2017). Given that extreme weather patterns climate change,8 the government considered cyclones, floods, play a part in creating these swarms, weather conditions and a deforestation, swidden agriculture, freshwater contamination, and changing climate can have a direct effect. In 2013, for example, drought to be the highest priority health-related environmental significant flooding from cyclones created a favorable breeding issues. This is notable as it includes processes broadly associ- environment for new swarms. ated with climate change (i.e., cyclones, floods, and droughts) but also includes other processes that are separate from climate impact on children’s nutrition, were estimated at Ar. 1,575 impacts, such as deforestation, swidden agriculture, and fresh- million (US$1.0 million). Recovery and rehabilitation needs water contamination. include the reconstruction and equipment of the community Understanding climate-health linkages and risk factors is essential to ongoing and pipeline WBG investments given the nutrition sites to cyclone resistant standards, at an estimated significant impacts on the success and sustainability of program- cost of Ar. 5,492 million (US$3.3 million). ming in both the immediate and longer terms. The human health Poor mental health effects of climate change, although present now, will become far more challenging in the future. That said, other types of envi- • Following climate shocks and stresses, populations are displaced, ronmental change—such as deforestation, fisheries and wildlife further impoverished, or affected by other environmentally population collapses, and freshwater contamination—have had determined diseases. Mental health also deteriorates. Few stud- a much broader and more devastating impact to the present ies address mental health impacts of disasters in developing Malagasy population. Recent work has investigated the role of countries, although it is a recognized impact area, drawing broadscale wildlife population declines (among lemurs, bats, from parallel literature in populations that are displaced by tenrecs, etc.) in an increase of micronutrient deficiencies due to other natural disasters or war. high human reliance on these wildlife for nutrition (Golden et al., Any illness that requires professional medical care7 2011). More recent work is establishing baselines of seafood dependency for human nutrition to understand the future role • Extreme weather events disrupt and damage health services of fishery collapses and coral bleaching on food security and that are essential in providing regular treatment, medications, nutrition. Absent climate change, these important ecosystem or hospital care for both communicable and noncommunicable transformations would still be critical processes driving ill health. diseases. Yet, it is likely that climate change will aggravate these impacts in additional ways. Vulnerable Populations combined results follows, and these results are referenced again The Government of Madagascar recently conducted an extensive in Section 4 in relation to interventions.8 climate change and health vulnerability assessment, describing types of vulnerable populations and geographies at risk (GoM, Vulnerability by Region Evaluation de la vulnerabilite et de l’adpatation du secteur sante au changement climatique 2015). The WHO has established gen- Overall, Atsimo-Atsinanana, Androy, Analanjirofo, and Anosy eral categories of vulnerable populations that are largely relevant are the most vulnerable to the health impacts of climate change. to Madagascar, particularly considering the overall picture on These regions have the weakest adaptive capacity, characterized a demographically targeted, project-by-project basis (such as by isolation, poor access to health services, insufficient health maternal and child health investments). A brief summary of these providers per capita, and low incomes. 8  In 2016, the government published a report outlining adaptation actions for the 7  A more detailed overview of climate impacts on the health sector is provided in health sector entitled Madagascar Plan d’Action National d’Adaptation du Secteur Section 3. Sante au Changement Climatique. 17 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC Figure 2.3 : Geographic regions of climate vulnerability and adaptive capacity as identified by the Government of Madagascar. Regional Sensitivities to Climate Impacts Legend Weak Moderate Strong Very Strong No Data Regional Adaptive Capacity Regional Vulnerability to to Climate Impacts Climate Impacts Legend Legend Weak Weak Moderate Moderate Strong Strong Very Strong Very Strong No Data No Data Source: (GoM 2015) 18 Clim ate Driv er s, I mpa ct s, and V ulnera ble Populations Table 2.2: Categories of populations vulnerable to the health impacts of climate change. Category Vulnerability Factor Vulnerability due to demographic • Age (proportion of young and old) factors • Gender (proportion of women) • Population density Vulnerability due to biological/ • Populations with seasonal or chronic malnutrition health factors • Populations with infectious disease burdens • Populations with chronic disease burdens • Immuno-compromised and HIV/AIDS-affected populations • Mental or physical disability Behavioural factors • Poor food preparation • Poor hygiene habits and knowledge • Unsafe defecation practices Vulnerability due to socio- • Poverty economic factors • Low education and illiteracy • Inadequate access to or use of healthcare • Inadequate safe water and sanitation access and use • Inadequate access to communications and information • Displaced and migrant populations • Marginalized populations (i.e., ethnic minorities, nomadic and seminomadic peoples) Vulnerability due to environmental • Exposure to environmental pollutants, livestock, and agricultural wastewater and geographic • Fragile ecosystems: dry lands, coastal areas, floodplains, mountains factors • Populations living in crowded, poor and/or unplanned urban and peri-urban settlements, worker settlements Vulnerability due to sociopolitical • Political instability factors • Existence of complex emergencies and conflict • Limited freedom of speech and information • Infringements of civil rights Source: Adapted from WHO 2013, and in consultation with the Malagasy Groupe de Travail de Sante et Changement Climatque. Atsimo-Andrefana, Atsimo-Atsinanana, Atsinanana, and Analamanga, Alaotra-Mangoro, Itasy, Betsiboka, Amoron’i Analamanga are the regions most frequently impacted by cyclones, Mania and Atsinanana have greater capacity for adaptation, floods, and drought, Madagascar’s most costly natural disasters explained by: (1) better coverage of established health services in both human and economic terms. that can facilitate management of potential epidemics, illnesses, Melaky, Androy, and Atsimo-Atsinanana are the most sensitive or injuries; (2) a higher level of literacy and adult education; and to the health risks posed by climate hazards, primarily due to high (3) a higher percentage of households that are not dependent on rates of household poverty, dependence on subsistence agriculture, agriculture—all of which aid in the preparation and recovery from poorly constructed housing, generally poor health status (as evi- climate extremes. denced by the low incidence of vaccination), elevated prevalence of pre-existing health conditions, and high rates of malnutrition. 19 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC Vulnerability by Population Type with centralized information networks, and regions that lack transport infrastructure were also noted. These experts offered In addition to geography, local experts have identified vulnerable examples of the nutritional risk and vulnerability associated with populations by other typologies. Migrant workers, independent this lack of infrastructure, particularly in the context of highly minors, and those working in the informal employment sector productive agricultural regions that cultivate only a single crop. (specifically mining and often illegal extractive industries) are If an extreme weather event cripples transportation networks, high on this list. From an urban perspective, the urban poor were it makes it impossible for regions like these to obtain adequate cited as highly vulnerable to nutritional and infectious diseases. dietary diversity. Table 2.2 further highlights these correlations Ecologically vulnerable populations were also identified as those and adds categories as defined by WHO, which may be useful for dependent on natural resources and those in water-scarce regions. consideration in Madagascar. They also recognized remote regions that lack communication 20 SECTION 3 Climate-Smart Healthcare Assessment Addressing climate change and health risks and opportunities in Madagascar would be impossible without consideration of the current capacity of the health sector. This section provides an assessment of Madagascar’s health sector, providing relevant facts and figures to inform climate and health decision making, while also exploring those dimensions of the sector that determine the degree to which it is climate smart. In the areas that it is not, this paper identifies intervention areas and expands upon these in Section 4. Climate-smart healthcare includes both low-carbon and resilience/adaptive dimensions. Both are important for the future and both stand to benefit Madagascar in ways beyond diminishing contributions toward climate change or reducing negative health impacts. A climate-smart healthcare assessment measures the ability of the health system to manage poten- tially disruptive climate-related shocks and stresses and, in effect, determines its resilience. This includes managing current and future exposure to climate-related hazards, including risks to the health of the population, as well as risks for the health sector. By overlaying the climate and health risks discussed in Section 2 with an assessment of the current and planned performance of the health system, prior- ity actions can be identified to reduce vulnerabilities and increase resilience before these shocks and stresses occur. The ability of health systems to manage the health risks of climate change is influenced by many factors, including (1) existing infrastructure and assets; (2) potential for expansion/scaling up; (3) social and human capital, including institutional strength of the government (nationally as well as locally) as well as other organizations; and (4) ability and experience in leveraging external support that can support interventions (World Bank 2017). This component of the climate-smart healthcare assessment is critical for a country like Madagascar with its high climate-health vulnerability. The other dimension of a climate-smart healthcare assessment is to review its low-carbon function- ality and potential. This is of lesser importance than assessment of resilience and adaptive capacity in Madagascar given the country’s climate-health vulnerability is greater than most countries, while its overall and health sector carbon emissions are much less. Nevertheless, consideration of low-carbon dimensions is both symbolically important for the health sector (showing a capacity for forward think- ing) and for a healthier population. Low-carbon technologies are generally less polluting and better for the environment, with ultimately positive impacts on human health, and they offer a compelling business case when compared to traditional infrastructure. Greener technologies are also expected to become more commonplace in the future; establishing them in systems now will place Madagascar at the forefront of the field. In Madagascar, power grids are susceptible to regular outages and blackouts; adoption of local and renewable sources can safeguard against this, while also lowering emissions. An embrace of low-carbon approaches can showcase Madagascar as an early adopter and encourage greater political and financial support for its efforts. Madagascar has the potential to be a leader in the field and attract funding from institutions that focus on climate and environment, such as the Green Climate Fund and Global Environment Facility. 21 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC Health Sector Background Box 3.1: Lacking Access to Care This section provides a brief description of the health sector with Is Worse with Climate Change the underlying intention of identifying climate change and health interventions. Existing low levels of access are a particular cause for con- cern with regard to the health system’s ability to manage future Overview climate-related stresses, including significant increases in patient numbers as a result of extreme weather events. The low ratio Despite political crisis in 2009–2013, there have been some of medical professionals to people suggests that there is very little capacity in the system to treat new patients. Should climate improvements in the country’s public health performance in the shocks result in a large number of cases, it is unlikely that the past decade, in particular, improved access to drinking water, current system will be able to respond effectively. pre-elimination efforts against malaria, and improved child Additionally, the urban concertation of health facilities rela- immunization rates and health outcomes (WHO 2014a; World tive to those available in rural areas, coupled with inadequate Bank 2015b). However, health coverage remains limited and the transportation infrastructure to reach clinics, indicates a further sector has generally suffered from instability and turnover (World pressure point regarding potential climate impacts on health: Bank 2015a): between 2009 and 2014, there were four different climate change is expected to impact poor people living in rural Ministers of Health appointed, while the National Health Strategy, areas disproportionately and yet the health sector is not currently which ended in 2011, was informally extended with no interim established to respond to these expected impacts. Scaling up in strategy put in place. The result has been general fragmentation rural areas will be difficult due to the high cost of such activities, in the health sector with negative consequences on health sector as well geographic challenges. With communities isolated due performance and available funding. to heavy rains, swollen rivers, and other climate-related hazards, access is expected to become an even graver stress on the The health sector has suffered from lack of financing, inequi- health sector’s ability to meet the growing needs of the country’s table service delivery, and poor quality of service. In addition to population. the low overall health financing budget, current health expenditure is highly inequitable. Prevalence of long-term (chronic) malnutri- tion among children under five is one of the highest in the world: 53 percent are stunted and 5.8 percent are wasted (World Bank Sector Structure 2015b). More than 66 percent of health facilities report missing at least one essential medicine. Since 2014, there has been an effort The public health sector is organized in a pyramid structure, with to address these challenges with the launch of the development four tiers of access to health services (Figure 3.1). Health services of the new health sector strategy, as well as revitalization of the can be accessed at: basic health centers (Centre de Santé de International Health Partnership in Madagascar (World Bank Base, CSB) I and II; district referral hospitals (Centre Hospitalier 2015a). Prior to 2014, national spending on health was lower de Référence de District, CHRD) without surgery and with sur- than the Sub-Saharan African average. However, since 2014 this gery; regional referral hospitals (Centre Hospitalier de Référence position was reversed. In 2015, national spending as a proportion Régionale, CHRR); and university hospitals (Centres Hospitaliers of GDP was 4.2 percent (WHO 2015; IMF 2015), higher than the Universitaires, CHU), including specialized centers. Sub-Saharan African average of 2.3 percent (World Bank 2014a). The system is organized around 112 health districts, which Medical centers are found throughout Madagascar, although correspond to administrative units referred to as Fivondronana. they are concentrated in urban areas, particularly in Antanana- Each health district typically contains 10 to 25 primary care facili- rivo. As such, access to healthcare is a serious challenge: with a ties and a hospital. The districts are divided into service areas for population of nearly 25 million (64 percent living in rural areas) community health centers (CSB1 and CSB2). CSB1s are managed access is beyond the reach of many Malagasy (World Bank 2015a; only by paramedical staff whereas CSB2s should be managed by a World Bank 2014b; Lancet 2015; WHO 2008). Additionally, fewer doctor and paramedical staff. In 2012, there were 3,074 functional people can afford to access healthcare due in part to the combined CSBs and 150 CHRDs, including approximately 90 with surgi- effects of increasing poverty levels and growing medical costs cal capacity (categorized as CHRD with surgery) (World Bank (World Bank 2014b; IMF 2015). 2015a). Across this structure, the prevalence of trained medical 22 Clim ate-Sm a rt H e althc a r e Assessment Figure 3.1: Structure of Madagascar’s health sector. • Specialized medical or surgical care CHU 6 provincial hospitals CHRR 16 regional level • Complicated surgery cases hospitals CHRD 60 CHD1 and 90 CHD2 • Essential medical cases or surgery (90 have surgical equipment) CSB 1 and 2 • Simple medical cases and prevention 3,074 community level health facilities professionals remains extremely low. There are only 3,150 doc- Not-for-profit health centers are required to adhere to Ministry tors in Madagascar, which equates to just 1.6 physicians for of Health norms and regulations and must integrate their work every 10,000 people (OECD 2006; Our Africa 2010). CSB1s are programs into district health planning. As such, between 2001 and typically understaffed, and comprise one nurse or midwife and 2010, the number of CSB2’s in the private sector doubled and the one support staffer. Only five regions had on average more than number of private hospitals (CHRD2) almost tripled. one staff member per functional CSB1 (World Bank 2015a). Over 40 percent of the population lives more than 5 kilometers from a Healthcare Expenditures health center, while only an estimated 50 percent of the popula- tion makes use of health facilities of health services due to their Madagascar’s heath sector is not adequately funded and has a very distribution or cost. constrained budget envelope (World Bank 2015a). The sector is largely reliant on external financing, with domestic financing low Private Healthcare and unstable. Public spending on health has increased recently, but has historically fallen well below the levels of Madagascar’s peers. There has been an increasing reliance on the private sector for Bearing in mind the budget and expenditure inconsistencies in the provision of health services over the past decade (World the country, the World Bank (2015a) estimated that, in real terms, Bank 2015a), both in terms of not-for-profit and for-profit clinics. public spending on health has not increased since the mid-1990s. 23 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC sustainability, ownership, and efficiency of existing resources. Box 3.2: Health System Structure Over 80 percent of health financing comes from external aid. Challenges in the Face The overreliance on external funding is a serious concern for the of Climate Change sustainability of funding to the sector, and potentially raises issues in terms of alignment, harmonization, and overall efficiency given The structure of health systems exacerbates the health challenges the high volume of external aid provided off-budget. Expenditure posed by climate change as, in general, different departments trends in the sector, coupled with historic underfinancing, indicate manage specific health outcomes (e.g., malaria or undernutrition) that this is the third fundamental weakness in the health sector’s with often limited interactions between departments. The health ability to meet current and future stresses. risks of climate change cut across most of the departments in a ministry of health, requiring crosscutting approaches to adaptation Distribution of Spending that are not standard practice. Further, programs and activities often make the implicit assumption that the same approach to Across the health budget, it is clear that since 2010, labor expen- managing a health risk is appropriate across spatial and temporal ditures have crowded out expenditures on goods, services, and scales. This top-down approach has worked well over the past investments managed by the Ministry of Health (World Bank 150 years to significantly increase public health, but may not hold 2015a). The share of regular wages increased from 33 to 78 percent true in the future as the underlying determinants of health may be (between 2006 and 2013) of the overall budget (including both rapidly affected or altered in some cases. However, the magnitude and pattern of climate-related health risks will depend heavily on internal and external financing) (World Bank 2015a). Regular sal- the local context, requiring consideration of local vulnerabilities ary expenditures in Madagascar have reached levels that are much and capacities into program planning. Approaches that have higher than those generally observed in less-developed countries; worked in the past may fail to work in the future given broad scale most other Sub-Saharan Africa countries had labor shares around and geographically variable ecosystem and climate changes 50 percent or less (World Bank 2015a). affecting the determinants of health. Expenditures related to the provision of healthcare constitute There is also large variation in health system coverage only a small (and decreasing) share of the budget, with the cost across urban/rural and geographic regions with urban centers of most medical consumables borne by the patient through cost better managed than rural centers (World Bank 2015a). Without recovery. A noticeable trend of decreased spending on maintenance adequate supervision, it is likely that the health sector will be and utility costs (from 5.5 percent of the budget in 2008 to less than unable to adequately respond to climate shocks and stresses as 1 percent in 2013) indicates a risk to the sector’s infrastructure. the climate signal becomes stronger over time. In terms of distribution across types of facilities, primary health Successful interventions will demand a strong grasp of this facilities (CSB1 and CSB2) receive 27 percent of total spending on structure. A large base of CSB implicates the level of healthcare with which most of the at-risk population may interact. Working wages, although they serve 50 percent of the population (World with local practitioners is critical for reaching into communities, Bank 2015a). Less than 5 percent of total health spending goes to educating the population, and building resilience to impacts. rural communities. Considering that approximately two-thirds of the population live in rural areas, this represents a highly unequal distribution of expenditure shares. The health sector’s systemic risk management capacity is significantly constrained, reflecting a history of political instability At approximately US$20 per capita in 2014, this is far below the and constrained budgets. It is likely that without notable efforts to average Sub-Saharan African spend of US$83 (World Bank 2015a). address the proximate (limited resources, skills and expenditure, Estimates indicate that public health expenditure increased from etc.) and ultimate (political instability and institutional) causes 2.9 percent of GDP in 2009 to a peak of 4.6 percent in 2010, with for its overall poor performance, the health sector will remain external support comprising a remarkably high amount (roughly vulnerable to any additional pressure, including increasing num- 83 percent in 2013). Internal funding at the Ministry of Health bers of patients or declines in the existing capacity of the already constituted 17 percent in 2013 (World Bank 2015a). constrained system. The extremely low share of domestic funding to the sector is lower than that of other countries, and very low compared with Climate-Related Health Sector Impacts other sectors in Madagascar. The country’s national contribution to education, for example, was approximately 80 percent in this Madagascar experiences about US$100 million in economic losses same year (World Bank 2015a). This poses serious concerns for annually from cyclones, earthquakes, and floods (GFDRR 2017). 24 Clim ate-Sm a rt H e althc a r e Assessment and Red Crescent Societies 2016). Madagascar’s vulnerability to Box 3.3: Importance of Reviewing such shocks and their impact on the economy—particularly on Spending in the Context infrastructure and health—has been recognized in Madagascar’s of Climate Change Nationally Determined Contribution report. The total economic cost of an extreme weather event can be Exploration of spending provides important insight into what a understood in terms of the immediate impact directly attributable system values and prioritizes: that which has been valued in the to the damage, plus secondary impacts throughout the economy past is not always that which will, or should, be valued in the as a result of decreased production, spending, and consumption. future. Priorities and circumstances change and it is critical to Long-term, chronic conditions also often result following a shock, adapt spending to prepare for and respond to new threats. Per- though they can be difficult to attribute and track. For example, haps there is no more immediate threat than climate change. certain infectious diseases can have long-term impacts on organs, Given the damage that climate is expected to inflict on the and loss of homes and livelihoods can result in years of mental health sector and its associated infrastructure, as well as the stress and poor nutrition. The extent of the damage to health increase in climate-related illnesses, there will need to be larger infrastructure is related to both the intensity of the climate event budgets allocated to maintenance, rehabilitation, and expansion and the pre-existing condition of buildings. of the sector. However, recent history has illustrated the opposite: Climate shocks have impacted the health sector in two ways: following Cyclone Enawo in March 2017, 17 of 41 health clinics in the Maroantsetra region were seriously damaged and four were directly through damage on healthcare facilities and associated completed destroyed. There is currently no financing or immedi- infrastructure (such as power and transport), as well as indirectly ate plans to renovate and rebuild these critical structures of health through an increase in patients and a rise in disaster-related ill- delivery (World Bank 2015b). The potential disruption of services nesses, such as infectious disease. Reports of cholera incidences attributed to climate-induced destruction will lead to consequent spiked after 2015 floods (Bickton 2016). The rains created favor- health challenges. able conditions for disease outbreaks, which added to the already Another potential threat is posed by the limited spending in precarious health situation of the country. The displacement of rural communities. Climate change provides further incentive for people after cyclones or droughts poses an additional health risk. increasing spending in rural areas given as it is the populations Cyclones and droughts often drive large internal population move- here who are most vulnerable to the impacts of climate change, ments, with attendant issues of establishing healthcare providers, which are anticipated to increase in the future. sanitation, and coping with the risk of spread of diseases. A reliance on centralized systems may also pose threats. While data are limited on the cost of such events on the Between 2006–2013, the central level managed between 50 and 70 percent of current nonwage health-related expenditures with health system and its ability to recover and manage the increases no clear trend toward deconcentration despite a tiered manage- in climate-related cases, the World Bank and United Nations car- ment and service delivery system down to the primary care level. ried out an assessment of the costs of cyclones in Madagascar Since 2011, there has been a reduction in the share of nonwage (World Bank and United Nations 2008). The report estimated current expenditures managed at the district level. In addition, that cyclones imposed economic costs of at least US$330 million the share of expenses that could potentially be deconcentrated on the country (in 2008 terms), with US$10.3 million borne by has gone down sharply, from over 20 percent to 13 percent in the health sector. An estimated 167 basic health centers and six 2013. This poses a risk to the adaptive capacity of the system in hospitals in 12 regions were damaged, with additional costs due responding to climate stresses as these are likely to be dispersed to outbreaks of diseases. In addition to the constraints imposed across the country, and will require quick disbursement of funds. on the health sector through physical damage, there were reports of 100 deaths directly attributable to cyclones, with more than 600 These impacts are seen across social and productive sectors, people reporting to health facilities to seek help for injuries. Most including health. The country is regularly impacted by large-scale of this damage was concentrated in the regions of Analanjirofo, climate events: for example, in January 2015, the country was hit Atsinanana, and Haute Matsiara. by tropical cyclone Chezda. According to preliminary assessments The health sector is also affected by slow-onset climate stress, by the Malagasy Red Cross Society (CRM), over 80,000 people including rising temperatures, changes in freshwater availability, were affected, and 68 died (International Federation of Red Cross and a rising sea level. As discussed in Section 2, these impacts will and Red Crescent Societies 2016). Just one month later, close to be felt through ecosystems and human systems, especially agricul- 100,000 people were affected by further heavy rainfall and flooding, ture. Increasingly, access to health services is also challenged by with 40,000 displaced and with damage across a range of social climate change, as numerous communities are seasonally isolated and productive sectors (International Federation of Red Cross for months at a time (World Bank 2015b). Even those communities 25 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC country has identified a national focal point for climate change Box 3.4: Quantifying the Cost in the Ministry of Health and is actively engaged in continuing of Climate Shocks on the to build institutional and technical capacities to work on climate Health Sector change and health (WHO 2015). The focal point plays a coordina- tion role between the Health Ministry and the country’s climate Madagascar experiences about US$100 million in economic change institutions. The Groupe de Travail—Santé et Changement losses annually from cyclones, earthquakes, and floods (GFDRR Climatique (GTSCC), established in partnership with the WMO/ 2017). WHO joint office, is also a key player in advancing work in this While data is limited on the cost of such events to the health field through the Director General of Meteorology in Madagascar. system, an assessment of the 2008 events give an indication The National Nutrition Office (ONN) is also an important stake- of the possible magnitude. Conservatively, and as mentioned holder given the expected impact of climate on nutrition. ONN, earlier in this section, the total cost to the economy was seen at although directly attached to the Prime Minister’s Office, is headed US$330 million, with health infrastructure representing US$10.3 by a National Coordinator. This is not a ministerial position but million of this amount. Physical assets represented approximately the equivalent to a general director within a ministry. The ONN 70 percent of this cost, with around 30 percent of this proportion has administrative and financial autonomy and is tasked with comprising equipment and furniture, medicines and supplies, the coordination and the implementation of the National Nutri- and losses of revenues to health facilities. Damage to health infrastructure, as well as to roads con- tion Policy and Strategy. However, given the hierarchy within the necting communities with health facilities, closed several health government, the National Coordinator cannot formally mobilize centers, disrupting the country’s health services at a time of the Ministers nor sit on the council of ministers. The National increased need. This included the treatment of common diseases Institute for Public and Community Health is the lead organization and diseases covered by control and prevention programs, for ethical review and education, training, and capacity building especially with regard to maternal-child health. Although already nationally. It is likely that these coordination issues will become significant, the damage estimates show only the quantifiable an additional stress point in future climate and health efforts in monetary costs associated with such an event and thus under- the country. state the true cost to the economy. In addition to the above key players, there are a series of ministries who will play an important multi-sector role: Ministry of the Environment, Ecology, and Water and Forests; Ministry of with a health center suffer during the rainy season, since refer- Rural Development; Ministry of Agriculture; Ministry of Fisher- rals to hospitals are impossible, replenishment of drugs is slower, ies; Ministry of Education; Ministry of Transportation; Ministry and supervisory visits are virtually nonexistent. Addressing the of Energy; Ministry of Finance and Budget; and Ministry of the impacts of climate variability and change on the health sector Interior. Additionally, the National Office of Catastrophic Risk requires addressing issues of poverty, sanitation, nutrition, and Management and the National Office of Climate Change Coordi- environmental degradation, all of which significantly hamper a nation are essential partners given their multi-sector functions. community’s resilience and its capacity to adapt. UNICEF is an example of an organization that is implementing key activities and interventions in Madagascar, and it recently Current Low-Carbon and Sustainability issued requests for approaches to biodiversity and human health Dimensions of the Healthcare Sector to begin integrating planetary health approaches. Lastly, civil society and academia are necessary partners to mainstream these There has yet to be an assessment of the low-carbon dimensions climate-health activities. of the health sector. Doing so is important for building climate- smart health systems, and this should be addressed in a detailed Relevant Development Policies, Plans, assessment. and Government Priorities Current Status of Health Madagascar is a signatory to the United Nations Framework and Climate-Related Activities Convention on Climate Change (UNFCCC), and the Government of Madagascar has taken a number of steps to identify priority Key Players activities to build resilience to the anticipated impacts of climate change. Health is a primary pillar of many of these strategies, and The Ministry of Health sits directly under the President’s Office will be a fundamental determinant of the ability of the country and is led by the Minister of Health (World Bank 2015b). The 26 Clim ate-Sm a rt H e althc a r e Assessment Health is noted as one of the priority areas for adaptation, along Box 3.5: Interagency Working Group with agriculture and coastal zone management. The NDC notes on Climate Change and Health that multi-hazard early warning systems, as well as public health surveillance, are priority adaption options. The First NDC estab- In 2008, the government established an interagency working lishes a focus on adaptation in healthcare and is expected to result group on climate change and health to identify the climate and in increased efforts from all stakeholders to increase the sector’s weather information and service needs of the health sector, ability to respond to potential climate risks. However, there is room including gaps in data, information, and service delivery. It also for expanded actions with regard to such activities. This Climate sought to help the Madagascar meteorological service meet and Health Diagnostic is expected to be an important input into the specific needs of the health sector. It also aimed to help the future revisions to the NDC and aims to highlight prioritized, high- health sector use climate data and information efficiently for the impact actions for the country that can fulfil both its adaption prevention of epidemics and for guiding response activities for and mitigation ambitions. While the health sector is not noted as climate-sensitive diseases in the country. The working group has a mitigation priority sector, large climate co-benefits are likely in been a catalyst for resource mobilization and climate and health engagement across the government. the provision of climate-smart health infrastructure construction The working group (Groupe de Travail—Santé et Change- and operation, as discussed later in Section 4. ment Climatique) has provided indispensable guidance and Madagascar ratified the Stockholm Convention on persistent insight during the course of this project and has organized two organic pollutants in 2005 and in 2015 ratified the Minamata Con- consultations to directly inform this work. vention on Mercury. Madagascar is one of four African countries implementing these two conventions in the health sector in a joint project with the UN Development Programme (UNDP), WHO, and to meet its Sustainable Development Goal targets in the face of Health Care Without Harm (a nongovernmental organization). The increasingly challenging weather conditions. aim is develop sustainable healthcare waste management systems Its National Adaptation Program of Action (NAPA) laid the and healthcare waste treatment technologies that do not produce groundwork for initiatives on climate change in 2006, identifying persistent organic pollutants, and the substitution of non-mercury health as one of the priority adaptation sectors for the country. containing thermometers and sphygmomanometers. The NAPA identified a need to build, strengthen, and decentral- Madagascar has established a number of other key policy ize local health services, staff, and infrastructure (GFDRR 2011). documents aimed to address the development challenges and It also identified the need for infrastructure that could withstand opportunities in the country, including the Common Country weather upheavals. Although the NAPA excludes an explicit men- Assessment (2003) and the Poverty Reduction Strategy Paper tion of the negative impact that climate might have on health, it (2007), among others. While these almost always identify health establishes health as a key determinant of climate adaptation for as a priority sector for the country’s economic development, with- the Malagasy population. Madagascar has an approved national out clear statements on the impact of climate on health and other health adaptation plan which serves as a road map for policy action important economic sectors, it is likely that the interplay between on health adaptation to climate change (WHO 2015). climate and economic development will be treated as separate. The Madagascar Action Plan (MAP), a five-year plan covering In reality, climate will impact the country’s ability to provide 2007–2012, established eight national strategies for the country: on all of its key objectives across sectors, including agriculture, responsible governance; connected infrastructure; educational infrastructure, water, and health. transformation; rural development and a ‘Green Revolution’; health, Given the importance of health on Madagascar’s development family planning, and the fight against HIV/AIDS; a high-growth outcomes, as well as the increasingly fundamental impact that economy; cherishing the environment; and national solidarity. climate change will likely have on the population (particularly While the MAP did not directly address the impacts of climate on among poor and vulnerable groups), the interplay between climate the country, climate is embedded in the document, particularly and health is an obvious priority for future adaptation efforts. through a disaster lens (GFDRR 2011). Following the change in Climate-smart healthcare, while encompassing the need to build political leadership, MAP has now transitioned into the National resilience to climate impacts into the health sector’s ability to Development Plan (PND). anticipate, respond, and recover from climate shocks and stresses, Madagascar’s First Nationally Determined Contribution is expected to also assist in the country’s mitigation efforts. Work (NDC) recognizes that Madagascar is committed to contributing in this regard is nascent and includes the establishment of this to mitigating climate change, as well as to reduce climate change Climate and Health Diagnostic. Madagascar should build on its vulnerability and promote adaptation measures (see Annex 2). approved national adaptation plan with regard to this emerging 27 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC health following the assessment of the system’s key stress points Box 3.6: Additional Key Policies in this diagnostic. and Programs for Consideration Inequities in Coverage and Other Hurdles Impede Improvement 1. National Policy to Combat Climate Change 2. National Action Plan for Nutrition Despite some progress toward building a more climate-smart sector 3. National Nutrition Policy since the political crises of 2009, the country’s health sector still 4. National Health-Environment Policy faces acute constraints in addressing public health challenges. Coverage of health and nutrition services is limited and marked 5. National Action of Appropriate Attenuation by substantial inequities. On the demand side, beneficiaries face a 6. National Medicines Management Policy number of financial, geographic, and cultural obstacles to accessing 7. National Environmental Action Plan services. The absence of prepayment mechanisms in Madagascar, combined with a cost recovery system that does not have formal 8. Madagascar National Action Plan for Adaptation of Health Sector to Climate Change fees for all services but requires patients to pay for materials and other small inputs when getting services, makes public health 9. National Strategy and Action Plan for Biodiversity, care expensive for the poor and limits their ability to seek help. 2015–2025 In short, the health sector’s performance is severely constrained, even without the anticipated increase in climate-related health impacts, as well as constraints imposed across the economy due work as a critical component of strengthening its ability to respond to climate shocks and stresses. to climate impacts across its economy (WHO 2015). In order to The government’s expert working group on climate change do so, the country will need to scale up its efforts on climate and and health has identified many of these threats and articulated them in the national action plan. Interventions building on these are presented in Section 4, and direct links to investment are given in Section 5. 28 SECTION 4 Recommended Interventions As opposed to most environmental health hazards where exposures can be reduced over time with improved control (e.g., exposure to tobacco smoke, groundwater sources of arsenic), climate change will increase for several decades after emissions are reduced. Further, vulnerabilities will shift because of changes in climate and because of changes in urban form, technology, access to safe water and improved sanitation, and factors associated with development choices. It is also a far more multi- factorial process than other types of exposure that public health specialists have tackled in the past. New evidence and knowledge on projections of climate change and vulnerability, and best practices in adaptation will affect options for managing the health risks of climate change. Together, these changes are likely to alter the effectiveness and success of health systems strategies and policies. In some cases, climate change could affect the longer term sustainability and resilience of a program, such as those designed to ensure access to safe water in coastal zones experiencing sea level rise and storm surges. Given that the health risks of climate variability and climate change are, in general, not new, health systems have policies and programs to manage climate-sensitive health outcomes. As these policies and programs were developed without taking climate into account, they will become increasingly less effective as climate change alters disease risk. Further, because health risks vary over spatial and tem- poral scales, the extent to which a particular program or intervention could be affected by a particular hazard at a particular time will depend on local vulnerabilities and capacities. What is a low risk in one context could be a high risk in another. Given that climate will continue to change for decades and longer, modifications to environmental and health systems should aim to increase resilience to current and future risks, creating where possible increased flexibility to address future hazards as they arise. What is needed is a programmatic approach to increasing health sector performance in the face of climate change. Modifying current programs to manage each climate-related hazard separately may lead to inadequate preparation of health systems to manage multiple and synergistic exposures. Instead, a holistic approach that incorporates a range of interconnected climate-smart interventions, as well as those that incorporate interventions outside of the health sector, should be adopted to meet climate- smart health system goals. In addition to addressing vulnerability and risk, it is worthwhile to also consider low-carbon inter- ventions. Mitigation and adaptation are truly two sides of the same climate change coin; if extensive efforts are to be undertaken to adapt to the health-related impacts of climate change, one should also consider how to improve health-related systems so they contribute less to underlying causes of the threats. The extensive exercise of conducting a climate change and health diagnostic enables consider- able generation of knowledge and convening of relevant personnel, and so discussion of greenhouse 29 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC gas reducing efforts is timely, appropriate, and necessary if we Figure 4.1: Climate smart healthcare. are to build truly climate-smart health systems. Resilience and Low-Carbon Interventions in the Health Sector New investments in any sector should contribute to building resilience to climate change. This is particularly important for the Low-Carbon Resilient Climate-Smart health sector, which serves on the frontline between human well- Healthcare Healthcare Healthcare being and the environment. The health sector must be built strong Interventions Interventions to meet changing climate pressures (e.g., higher temperatures, increased precipitation, and stronger storms) and also increasing populations, local environmental degradation, and emerging infec- tious disease outbreaks. Resilience is particularly important in the context of climate change given the complex, unpredictable, and multifaceted ways in which climate change affects health systems and infrastructure. Vulnerable health systems will simply be unable to cope with threats posed by climate change. There is also no doubt that health systems in many countries contribute significant greenhouse gas emissions. Although the 2. Presented interventions are illustrative of the types of actions relative carbon footprint of the health sector in Madagascar is that can be taken based on the national consultation process low compared to other countries, it is still important to consider and should not be regarded as exhaustive or comprehensive. low-carbon interventions, particularly as access to healthcare and 3. Five climate-sensitive health impacts have been chosen as the service delivery improve as the country develops. Investment in focus of this diagnostic but do not represent all the potential low-carbon healthcare systems can foster clean and independent health impacts of climate change. These include nutrition, energy, safe water, clean transport, and clean waste disposal waterborne diseases, vector-borne diseases, health impacts mechanisms. These can help create local capacity and services by of extreme weather events (EWEs), and health impacts of strengthening the infrastructure needed for low cost, sustainable, air pollution. and resilient facilities while strengthening the market viability of 4. Interventions are interrelated and depend on sequencing low-carbon technologies. Low-carbon healthcare brings added within existing initiatives in the country. For these reasons, benefits to health and local economies, and it provides financial they are not prioritized. incentives. It also demonstrates leadership from health systems, providing an example for others to follow. The positive contribu- 5. Recommended interventions largely aim to improve under- tion to health is most easily demonstrated through reduced air standing and monitoring of health vulnerability and the pollution and its subsequent reduction in the burden of disease. relationship to the environment and climate; to anticipate Given Madagascar’s cohesion on the climate and health agenda, and prepare for changing risks over different spatial and it is well positioned to become a leader in the new field of climate- time frames; to promote multi-dimensional and iterative risk smart healthcare (Figure 4.1), which combines low-carbon and management; and to add flexibility to current public health resilience approaches into a new practice that maximizes benefits interventions that can help them perform better under a for people and the planet. In line with the overview presented in variety of climates. Section 3, this section will describe investment opportunities with 6. The interventions point to no regrets investments to strengthen the greatest potential to safeguard development gains and address systems to manage health risks regardless of how the climate health risks and opportunities in a systematic way. changes in the future. About the interventions 1. All recommended interventions have been identified as Resilience-Building Priority Interventions “climate-specific top-ups” that should be considered as addi- During government consultation, it became clear that resilience tional to existing and planned interventions in evidence-based interventions specifically applied to the health sector through WBG public health risk management and disease control. HNP investments would be insufficient in achieving climate-smart 30 Re c ommen d ed I nte rv ention s health outcomes. Climate-smart interventions in many other the environment and climate; anticipate and prepare for changing sectors, like agriculture, water and sanitation, and disaster risk risks over different spatial and temporal scales; promote multi- management are key to safeguarding health in the face of climate dimensional and iterative risk management; and add flexibility to change. This section therefore describes resilience building inter- current public health interventions, which can help them perform ventions across sectors that are needed to achieve these overall better under a variety of climate scenarios. best results. Those that fit squarely within the health sector can be thought to be part of climate-smart healthcare; those recom- Interventions Focused on Outcomes and Sector mended in other sectors are simply directed toward achieving climate-smart health outcomes. Nutrition They have been categorized by sector for best alignment with Undernutrition is widely recognized as the most critical human ministry work as well as WBG lending. Through the national con- health issue in Madagascar, and new climate stresses will sultation process, interventions in five key areas were identified: only worsen outcomes. Close to 50 percent of the population (1) nutrition, (2) water and sanitation, (3) disasters and extreme stunted and more than 40 percent of the population anemic, weather, (4) vector-borne disease, and (5) air pollution (Figure 4.2). undernutrition is pointedly suspected as being the underlying While each corresponds to specific areas of investment within the driver. Inadequate food access and borderline famine condi- WBG, there are higher level programmatic approaches independent tions in some regions, inaccessible infrastructure to transport of discipline. As a result, crosscutting systemic support interven- food nationally, and very low-input, low-tech agricultural tions that may be taken at a central level or amongst multiple production systems clearly illustrate the entire Malagasy food government departments have also been included to establish an system’s dependence on climate. Extreme weather events like enabling environment for sector work. Some of the recommended droughts, flooding, and cyclones will lead to shocks in food intervention themes recur under different sectors; these have been production. Increasing temperatures and CO2 will cause crop intentionally left in place to ensure that any readers looking only failure and reduced nutritional quality in food crops in some at one section will see the full list. regions. Protein and nutrient content of some cereal crops will The interventions here (see Tables 4.1 and 4.2) are illustrative of decline with rising atmospheric concentrations of CO2 (Myers the types of actions that can be taken, but are not comprehensive, et al., 2014). Poor households that are reliant on autarchic given the expectation that more will emerge with implementa- food production systems (those that are entirely subsistence tion and as the full scope of needs becomes apparent. Broadly, in nature) are easily disrupted by climate-related exposures recommended interventions aim to: improve understanding and like flooding, extreme heat, or pestilence. Given these systems monitoring of health vulnerability and the relationship between are not market integrated, there is no trade option to smooth Figure 4.2: Madagascar climate-related health priorities and intervention areas. CLIMATE-RELATED HEALTH PRIORITIES 1 2 3 4 5 Water-related Extreme weather Vector-borne Nutrition Air pollution illness events diseases CROSS-CUTTING SYSTEM SUPPORT INTERVENTIONS Governance, Policy, and Coordination Human Resources and Capacity Development Research Data, Mapping, and Information Systems Information Infrastructure 31 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC Figure 4.3: Connecting climate change to undernutrition. • Increases in Climate temperature change • Changes in precipitation • Changes in the and soil quality and moisture quantity of crops • Increases in • Increases in pests extreme and pathogens events Increasing carbon • Reduced water dioxide quality Undernutrition concentrations • Increased infectious disease risks • Interrupted food Decreased crop and social concentrations of networks • iron • zinc • protein Source: Ebi 2017. shocks and stresses, leaving populations highly vulnerable and • Promote education and training in meal preparation and choice putting poor nutrition at the top of the list of climate-related for balanced and diverse meal consumption. health impacts (Figure 4.3). Maintaining ecological integrity and appropriate agricultural Knowledge gaps: land-use planning will protect Malagasy populations that are heav- • Conduct climate and nutrition focused research to inform ily reliant on natural resources. Strategic interventions designed projects and investment and translate research findings for to build resilient and climate-smart food systems will enable the public (see Section 5 for further elaboration). sustainable nutrition flows throughout the country. With the vast • Analyze nutrient value of food products to inform appropriate majority of Malagasy being agriculturalists, it is also essential dietary recommendations. to recognize the role of women in this sector as they represent 60 percent of the production force (INSTAT 2015). Mainstreaming Monitoring: gender sensitivity into agricultural and nutritional interventions • Assess dietary intake patterns and establish nutritional surveil- will be of the utmost importance in determining the success and lance monitoring to pre-position aid and support for climate- efficiency of interventions. related food shortages and undernutrition. Climate-Smart Nutrition Interventions • Develop a strategy to monitor changing food production, quality, and safety in relation to changing climate conditions. Target regions: Atsimo-Atsinanana, Anosy, Androy, Amoron’i Policy/Planning: Mania, Analanjirofo, Morombe • Align and integrate nutrition sensitive climate-smart agriculture Education/Communication: approaches with the development of (i) multi-hazard disas- • Integrate climate considerations into mass media and com- ter protocols and risk management protocols for the health munity awareness campaigns for nutrition and health. 32 Re c ommen d ed I nte rv ention s sector, and (ii) multi-sector guidance on norms and standards • Train health and nutrition workers to anticipate and activate for enhancing nutritional outcomes through sustainable land prevention measures to minimize increases in diarrheal disease use, soil conservation, marine spatial planning, and resource following flooding, drought, and other extreme weather events. management. Education/Communication: Water and Sanitation • Integrate water and sanitation education in primary school education programs. Water- and sanitation-related illnesses are still a major driver of Knowledge gaps: disease in Madagascar; less than 14 percent of the population had access to safe sanitation in 2012 (WSP 2015). This means • Improve knowledge base and mapping of existing water and that 19.2 million Malagasies did not have access to adequate sanitation infrastructure and practices including location of sanitation in 2012, 8.6 million of whom practice open defecation. medical waste facilities. Additionally, surface water and shallow wells remain a source of • Determine risks and susceptibility of water and sanitation water for many populations (WSP 2012). Madagascar’s economy infrastructure and practices to sea level rise, cyclonic disrup- loses US$103 million each year due to poor sanitation, of which tion from flooding, etc., and develop appropriate planning 75 percent reflects annual premature death from diarrheal disease, that accommodates long-term change. and 90 percent of that is directly attributable to poor water, sanita- • Identify major regional gaps in infrastructure and then rank tion, and hygiene. (World Bank 2012). areas most likely to be affected by climate-induced increases The precarious water supply and sanitation systems in Madagas- in diarrheal disease. car are already highly vulnerable to present-day climate variability and are expected to worsen with climate change. Extended dry • Conduct anthropological studies on water and sanitation prac- periods may cause water sources to dry up or become intermittent, tices in the targeted regions to improve intervention design. reduce good hygiene practices, and accelerate airborne fecal dust Monitoring: in open defecation zones, all while reducing the performance of sewers, where they do exist. Extreme weather events may dam- • Develop integrated meteorological and water and sanitation age water- and sanitation-related infrastructure, while flooding disease surveillance to help predict risk areas and to pre- may result in the contamination of water supplies. Sea level rise position aid and support to at risk areas. is expected to compromise water sources in some coastal regions Policy/Planning: through a range of impact pathways. As a result, it is highly likely that the incidence of diarrheal diseases will rise. • Develop climate-smart water and sanitation infrastructure Strategic interventions designed to build climate-smart water in high-risk regions, accompanied by an iterative climate and sanitation infrastructure and to align land-use planning across risk management plan to maintain and improve services as the environmental and rural development sectors will minimize the the climate changes. Interventions would need to be context risk of an accelerating burden of diarrheal disease by minimizing specific, but should include interventions in ‘safe’ water and contaminant exposures and ensuring sustainable infrastructure. sanitation supply such as improved water supply sources, for Failure to ensure that services are resilient will have significant example, hand pumps, or improved latrines (the UNICEF and public health consequences. Without taking climate change into Global Water Partnership’s report WASH: Climate Resilient account, the limited progress made toward increasing access to Development provides a useful approach for preparing such drinking water supplies and sanitation is likely to suffer reversals interventions). in the near future. • Align agricultural, livestock, and forestry land-use planning to minimize downstream water contamination. Climate-Smart Water and Sanitation Interventions Disaster and Extreme Weather Target regions: Anosy, Androy, Atsimo-Andrefana, and Atsimo-Atsinanana Madagascar is expected to experience greater variability in pre- cipitation and increases in temperature, sea level, sea surface Capacity/Training: temperature, and cyclonic activity and intensity. Each of these • Integrate water and sanitation education into health worker climate-related environmental changes is expected to magnify direct training and activities, including house-hold water treatment health impacts (drownings, physical trauma, forced migration), and medical waste management. 33 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC indirect health impacts (diarrheal disease, vector-borne disease, facilities and development of health services that can withstand etc.) and direct impacts on health system infrastructure and health flood, drought, temperature extremes, and cyclones (including care delivery. Ultimately, all will exacerbate the disease burden ambulatory and health logistics transport, communication and in Madagascar. Strategic interventions are needed to link disaster information and technology infrastructure, and water and sanita- relief operations to health operations and to improve disaster tion infrastructure). Create government-led mandatory norms. preparedness, to build climate-smart health infrastructure, to • Leverage humanitarian aid to raise awareness of specific develop climate-smart healthcare delivery, and to develop land-use climate-related health concerns and advocate for inter-sector planning protocols that create ecosystem resilience against likely coordination and risk management. climate change impacts. • Establish a clear partnership with neighboring facilities that Climate-Smart Disaster and Extreme will support the sharing of resources in a disaster including Weather Interventions financial recoupment. This is something that can be performed immediately given the existing disaster response work in the Target region: nationwide, but particularly areas prone to drought, country. cyclones, and flooding. • Invest in measures to improve water and energy security of Capacity/Training: health facilities in regions prone to droughts, cyclones, and floods (e.g., solar/turbines and independent water sources) • Train and mobilize health workers in climate-related disaster as well as disaster-proof medical waste management facilities. preparedness, response, and case detection for disaster-related outbreaks. Vector-Borne Disease Education/Communication: • Develop and deploy community awareness campaigns and sea- Madagascar is likely to experience an increase in vector-borne sonal disaster preparedness programming for floods, cyclones, disease for a number of reasons. As climate change is expected and droughts; promote advisory and outreach services (using to increase temperatures and precipitation, this will create condi- severe weather forecasting) via risk communication technolo- tions that are ripe for the biological proliferation of vector-borne gies to alert at risk populations. diseases. Climate influences virtually all components of disease systems (Figure 4.4): the pathogen (for instance, influencing the Knowledge gaps: development rate or survival outside the host or vector), the host (through the immune response or changes in host distribu- • Map and audit the safety and preparedness of health infra- tion), and the vectors (arthropod vector development is tightly structures and update flood, drought, and cyclone risk map- linked to climatic parameters such as temperature and humidity). ping nationally. Temperature affects arthropod vector development at embryonic, Monitoring: larval, and pupal stages, it influences adult feeding behavior, and it affects adult life spans. Similarly, aquatic or moist environments • Create a systematic and coherent registry to track health facil- are often needed for breeding stages; high precipitation can create ity damages, economic costs, and human impacts of extreme more reservoirs and thus amplify the number of breeding sites. weather events. Physically, storms that create debris establish breeding grounds • Enhance hydrometeorological systems by strengthening and for urban disease outbreaks, enabling further proliferation of tailoring multi-hazard early warning systems for cyclones, disease carrying species, while drought can also lead to increased floods, and droughts for health decision making, while creating vector abundance. Vectors and hosts may also move as a result more direct links to public health surveillance and monitoring of climate impacts, such as floods or heat waves bringing the systems (including air quality, harmful algal blooms, water diseases to new areas. quality, etc.). Careful assessment and prediction in some regions and disease systems remain possible, as demonstrated by the numerous studies Policy/Planning: that have used statistical modeling to forecast the future distribution • Provide operational guidance including norms and standards of species or disease (Rogers, Hay, and Packer 1996; McDermott (i.e., protocols) to guide investments for the construction of et al., 2002; Purse et al., 2008). Even if other mechanistic causes 34 Re c ommen d ed I nte rv ention s Figure 4.4: Pathways by which climate change may influence vector-borne diseases. Climate change Affects Regional climate variables Humidity, temperature, precipitation For example, population density, sanitation infrastructure, land use Affects Non-climate change pressures Vector-borne disease Pathogen Vector Replication, Transmission Distribution, virulence exposure reproduction, maturation, feeding behavior, longevity Host Animal and human Impacts Vulnerable populations Economic Health Livelihood 35 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC are implicated, addressing and mitigating the potential effects of Air Pollution climate change and climate variability on vector-borne disease promises significant benefits in Madagascar where humans live The emissions that drive climate change are largely co-emitted so closely in contact with livestock and other animals that are by the same sources that are responsible for air pollution. WHO part of many vector-borne disease transmission life cycles. Key has recognized the large and significant role that ambient air pol- areas of focus include strategic interventions that link weather and lution (AAP) and household air pollution (HAP), particularly in disease surveillance to contribute to early warning systems and the developing world, play in increasing morbidity and mortality risk mapping, and aligning the livestock, forestry, agriculture, and (WHO 2014b). The most recent Global Burden of Disease report land-use sectors for integrated vector management. estimates suggest that AAP and HAP combined were killing more than 5.5 million people annually by 2013 (IHME 2016; Risk Fac- Climate-Smart Vector-Borne tors Collaborators 2015), more deaths than those attributable to Disease Interventions malaria or tuberculosis. Of these, 2.9 million were due to exposure to household smoke from cooking, which constitutes the fourth- Target regions (as defined by three important diseases identified ranked risk factor for disease in developing countries (WHO by the interagency climate change and health working group): 2014b). This is also a major source of black carbon, a short-lived • Malaria: Southeast, Analanjirofo, Atsimo-Andrefana, Vato but powerful driver of a warmer atmosphere. Tens of millions more Vavy, Melaky, Morombe suffer from related, preventable diseases, including pneumonia (which predominantly affects children), lung cancer, cardiovascular • Filariasis: Southeast and Vato Vavy disease, stroke, and chronic obstructive pulmonary disease, which • Schistosomiasis: Southeast, Vato Vavy, Androy includes emphysema and bronchitis (WHO 2014b). Both AAP and HAP pose significant risks in Madagascar, with the effects of Knowledge gaps: AAP felt in cities and in areas with certain types of industry, and • Create population-based and geographically specific risk maps HAP in rural areas where families are reliant upon cook-stoves. for vector-borne diseases, and conduct operational and social Target regions include Antananarivo (AAP) and nationwide science research on effective behaviors and control measures. in rural areas (HAP). Monitoring: Climate-Smart Air Pollution Interventions • Locate, collate, clean, and digitize paper records to improve datasets for disease data, vectors, meteorological conditions, Capacity/Training: and environmental indicators (percentage of forest fires, • Train healthcare workers about pollution avoidance techniques percentage and locations of ecological zones). Improve abil- that can be communicated to local patient populations. ity to access and use remote sensing data of proxy variables environmental conditions (e.g., land use). Once existing data Education/Communication: are understood, invest in hardware and software to carry out • Educate urban populations and rural populations about dangers skill-based training to improve data collection, management, of prolonged exposure to harmful air, specific to their region. and analysis. Knowledge gaps: Policy/Planning: • Establish a database and registers of pollution sensitive diseases, • Develop an integrated health and environmental surveillance mapped to case incidences in cities and regions. system that includes, at a minimum, meteorological and health data for use as an early warning system. Monitoring: • Strengthen integrated vector management approaches and • Identify concentration and types of pollutants in major cities align timing and location of activities with potential climate- using local sensors and satellite remote sensing data. induced shifts in disease burden. Policy/Planning: • Align agricultural, livestock, and forestry land-use planning • Scale up clean cookstove programs and coordinate across to minimize disease transmission. ministries. • Adopt a government-wide One Health approach to manage • Develop and adopt city-wide plan to reduce transport-related zoonotic disease risks. air pollution in Antananarivo. 36 Re c ommen d ed I nte rv ention s Table 4.1: Overview of climate and health interventions by impact category. Impact category Intervention Targeted regions Nutrition • Align and integrate nutrition sensitive and climate-smart agriculture with the development Atsimo-Atsinanana, of multi-hazard disaster protocols and guidance protocols for enhancing nutrition Androy, Amoron’i Mania, through sustainable land use, soil conservation, marine spatial planning, and resource Analanjirofo, Morombe management • Assess dietary intake patterns and analyze nutrient composition of foods to inform dietary recommendations • Establish nutritional surveillance and the monitoring of food system production, food safety, and food quality • Develop mass media and community awareness messaging that embeds climate change into health and nutrition programs • Promote education and training in meal preparation for optimal nutrition Water and sanitation • Develop climate-smart water and sanitation infrastructure in high risk regions Anosy, Androy, Atsimo- • Map locations of existing water and sanitation infrastructure as well as health and waste Andrefana, Atsimo- management facilities Atsinanana, Analanjirofo, • Identify major regional gaps in infrastructure and triage according to climate-induced risk Sava • Conduct anthropological studies on water and sanitation practices in regions selected for intervention • Integrate water and sanitation education and training into both community health worker training, as well as primary school education • Train health and nutrition workers to anticipate and activate prevention measures to minimize disease risk following flooding and drought • Align agricultural, livestock, and forestry land-use planning to minimize downstream water contamination Disaster and extreme • Provide operational guidance—including norms and standards—for the construction Nation-wide, but weather of health facilities and healthcare delivery systems that will resist floods, droughts, particularly flood, temperature extremes, and cyclones. Generate government-led norms and standards drought, and cyclone • Leverage aid to raise awareness of specific climate-health concerns and advocate for prone regions inter-sector management • Map and audit health infrastructures and update flood, drought, and cyclone risk mapping nationally • Invest in measures to improve water and energy security of health facilities • Create a systematic and coherent registry to track health facility damages, economic costs, and human impacts of EWEs • Develop and deploy community awareness campaigns and seasonal disaster preparedness for EWEs; provide advisory and outreach services via risk communication technologies to alert at-risk populations • Train and mobilize health workers in climate-related disaster preparedness • Strengthen and tailor multi-hazard early warning systems for EWEs, deteriorating air quality, and algal blooms and link them to human health surveillance (continued) 37 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC Table 4.1: Continued Impact category Intervention Targeted regions Vector-borne disease • Create population-based and geographically specific risk maps for vector-borne Malaria: Atsimo- diseases, and conduct operational and social science research on effective behavior and Atsinanana, Analanjirofo, control mechanisms Vatovavy, Melaky, • Improve the understanding of relationships between weather variables, land-use Morombe patterns, and infectious diseases, and how climate change will affect them Filariasis: Atsimo- • Create a disease forecasting, early warning initiative Atsinanana, Vatovavy • Develop an integrated health and environmental surveillance system that includes Schistosomiasis: Atsimo- meteorological and health data Atsinanana, Vatovavy • Strengthen integrated vector management approaches and align activities to with potential climate-induced burden shifts • Align agricultural, livestock, and forestry land use planning to minimize disease transmission • Adopt a government-wide “One Health” approach to manage zoonotic disease risks Air pollution • Identify types and concentrations of pollutants in major cities using local sensors and Ambient air pollution: satellite remote sensing data Antananarivo • Establish database and registers of pollution sensitive diseases, mapped to case Household air pollution: incidences in cities and regions rural areas nationwide • Scale up clean cookstove programs and coordinate across ministries • Develop and adopt a citywide plan to reduce transport-related air pollution in Antananarivo • Educate urban and rural populations about the dangers of prolonged exposure to harmful air, specific to their region • Train healthcare workers in pollution avoidance techniques that can be communicated to local patient populations Crosscutting Systemic Support that are highly vulnerable to climate impacts on health to Build Resilience (World Bank 2015b). 2. Strengthen the existing working group on health and In many ways, sector and health outcome focused interventions climate change, and mobilize resources for the imple- are impossible without the necessary crosscutting systemic support mentation of the National Adaptation Plan on health and enabling functions of: (i) governance, policy and coordination; and climate change. (ii) human resources and capacity development; (iii) research; (iv) data, mapping, and information systems; and (v) information 3. Improve coordination between the country’s health sec- infrastructure. These primary crosscutting interventions—­ upon tor and broader development and humanitarian actors which all of the recommended interventions rest—are described to ensure climate change and health considerations are below. mainstreamed into development activities. I. Governance, policy, and coordination 4. Reinforce action on drivers and impacts of other environ- mental degradations and develop synergies with relevant 1. Strengthen the health sector’s general performance initiatives that also require an integrated approach, such through policies and interventions to reduce out-of-pocket as national action plans and implementation efforts for expenditure on health for the poor, as well as healthcare health security, disaster risk reduction, and ecosystem provisions across the country, particularly in rural areas and biodiversity conservation. 38 Re c ommen d ed I nte rv ention s 5. Strengthen health services through rapid response 2. Establish a climate and health research program that is capacity for climate sensitive outcomes, including accompanied by higher education and a specialized skill surveillance and monitoring and raising awareness. An training programming. integrated surveillance system that includes health and IV. Data, mapping, and information systems environmental data is the foundation for developing early warning and response systems to improve current 1. Improve coordination and joint efforts between the Min- and future resilience to climate change. istry of the Interior and Institut National de la Statistique (INSTAT) to improve the interoperability of their data- II. Human resources and capacity development bases, and update statistics more effectively between the 1. Assess environmental health human resources and insti- two entities for alignment of political boundaries, name tutional capacities in health and relevant multi-sector changes, and population-based statistics. programming. 2. Train staff, update technology, and support improved 2. Establish subject- and competency-based training pro- health and related risk factor data collection and grams on health and climate, as well as disaster prepared- management. ness, that are appropriate for specific actors and their 3. Establish a system for integrated surveillance to enable professional functions. This includes: monitoring of key climate-sensitive diseases, as high- • Health Ministry technical and planning staff (especially lighted and articulated in Climate Change and Health GTSCC members) Diagnostic: A Country-Based Approach for Assessing Risks and Investing in Climate-Smart Health Systems • Health workers (World Bank 2017). • Laboratory workers 4. Reinforce sentinel systems and community-based sur- • University faculty and researchers veillance for climate-sensitive health outcomes and • Staff at relevant partner institutions and ministries. disaster-related impacts. 3. Conduct a comprehensive environmental health human 5. Establish indicators of adaptation, losses, and damages, resource development program that includes both train- and the burden of climate-sensitive health outcomes to ing and job placement. track progress. 4. Support national academic and research community 6. Include climate and disaster risk screening in health (Université d’Antananarivo, IPM, Institut Merieux) to system risk assessments and planning. (1) develop higher education curriculum in environmental 7. Conduct social and anthropological research on behaviors health and climate; competency-based modules integrated for waterborne and vector-borne disease risk. in professional training programs (2) sponsor faculty 8. Establish dynamic mapping of climate related health to be trained in this; (3) provide training scholarships; risks, updated seasonally or periodically and (4) facilitate job creation and on-the-job placement opportunities. V. Information Infrastructure 5. Monitor and evaluate efficacy of training programs and 1. Improve information and communications technologies, skill base in associated programming coordination, and openness to improving infrastructure for real-time risk communication, including expansion III. Research of cellular networks and wireless connectivity. 1. Support research and the capacity of research institu- 2. Invest in hardware and software necessary for collecting, tions to generate evidence and relevant skills to identify, managing, and analyzing new environmental health data. anticipate, and manage the health risks of climate vari- ability at national and local levels. 3. Build new—or increase access to—facilities that are capable of housing servers and information and com- munication technology (ICT) hardware. 39 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC Box 4.1: Madagascar’s Nationally Box 4.2: Madagascar National Health Determined Contributions Sector Adaptation Plan In anticipation of an historic international climate agreement at WHO recommends that Health National Adaptation Plans (HNAP) the December 2015 United Nations Framework Convention on follow an assessment of climate and health vulnerability and Climate Change Conference (UNFCCC) of Parties in Paris, many adaptation needs as a means to plan and deliver necessary countries described climate actions they intended to take after changes. In Madagascar, the Plan d’Action National d’Adaptation 2020. Such statements came to be known as Intended Nationally du Secteur Sante au Changement Climatique or PNASS was Determined Contributions, pairing national policy with the global conducted in 2016, and represents a strong commitment of the framework. The use of “intended” ceased following ratification government to take action in this area. It is an important unifying of the Paris Agreement, and these declarations are now called framework for climate change and health issues and highlights Nationally Determined Contributions (NDCs). So far, 121 of 184 Malagasy priority areas. The list of recommendations is also countries (66 percent) highlighted health in their NDCs; Mada- relatively exhaustive and includes interventions that span multiple gascar was one of these. sectors, although the primary focus is within the health field. Three of Madagascar’s 13 priority actions (specifically, 3, 4, Many of the recommendations listed in the PNASS overlap with and 10) explicitly include heath and sanitation, highlighting a rec- the interventions described in Table 4.1, which is anticipated ognized need for climate and health action. Others (6 and 7) deal since the PNASS recommendations were the basis for the gov- with food security and agriculture, providing recognition of the link ernment discussions on interventions. between climate and health, and by extrapolation, to nutrition. Though PNASS recommendations are not largely different from There are new financial facilities that have been established WBG-suggested interventions, there are some points of departure. to assist countries in achieving their contributions, and so it is For example, PNASS interventions are presented in a series, begin- important to highlight these here as consideration of NDC priori- ning with risk evaluation and moving through program evaluation ties may point to opportunities for further investment. Priority and management, whereas WBG interventions are delineated by actions from the Madagascar NDC are included in Annex 3. category of health impact according to lending need. PNASS inter- ventions are also more comprehensive in scope than the actions suggested by WBG, which were narrowed to focus on specific lending needs. Nevertheless, highlighting linkages to the PNASS Low-Carbon Priority Interventions is critical because it ensures the work that went into the multiyear process of preparation is preserved and the recommendations While the above section describes resilience interventions across acknowledged, even if they must be narrowed in scope to be most sectors toward achievement of climate-smart health outcomes, useful to the WBG and other investors. For example, while “mobiliz- this section focuses on low-carbon interventions specifically for ing all healthcare and related actors in the event of disasters” or the health sector. The reason being that the list of recommended “advocating with public and private partners to provide nutritious low-carbon interventions to improve health outcomes in any food to disaster victims” are important activities, they are difficult to sector would simply include all low-carbon interventions. As itemize in investment and so have not been included in our list of low-carbon interventions primarily work toward decreasing pol- interventions and should instead be used to inform the develop- ment of plans among different ministries. Nevertheless, the PNASS lution and limiting GHG emission, there are clear health benefits was a critical resource in the development of these interventions for cardiovascular and respiratory health regardless of the sector and the full list of recommendations is included in Annex 3. in which they are undertaken. Recent WBG work has detailed key elements of low-carbon healthcare. These include: • Low-carbon procurement policies for pharmaceuticals, medical devices, food, and other products 
 • Low-carbon health system design and models of care based on climate-smart technology, coordinated care, emphasis on • Resilience strategies to withstand extreme weather events 
 local providers, and driven by public health needs 
 Using these as high-level principles and in consultation with • Building design and construction based on low-carbon approaches
 government partners, specific low-carbon interventions have been recommended for Madagascar that build on current programming • Investment programs in renewable energy and energy efficiency
 and optimize for current capacity within the health system: • Waste minimization and sustainable healthcare waste 1. Develop a low-carbon strategy for the health sector. management 
 2. Scale up community SME programming and markets around • Sustainable transport and water consumption policies 
 efficient and clean cookstoves, solar lamps, and communal energy charging activities. 40 Re c ommen d ed I nte rv ention s Table 4.2: Low-carbon health sector interventions toward achieving climate-smart healthcare. Intervention Activities Develop a low- • Conduct an assessment of current capacities and needs carbon strategy • Meet with partners in the infrastructure and energy sectors toward establishing a plan for the health • Support countries in gaining a deeper understanding of their energy vulnerabilities and in identifying opportunities for cost sector saving now and in the future • Map out a plan for the design of new facilities as well as retrofitting existing facilities • Work with international partners, such as Health Care Without Harm, that specialize in low-carbon health facility development Scale up • Take stock of current small and medium enterprise (SME) activities in low-carbon energy that might be available to the community SME health sector programming and • Develop on-site renewable energy sources and storage capacity for resilience markets for energy • Install reduced energy devices (e.g., lighting etc.) efficiency • Install passive cooling, heating, and ventilation • Use cold water detergents Scale up waste • Reduce waste through reusable instruments and medical supplies in accordance with relevant hygiene and safety management standards programs, • Implement waste segregation programs to reduce the amount of waste that must be treated particularly • Implement ecologically sustainable, low-carbon solutions for healthcare waste management, such as bio-digestion and existing pilot autoclaving of infectious waste projects that use • Develop food waste biogas pilot projects that generate energy for health facilities on-site for potential scaling autoclaves • Identify local landfills for medical waste recycling • Scale up existing autoclave programs for sterilizing pathogenic healthcare waste as an alternative to incineration Scale up the Green • Conduct an analysis to determine those facilities that could be included in the Green Hospital Initiative Hospital initiative • Develop a plan for expansion that includes a range of healthcare facilities Promote water use • Conduct a system-wide readiness assessment for health facility efficient water programs efficiency through • Establish a plan to introduce rainwater harvesting multiple use • Install low flow devices • Install recycling devices in appropriate facilities Establish training • Develop training curricula to train developers and health system facility managers in the value of low-carbon health sector programs interventions • Conduct training aligned with international standards to influence the construction of future facilities and the retrofitting of existing facilities Conduct health • Conduct long-term cost-benefit analyses of the low-carbon interventions described in this document at the level of health system-wide system facilities cost-benefit • Integrate cost-benefit analyses into a low-carbon strategy analyses • Present findings to health and finance ministries See Climate Smart Healthcare: Low-Carbon and Resilience Strategies for the Health Sector (WBG 2017) report for further details. 3. Scale up waste management programs, particularly existing 6. Establish training programs to educate health policy decision pilot projects using autoclaves. makers in the value of low-carbon interventions. 4. Scale up the Green Hospitals initiative. 7. Conduct health system-wide cost-benefit economic analyses to assess the value of decarbonizing the health sector. 5. Promote water use efficiency through multiple-use (i.e., grey water recycling) approaches. Further details are provided in Table 4.2. 41 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC Climate and Disaster Risk Screening Tools Box 4.3: Global Green and Healthy Hospitals WBG’s Climate and Disaster Risk Screening Tools developed provide a systematic means to considering short- and long-term The Global Green and Healthy Hospitals network (GGHH) is a climate and disaster risks in project and national/sector planning worldwide network of more than 900 institutional members repre- processes. Screening is an initial, but essential, step to ensure senting the interests of over 29,000 hospitals and health centers these risks are assessed and managed to support mainstreaming in 50 countries, including Madagascar. GGHH works with health of climate and disaster resilience into key development policies, facilities, health systems, ministries of health, international organiza- programs, and projects. tions (including WBG and WHO and health professional organi- These self-paced tools provide high-level screening at an zations to help foster sustainable and climate-smart healthcare. early stage of program and/or project development. The tools do Based on a 10-goal framework, the network offers a series of tools not provide a detailed risk analysis, nor do they suggest specific and resources, including case studies from hospitals around the world, guidance documents on energy, waste, water, buildings, options for increasing the project’s resilience. They are intended procurement, and more. It also hosts an online data center and to help determine the need for further studies, consultation, and tool (Hippocrates) for managing and reducing the environmental dialogue in the course of program or project design. footprint and GGHH Connect, a social media platform for members These tools can be applied to a range of development sectors to communicate and collaborate with one another. It has launched in support of national plans and strategies, and also project-level the Green Health Challenges, which is an initiative to encourage investments. The national/policy level tool targets national plans, sector-wide collaboration on waste, energy, and climate. sector-wide strategies, and development policy and institutional GGHH held a workshop in Madagascar in August 2017 at strengthening and reforms (https://climatescreeningtools.world the request of UNDP and the Ministry of Health to build capacity bank.org). for a comprehensive sustainability program. Environmental Health Capacity Assessment Tool Relevant WBG Tools and Resources WBG, in partnership with EcoHealth Alliance, has developed a tool for the country assessment of environmental health services. The This section describes several existing tools within the WBG that tool aims to assist countries in: prioritizing and tracking capacity may be useful in helping task teams address the recommendations development; optimizing the use of existing infrastructure; and and implement the interventions. reinforcing progress in addressing other goals and action plans (e.g., climate adaptation, biodiversity conservation, tackling antimicrobial Climate Change and Health Website resistance, disaster risk reduction, and health security). Structured around core components of governance, technical, and focal (alien The World Bank has been working to address climate change and species) components, the tool establishes standardized criteria for health risks and opportunities for several years. As a result, there environmental health capacity, while noting that the participation are a number of reports and knowledge resources generated that can of multiple sectors is likely required for effective operations. assist in the operationalization of climate change and health project The tool is designed to highlight relevant areas that can rein- interventions. For example, The World Bank Approach and Action force overall ecosystem resilience, intending to build directly on Plan for Climate Change and Health offers guidance on framing existing climate and disaster risk screening tools and risk reduc- climate change and health. Climate Smart Healthcare: Low-Carbon tion resources. It also supports country capacity to anticipate and Resilience Strategies for the Health Sector offers a comprehensive how weather and climate change-related risks interact with other list of tools and resources for climate-smart health programming. changing environmental factors. The tool’s development originated Geographic Hotspots for World Bank Action on Climate Change and from the WBG Operational Framework for Strengthening Public Health provides a methodology for determining regions that are Health Systems at the Human-Animal-Environment Interface (aka. susceptible to climate change and health risks. Each of these, as One Health Operational Framework), which emphasizes value- well as other reports, training segments, factsheets, and links to added application of One Health and the benefits of environment non-WBG climate change and health work can be found at: http:// sector involvement in the public health system. www.worldbank.org/en/topic/climatechange. 42 Re c ommen d ed I nte rv ention s The assessment tool establishes an approach toward collect- case studies and project documents9 (https://www.gfdrr.org/ ing and analyzing available data sources to produce a qualitative recovery-hub). assessment report (modeling the assessment mission and report after the format used for the WHO’s Joint External Evaluations). Operational Framework for Strengthening Application of the tool includes the convening of a stakeholder Public Health Systems at the Human-Animal- meeting with participating ministries to present the pilot assess- Environment Interface ment findings while verifying capacity strengths and gaps with country partners. The stakeholder meeting also serves to review The One Health concept recognizes the connections between possible opportunities to leverage existing capacity and initiate humans, animals, and the environment and promotes coordina- discussion on prioritization of capacity building needs and areas tion to better understand and manage risks. For over a decade, of alignment and/or reinforcement of existing goals. This is also the WBG has worked to promote and operationalize One Health an opportunity to seek feedback on the tool’s overall utility and approaches, supported by country partners, technical institutions, establish a possible scoring structure. Overall, this assessment international organizations, and development funders. There has tool will highlight country leadership, experience, and expertise been a considerable evidence base established on the topic, with while advocating for capacity support to strengthen areas within reports and studies addressing various One Health dimensions, environmental health services. such as People, Pathogens, and Our Planet, the Investing in Climate Change and Health series, and Drug-Resistant Infections: A Threat Global Facility for Disaster Risk to Our Economic Future. This analytical work has underpinned Reduction Resources country operations like the Global Program for Avian Influenza and Human Pandemic Preparedness and Response, and the Regional The Global Facility for Disaster Reduction and Recovery (GFDRR) Disease Surveillance Systems Enhancement program. An Opera- is a global partnership that helps developing countries better tional Framework for Strengthening Public Health Systems at the understand and reduce their vulnerability to natural hazards and Human-Animal-Environment Interface (or One Health Operational climate change. GFDRR is a grant funding mechanism, managed Framework) now builds on this experience and provides guidance by the WBG, that supports disaster risk management projects to help optimize One Health operations. worldwide. Working with over 400 local, national, regional, and The One Health Operational Framework supports country international partners, GFDRR provides knowledge, funding, and lending programs and establishes a step-by-step, how-to meth- technical assistance. odology for applying One Health in development operations. It In recent months, GFDRR has developed two tools that may outlines activities and interventions to target disease threats at be of use to the climate and health community: guidance mate- the human-animal-environment (climate) interface, highlighting rial on post-disaster health sector recovery, and a knowledge hub mechanisms for institutional and technical implementation to build concentrating on recovery operations. more collaborative public health systems. It emphasizes elements In partnership with the International Recovery Platform (IRP) that are critical to include in projects, including specific country and Pan-American Health Organization (PAHO), WBG (through requests for national priority issues. The approach presents steps GFDRR) has developed a guidance note for post-disaster health and provides technical guidance for actions and capacity that can sector recovery. The note is intended to provide action-oriented be taken at the country level along the ‘prevent-detect-respond- advice and interventions for local and central government health recover’ spectrum. It also provides examples of successful One sector officials who face post-disaster challenges. Milestones are Health projects to draw upon and replicate, while creating a platform categorized by phases of recovery (immediate, short-term, and for engagement among international organizations, development medium- to long-term) and specify policy, planning, financial, and lending institutions, and national governments. See Annex 2 for implementation decisions that go into developing and implement- further details of the One Health Operational Framework. ing a health sector recovery plan. This guidance is available on the GFDRR website in English 9  Other related, publicly available disaster preparedness tools include ThinkHazard, and French (https://www.gfdrr.org/sites/default/files/2017-09/ which provides a general view of the threats, for a given location, that should be considered in project design and implementation to promote disaster and climate Health%20Guidance%20Note.pdf). resilience, and the INFORM Risk Index, an open-source risk assessment for humanitar- WBG has also developed the ‘Recovery Hub’, a ‘one-stop ian crises and disasters. INFORM Risk Index can support decisions about prevention, shop’ for disaster recovery operations of which health is one of preparedness, and response. five featured sectors. The hub will feature knowledge resources, 43 SECTION 5 Linking to Investment As is clear from the previous sections of this report, there are considerable health risks associated with environmental degradation and climate change in Madagascar. In several respects, over centuries and decades, many of these impacts have already become apparent: undernutrition, diarrheal disease, vector-borne disease, disaster-related disease, and respiratory disease; not one is new to the island, yet each stands to expand geographically and among populations in our new era of climate reality. Section 2 outlined the effect of climate change in Madagascar and highlighted known and potential health risks in attempt to catalogue what is known and to establish a basis for action. Section 3 then provided an overview of the health system in country, spotlighting areas of potential weakness so that we may work toward making health systems more climate smart, and in effect strengthen institutions on the front lines of human protection and well-being. Section 4 offered interventions, both for the health sector and others, and sought to ensure that practitioners have resources and examples at their fingertips in designing programs. Informed by this knowledge, Section 5 defines direct connections to WBG sectors and projects, describing interventions that could align with work on the ground. The aim is to provide a resource useful to WBG task teams working in each of the areas that follow. This does not preclude others at non-WBG organizations from using the above analysis and interventions for their own projects. Climate interventions can be made at any point during the project cycle, from preparation through implementation, and appraisal. This is important as it suggests that no project is too early nor late to be considered for enhancement by integrating climate change and health considerations. Optimally, projects will be aligned during the design and preparation phase so that climate and health can be included from an early stage. 45 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC Figure 5.1: Interventions throughout the project cycle. Embed climate Problem scoping Deploy diagnostic and health Project of the full range of tool to identify interventions preparation and potential climate country-specific into project design, approval benefits; work climate and health including broader with task teams to risks and outcomes (e.g., food determine relevance opportunities and nutrition security) Develop systematic Engage with project plans to establish Link on-going Communicate with team, including WBG timelines, actions project stakeholders about staff, client and and monitoring Implementation outcomes with climate and health expert networks mechanisms that climate and strategies and their about climate-smart reinforce climate health priorities implementation role health interventions and health interventions Measure and report Measure added Embed climate and progress against value from health updates in Appraisal core climate and application of project revisions health indicators climate-smart where necessary and objectives approach Overview of WBG Lending in fund-related activities that could also benefit from climate change and health interventions; these are described in the subsequent Madagascar subsection regarding trust fund activities. The bank’s current portfolio in Madagascar consists of 13 invest- ments totaling US$758 million. New funding of US$1.3 billion Madagascar Projects and has been announced for 2017–2020. This finance represents an Recommended Interventions opportunity to bring climate and health considerations into current future projects. Improving Nutrition Outcomes Using The interventions below are categorized by lending program. the Multiphase Programmatic Particular focus has been paid to the Improving Nutrition Outcomes Approach Project (P160848) using the Multiphase Programmatic Approach Project (P160848), as this was the primary entry point for conducting this diagnostic and WBG GP: HNP is the project most closely aligned with the assessment (results are The Improving Nutrition Outcomes using the Multiphase Program- presented in Table 5.1). A review of the Madagascar portfolio (both matic Approach project aims to increase utilization of a package of active and pipeline) was conducted, and three programs were identi- reproductive, maternal, and child health and nutrition interventions fied for which climate and health interventions would be particularly and improve key nutrition behaviors known to reduce stunting relevant. Other Madagascar programs with lighter touch interven- in targeted regions. This operation is a contribution to the first tion options are listed in Table 5.2. There are additional global trust phase of the government’s longer term vision in achieving greater 46 L in kin g to I nv es tment Figure 5.2: Sector focus of active WBG projects, by value. human capital. In this context, this project will aim to increase the utilization of a defined minimum package of maternal and child health and nutrition services and improve key nutrition behaviors known to reduce stunting by addressing a focused set of bottlenecks. Necessarily, the operation will focus on improving coordination between the nutrition and health sectors to jointly Other deliver the package. The project will also provide the necessary Transport and 19% infrastructure analytic and technical assistance support to inform the government 22% on the more complex and longer-term institutional, financing, and policy reforms required to achieve and sustain results over time. The Improving Nutrition Outcomes using the Multiphase Rural Programmatic Approach project is envisioned as a 10-year esti- development mated $US200 million investment. The first phrase was World 17% Education and Bank Board approved in December 2017 as a US$90 million-dollar health/nutrition 21% investment (including US$10 million in cofinancing from Scaling Up Nutrition), and is expected to be facilitated during 2018–2022. Not all of the climate change and health interventions pre- Fiscal support 21% sented in Section 4 are relevant to this project given the focus on maternal and childhood health and nutrition and the geographic focus in the central highlands (as they are not susceptible to all climate impacts). The interventions that follow are those that specifically align with project intentions. Interventions Throughout the diagnostic process, consultations have been held Box 5.1: Working with the with the HNP task team to inform the development of this project. Government of Madagascar As a result, many climate and health linkages and recommenda- on Climate Change and Health tions have been embedded within the Project Appraisal Document (PAD). The following section describes in detail the climate and As described in Section 3, there are many potential government health interventions associated with each PAD reference, as well collaborators on climate change and health. Depending on as additional interventions that have been identified during coun- intervention type and WBG project, the implementation partner try consultations. These interventions have also been reviewed will vary. However, an important first step in the preparation of and discussed with government and can be integrated during any climate change and health intervention is discussion with the project implementation phase. (High level recommendations the interagency working group on climate change and health are presented below, with further details presented in Table 5.1) (Groupe de Travail—Santé et Chagement Climatique). The working group has been a catalyst for resource mobilization and Low-carbon interventions: climate and health engagement across the government since • Integrate climate-smart health education, inclusive of resilience 2008 and has provided considerable guidance and support dur- dimensions, into healthcare worker and community training ing the development of this report. First contact with this group (PAD Section 3; para 37; page 25) will support the development of appropriate investments, frame subsequent government interactions, and ensure work builds on • Scale up the use of solar refrigerators used in healthcare facili- that which has already been undertaken. ties and solar batteries in data collection tablets used during Contact: surveillance and research (PAD Section 3; para 37; page 25) Norohasina Rakotoarison, Point focal en Santé et Environnement, MSANP Email: norohasinarakotoarison@gmail.com 47 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC Resilience interventions: • Contribute to disaster protocols that consider climate and health risks (PAD Section II.A; Component 4; para 49; page 29) • Ensure supported Neglected Tropical Disease (NTD) interven- tions include consideration of climate-sensitive threats (PAD • Embed climate change in health and nutrition mass media Section 1.A; para 5; page 11) campaigns (PAD Section III.A; para 40 and annex 5, Compo- nent 4; para 18; page 68) • Develop guidance that links climate-smart healthcare to climate- smart agriculture (PAD section 1.A.5; para 11) Research: • Integrate climate-smart health education, inclusive of resilience • Conduct climate and health-relevant research to inform project dimensions, into healthcare worker and community training implementation (PAD annex 3, para 4 and annex 5, para 16) (PAD Section 3; para 37; page 25) Table 5.1: Descriptions of climate-smart health interventions for Improving Nutrition Outcomes using the Multiphase Programmatic Approach project. Activity Activity description Climate change and health reference in PAD Low carbon Integrate climate-smart This involves developing training courses and Section 3; para 37; page 25 health education, materials for health professionals, teachers, and the inclusive of low-carbon general public. The process will take several months dimensions, into as training materials need to be developed, translated, healthcare worker and and courses conducted. community training Scale up use of solar Switching to solar refrigeration units is advantageous Section 3; para 37; page 25 refrigerators used in for multiple reasons: it decreases grid dependency healthcare facilities and in regions prone to blackouts and it diminishes the solar batteries in all data overall carbon footprint of healthcare facilities. Use collection tablets used of solar batteries, in addition to being more climate during research and smart, are also rechargeable and better for field surveillance research and surveillance. Resilience Ensure supported NTD There are a number of NTD-related interventions Section 1.A; para 5; page 11 interventions include described in section 4. As this project works with consideration of climate- the NTD community, climate-smart approaches to sensitive threats managing NTD risks should be advocated for. Develop guidance that Both are of critical importance in Madagascar where Section 1.A; para 5; page 11 links climate-smart the threat is shared. The known terminology around healthcare to climate- agriculture can perhaps make implementation of smart agriculture climate-smart healthcare more acceptable and efficient. Embedding climate-smart healthcare in this program will place it well ahead of the curve for when it becomes the norm for health systems to include low-carbon and resilience considerations. 48 L in kin g to I nv es tment Activity Activity description Climate change and health reference in PAD Integrate climate-smart This involves developing training courses and Section 3; para 37; page 25 health education, materials for health professionals, teachers, and the inclusive of resilience general public. The process take several months as dimensions, into training materials need to be developed, translated, healthcare worker and and courses conducted. community training Develop disaster Health sector disaster and emergency response Section II.A. Component 4; para 49; page 29 protocols that consider protocols, which are inclusive of climate change. Annex 5 Component 4; para 18; page 68 climate and health risks Research Conduct climate and Research options presented below. Annex 3; para 4; page 56 health relevant research Annex 5; para 16; page 67 to inform project implementation Embed climate change Add climate considerations into ongoing and future Section III.A; para 40 into health and nutrition campaigns and awareness raising initiatives that are mass media campaigns focused on health and nutrition. research options (To be explored through multiple World Bank lending programs in Madagascar) Research Area Description Approach and Estimated Cost Assessment of dietary What are people eating and when in different parts 1) US$40,000. Create a task force to synthesize and integrate habits of Madagascar? The aim is to evaluate the food existing research data from separate regions of Madagascar. system-related vulnerability to climate change. It is This will be sparse and unlikely to have broad national essential to establish an understanding of existing coverage. It will also be collected in different ways so inter- problems, potential future problems, and appropriate regional comparison would be difficult. interventions according to geography. There are a few 2) US$250,000–US$300,000. Work jointly with INSTAT and possibilities for this research, all with different costs. Ministry of Health to launch a series of enumerators across the varying regions of Madagascar to collect prospective 24-hour recall data at low and high food seasons. This would involve the hiring and training of large teams of enumerators but would result in systematically collected data. Baseline data collection This is to include both anthropometry and 1) US$800,000–US$900,000 for comprehensive testing of on nutritional deficiency micronutrient evaluation and link to infectious disease all forms of micronutrients, vitamins, and fatty acids for all types and noncommunicable disease emergence (through subjects, though the cost could be reduced based on a focus community-based epidemiological surveillance on certain subpopulations or forms of nutrition. programs). Identification and analysis of baselines 2) Current cost is US$75,000 for 2 years of work for 8,000 will facilitate data integration with environmental and people. This would reduce with scale. Perhaps US$1 million climate parameters to project climate vulnerability. total. This is essentially two separate activities with the surveillance being most important to move the climate-smart health infrastructure forward: (i) estimation of nutritional deficiency types and (ii) development of epidemiological surveillance programs at the community level. (continued) 49 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC Table 5.1: Continued Activity Activity description Climate change and health reference in PAD Drivers of maternal This is to include (1) down-eating during pregnancy US$10,000–US$15,000. This work could be included in the mortality for fear of difficult births; (2) nutritional choices during dietary intake surveys. Cost would be the addition of a team pregnancy; (3) use of uterotonics during and after of slightly different skilled enumerators. If done alone without delivery; (4) challenges in accessing prenatal care and the dietary intake surveys, then all of the travel and other costs a secure and safe and staffed place for delivery; and would need to be embedded; likely near US$50,000. (5) ways in which climate change will affect healthcare infrastructures. Some are climate related, others are not. From a ministry perspective, maternal mortality is a priority. This would only need to be done on subsets, small focus groups, and limited surveys across different regions of Madagascar. Influence of seasonal Uses all of the other data being collected with US$100,000–US$200,000 at low end and US$500,000 at high weather patterns and collaborators from across Madagascar and beyond end, if inclusive of new modeling. climate change on to run analyses, projections, etc. Would require some health and disease North-South partnership funding, student exchange, workshop costs, etc. Population microbiomes Determine underlying drivers. Is stunting diet related, Most microbiome analyses are roughly US$100–US$150 per to understand the absorptive, intestinal parasites, etc.? Important sample and microscopic analysis of fecal samples would be etiology of stunting to ensure dietary interventions are appropriately approximately US$10 per sample. Therefore, US$150 x “X” for targeted. Anecdotally, many believe that there are a meaningful study. diverse dynamics driving the very high rates of stunting in Madagascar. Integrated Urban Development and Resilience for existing low-income and highly vulnerable neighborhoods. Project for Greater Antananarivo (P159756) Preventive actions would cover urban management processes, including planning, strategy, inter-communal and multi-stakeholder WBG GPs and Programs: GPSURR, Water, GFDRR coordination, and municipal finance. The project would also help The Integrated Urban Development and Resilience Project for improve institutional arrangements (including potential reforms Greater Antananarivo aims to improve the living conditions of the for solid waste management systems, storm water drainage, and poor in selected low-income neighborhoods of Greater Antanana- flood protection) and capacities for service delivery at a metro- rivo (GA). The focus is on enhancing basic service delivery and politan level. This US$70-million investment is expected to be flood resilience and strengthening the government’s capacity for implemented 2018–2021. integrated urban management and effective response to eligible crises and emergencies. Climate Change and Health Entry Points The overall design of the project would represent the first phase Climate-related events are a key consideration in the design of the of a series of projects under a long-term programmatic approach current project, particularly extreme weather events and flooding. around improving integrated urban development and resilience While investment in management capacity and flood infrastructure for GA. Using a two-pronged approach, the project design would will go some way toward addressing health challenges associated focus on: (i) targeting selected neighborhoods that are highly with current and future climate risks, further linking the project prone to flooding for upgrading basic services and flood resilience; with findings from this diagnostic would improve its overall and (ii) initiating key activities that would help the institutions impact on resilience. tackle systemic issues of integrated urban development at the Of particular relevance to this investment are recommenda- metropolitan level. It would thereby finance both corrective and tions relating to water and sanitation and disasters and extreme preventive actions at both the neighborhood and GA levels. Cor- weather (see Section 4). rective activities would include remedial interventions, mostly Capacity development with regard to urban planning should infrastructure and urban upgrading/improved service delivery account in particular for climate risks associated with water supply, 50 L in kin g to I nv es tment sanitation, and hygiene. Specifically, there is the opportunity to of climate change, cash transfers should include consideration of create guidance that integrates water and sanitation infrastructure climate-sensitive threats, while including education and sensitiza- with health outcomes and urban planning. The development of tion as to growing climate and health and nutrition concerns. In climate-smart water and sanitation facilitates should be incor- order to do this, it is suggested that cash transfer interventions are porated with specific reference to the fact that climate poses a aligned with the climate-smart healthcare and nutrition sensitive considerable future burden on the city through its negative impact climate-smart agriculture interventions described in Section 4. It on water-related illness. Additionally, any further infrastructure is also recommended that communication campaigns include an development should include targeted climate-smart water and awareness of seasonal nutrition needs and how these could be sanitation infrastructure in priority areas and develop a plan for exacerbated by climate change. Efforts should also be made to how to maintain and improve services as the climate changes in promote education and training in meal preparation and choice the context of urban development. Integrating water and sanitation for balanced and diverse meal consumption. Developing multi- education should also be included into any training or capacity sector guidance on norms and standards for enhancing nutritional building the project provides. Lastly, where early warning systems outcomes through sustainable land use, soil conservation, marine are implemented or improved, these can easily be extended to spatial planning, and resource management would also enhance include health warnings, and training should be given to build the climate resilience of this portfolio of work. the capacity of urban planners and health providers to activate prevention measures to minimize increases in diarrheal disease Trust Fund-Related Activities following floods. Health risks should be included in any disaster in Madagascar and Recommended preparedness training. All project investments should be low Interventions carbon and integrate climate-smart health education, inclusive of resilience dimensions, into community training. In addition to discrete sectoral-focused projects, WBG operates a number of global goods-focused initiatives linked to centrally Resiliency in the South (FY ’19) managed trust funds that have some relevance to climate change and health (and importantly, have relevance to work under way WBG GPs and Programs: Social Inclusion in Madagascar). Several of these are described below, as are con- and Labor, HNP nections to climate change and health work and opportunities for The Social Safety Net Project (SSNP) for Madagascar aims to sup- engagement with in-country lending. port the government in increasing the access of extremely poor households to safety net services and in laying the foundations Pilot Program for Climate Resilience for a social protection system. Cash transfers and community and Scaling Up Renewable Energy nutrition services would scale up existing safety nets to address in Low-Income Countries Program urgent needs of the poorest populations in the five most affected districts (Tsihombe, Beloha, Ambovombe, Amboasary, and Bekily) The US$1.2-billion Pilot Program for Climate Resilience (PPCR) suffering from the severe drought in the south of Madagascar. The is a funding window of the Climate Investment Funds (CIF) drought has been exacerbated by climate-related factors, such as for climate change adaptation and resilience building. Using a El Niño. The US$35-million grant was approved in 2016 in response two-phase, programmatic approach, the PPCR assists national to the government’s declaration of a humanitarian emergency governments in integrating climate resilience into development for the region. As a result of El Niño, rainfall has been about planning across sectors and stakeholder groups. It also provides 75 percent lower than the average of the last 20 years, causing additional funding to put the plan into action and pilot innovative harvest losses of up to 95 percent. Additionally, more than 1 mil- public and private sector solutions to pressing climate-related lion people have become food insecure, 35,000 children under 5 risks. PPCR has been supporting Madagascar in better under- suffer from moderate acute malnutrition, and another 12,000 from standing overall climate vulnerability across sectors, identifying severe acute malnutrition. The future climate-related implications investments to strengthen institutional capacity and channeling are considerable, as impacts seen here closely align with climate public investments toward infrastructure and improved climate change expected in the future. services. The country is developing a Strategic Program for Cli- mate Resilience under the PPCR, aligned to five principles (spatial Climate Change and Health Entry Points resilience; sector resilience; community resilience; infrastructure The project aligns closely with the findings in this diagnostic, resilience; and fiscal resilience) as well as utilizing funds for the particularly those regarding nutrition. Identification of vulner- Scaling Up Renewable Energy in Low Income Countries Program able populations in this report further underline the impacted under the CIF. populations of this project. To be most effective and considerate 51 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC Table 5.2: Other World Bank projects in preparation in Madagascar and links to climate-smart health-related interventions Project intervention description Madagascar Basic Support the implementation of key elements of Embed climate and health education in primary schools, Education Support the government’s sector plan to improve learning particularly regarding water-related illness (and the expected Project and completion of primary education, particularly negative impact of climate on these) as well as on changing (P160442) access and quality of preschool/early childhood vector-borne disease distribution and seasonality. Doing so will education. establish the basis for a well-informed, environmentally, and health aware public, while potentially inspiring young people toward future careers in public health and environment to address some of the capacity issues outlined in Section 3. Private sector Support private sector growth through small-scale Include low-carbon development in tourism-related infrastructure; development: agriculture and tourism development. include health in development of climate-smart programs to agriculture and tourism address challenges in agriculture, such as worsening nutritional (FY ’18) outcomes due to climate change (increasing temperatures, water scarcity and extreme weather events). Many of the interventions described in the Section 3 nutrition section may be applicable; e.g., early warning system development, education, syncing of climate-smart health and agriculture agendas. Madagascar Inclusive Improve financial inclusion in Madagascar and Consider populations vulnerable to climate change and health and Resilient Growth increase access to credit for micro, small and issues in early assessments of target populations; incorporate (P162279) medium enterprises. projections to determine who will also be impacted in the future. Agricultural support Build on current WBG agricultural projects that Align climate-smart healthcare and nutrition-sensitive climate- to the south support market development and land rights by smart agriculture approaches that address the negative (FY ’18) targeting vulnerable populations in the south of outcomes of climate change on crop yield as well as nutritional the country as identified in the current Country content of crops. Inclusion of disaster protocols to build Partnership Framework (CPF). resilience to droughts and floods should also be included. Many of the interventions described in the Section 3 nutrition section may be applicable; e.g., early warning system development, education, syncing of climate-smart health and agriculture agendas. Lead-cost Electricity Improve electricity sector planning and financial Consider low-carbon health facility assessment and planning in Access Development sustainability, strengthen operational performance the development of electricity sector planning. Support the health (FY ’18) and governance of the state-run utility company, sector to conduct a low-carbon (and energy access) study that JIRAMA, and facilitate investments to enhance could serve as a sentinel for other sectors in projecting future reliability of electricity transmission and distribution. energy needs and opportunities. For more details see low-carbon interventions 1, 2, and 7 in Section 4. Climate Change and Health Entry Points Resilience (SPCR), Pilot Program for Climate Resilience (PPCR) and Health is a fundamental component of climate change adaptation the interventions highlighted in this diagnostic. The recommended and resilience building, particularly in Madagascar where health initiatives outlined in this diagnostic, particularly regarding national and nutrition is identified in the Systemic Country Diagnostic (SCD) health adaptation strategies, should be drawn on, while aligning as a major area of concern for the country. There are significant with all four themes of the interventions described in Section 4. areas of alignment between the Strategic Program for Climate 52 L in kin g to I nv es tment Madagascar Ethanol Clean Cooking Climate GFDRR enabled the development and dissemination of risk Finance Program atlases for high-risk regions and of construction codes for build- ings and infrastructure. The construction codes provide climate The Madagascar Ethanol Clean Cooking Climate Finance Program proof standards for agriculture, irrigation systems, public health aims to increase household use of ethanol in cookstoves as a means centers, roads, and schools in areas highly vulnerable to cyclones, of addressing the high incidence of acute respiratory infections due to droughts, and other climate shocks. Enforced construction codes household air pollution (HAP) and decrease the market demand for are expected to stimulate economic development by improving charcoal. Nearly 12,000 deaths per year in Madagascar are attributed building performance and reducing reconstruction and repair to respiratory infections caused by inhalation of HAP from traditional costs. The risk atlases are expected to strengthen regional and cooking with biomass, of which over 10,000 involve children under national decision making. five. The program makes use of results-based climate finance payments GFDRR supported an initiative in the southwest Indian Ocean that are to be generated from Malagasy households adopting ethanol region to help countries better identify risks and strengthen cooking solutions. Each household participating in this program is financial resilience to disasters. Activities have supported hazard expected to consume 220 liters of ethanol, which replaces 2 tons data collection and developed country-specific risk profiles. This of charcoal consumption and eliminates 5 tons of GHG emissions. will assist Madagascar in assessing regional and national risk financing options. Climate Change and Health Entry Points Currently, GFDRR is facilitating a study to identify policy There are obvious health benefits to be achieved through the use actions that have high potential to increase urban resilience and of cleaner cookstoves and clear climate benefits to switching away improve the quality of life of the poor in Antananarivo. This study highly polluting sources that also compound local environmental will analyze household-level surveys; the study helps inform the degradation. Aligning climate change and health messaging and national government and municipal authorities on how to better interventions with this work is critical because the project has target and finance poverty reduction programs. similar endpoints (toward improving health and environmental GFDRR anticipates demand from the Government of Mada- impacts). Convening the cookstove community with the health gascar to support: and climate community will serve to cross-pollinate ideas amongst • Preparing risk atlases and regional disaster response plans leaders in health, energy, and rural development. Of the inter- for priority regions ventions described in Section 4, there are clear synergies around education, capacity building, training, low-carbon development • Mainstreaming disaster risk management in urban and land- plans, household interventions, research, and risk assessment. use planning and other priority sectors • Strengthening urban resilience in the capital and other cities Global Facility for Disaster Risk Reduction • Modeling contingency funds at central and decentralized levels This facility (GFDRR) has supported disaster risk management • Expanding the risk assessment and financing initiative efforts in Madagascar since 2008, with a focus on identifying risks, mainstreaming climate and disaster resilience in economic Climate Change and Health Entry Points development, and fostering disaster risk financing strategies. The links between climate change, health, and disasters are well With GFDRR assistance, Madagascar became the first country described in Section 4. Many of these disaster risk management in Africa to conduct a joint damage, loss, and needs assessment. interventions will implicitly incorporate improvements in health, The assessment, conducted in collaboration with the European but may not measure health outcomes explicitly, or lead to projects Union and the UN after the 2008 cyclones, estimated the damage with a health focus. The methods proposed in this report could be caused to infrastructure, changes in economic flows, and impacts helpful for the preparation of most of these projects. on social sectors. It also helped identify needs for post-disaster reconstruction and recovery. 53 Annex 1 Global Context of Climate Change and Health Impacts Climate impacts health and this is likely to be greater in low- and middle-income countries. These are often most vulnerable to climate shifts and have the least capacity to take adaptation or mitigation measures given their weak health infrastructure and capacity. The threat posed by climate to health outcomes has been extensively discussed for some years and is seen to be growing. Climate change impacts could drag more than 100 million people back into extreme poverty by 2030 (Hallegate et al., 2016), with a significant part of this reversal attributable to negative impacts on health outcomes. There is clear and mounting evidence that health outcomes will—in large part—be negatively impacted by rising sea levels and temperatures and weather extremes due to climate change. Several of the emissions that drive climate change also affect health directly. These impacts will be greatest in the poorest countries and regions where the population is densest, most vulnerable, and least equipped to adapt (World Bank 2012, 2013, and 2014a; Smith et al. 2014). Given the complexity of social and environmental factors that influence disease and health outcomes, the precise extent of this impact is difficult to establish. WHO, for example, estimated in the early 2000s that climate change was already accounting for an additional 150,000 annual deaths (WHO 2004). Forecasts suggest that by 2030 an additional 250,000 deaths per year will occur from heat exposure, undernutrition, malaria, and diarrheal disease due to climate change. These estimates are regarded as conservative and do not include all climate-sensitive health impacts, such as pollution, injuries, non- malaria infectious disease, and others for which projection data are lacking (WHO 2014a). This additional burden of disease comes with a significant economic global and local impact. One study (Ebi 2008) estimates the global additional costs associated with climate change-related cases of just three sets of diseases—malaria, diarrheal diseases, and malnutrition—to be US$4–12 billion in 2030 under the business-as-usual scenario. A significant part of this burden is borne by poor countries where those three conditions are already persistent. Separate work suggests there are also significant costs associated with disaster-related health impacts. Although little research has been undertaken for the developing world, it was estimated that climate-related disasters have already caused US$14 billion in health-related costs over a 10-year period in the United States alone (Knowlton et al. 2011). Other research has estimated that impacts associ- ated with labor productivity losses due to excess heat (correlating to health stress) may be as much as 11–20 percent in heat-prone regions such as Asia and the Caribbean by 2080 (Kjellstrom 2009). If avoided, these aggregate health costs—along with other benefits of limiting warming to 2°C—can amount to economic savings that exceed US$1.5–2 billion per year for health sector adaptation and start to approach the estimated US$70–100 billion per year of overall adaptation investment needed by 2050 (World Bank 2009). Not all climate-related health impacts of concern will occur in the future. Along with some direct impacts, the emissions that drive climate change are largely co-emitted by the same sources that are responsible for air pollution. The Global Burden of Disease suggests that ambient air pollution (AAP) and, in the developing world, household air pollution (HAP) already kill more than 5.5 million people 55 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC annually (IHME 2016). Tens of millions more suffer from related Climate Change Impacts diseases, including pneumonia (particularly affecting children), on Human Health lung cancer, cardiovascular disease, stroke, and chronic obstructive pulmonary diseases (WHO 2015). As such, reducing emissions There are many ways to categorize the health impacts of climate of greenhouse gases through better transport, food, and energy change. One way is through drivers (Figure 2.2), another is by use choices can result in improved health, especially through the visualizing impacts (Figure A1.1). reduction of air pollution. A significant percentage of the impacts of climate change The economic costs associated with the air pollution-related and its drivers is preventable through a range of proven health burden of disease are also considerable. A study by the Organisation and nonhealth interventions and adaptation measures that help for Economic Co-operation and Development (OECD 2014) found increase a population’s resilience. According to the IPCC, there is that air pollution illnesses and mortalities correspond to US$1.7 tril- substantial potential to reduce climate impacts on health across lion of lost output annually in OECD countries, US$1.4 trillion in eight dimensions by shifting to higher levels of adaptation than China, and US$500 billion in India. Figure A1.1: Exposure pathways by which climate change affects health.* Impact of Climate Change on Human Health Injuries, fatalities, Asthma, mental health impacts cardiovascular disease Severe Air Heat-related illness Weather Population Malaria, dengue, and deaths, encephalitis, hantavirus, cardiovascular failure Rift Valley fever, Lyme disease, chikungunya, West Nile virus ING RES MO R IS ATU W E Changes Extreme ER TEM R E in Vector EX HER Heat P AT TR Ecology EME SIN S EA VEL G LE Increasing L I RI Environmental 2 EV CO CR S NG ELS Allergens Degradation IN SEA Respiratory Forced migration, allergies, asthma civil conflict, Water and Food Water mental health impacts Supply Impacts Quality Impacts Cholera, Malnutrition, cryptosporidiosis, diarrheal disease campylobacter, leptospirosis, harmful algal blooms Source: Dr. George Luber, CDC. 56 Glob a l Conte xt of Clim ate Cha ng e a nd H ealth I mpacts those currently proposed. Whether in infectious disease, heat Importantly, the present health status of a population may waves, or natural disasters, history has shown that preparedness be the single most important predictor of both the future health and response to threats can greatly limit the losses to health, impacts of climate change and the costs of adaptation (Smith human life, and economies. For example, in 1970 a Category 3 et al., 2014). A population’s health status is a function of both hurricane battered East Pakistan (present day Bangladesh) result- access to health services and general development, the latter ing in 500,000 deaths. Similar storms hit Bangladesh again in measured through access to other basic goods and services such 1991 and 2007, causing 140,000 and 3,400 deaths, respectively. as food, education, clean water and energy, clean air, and disaster Collaborative adaptation over the intervening decades led to preparedness and protection. Currently, universal health coverage these dramatic improvements in lives lost (Smith et al. 2014) by (UHC) is the ultimate goal of the health community as reflected in increasing Bangladesh’s resilience to natural disasters. The country the new Sustainable Development Goals (SDGs), national health shifted to a higher level of adaptation that included improving policies, and strategies at development institutions. Achieving general disaster education (greatly assisted by rising literacy rates, UHC—that is, ensuring that 100 percent of the population has access especially among women), deployment of early warning systems to equitable and affordable basic health promotion, prevention, (which included community mobilization), building a network of and treatment and rehabilitation services—would significantly cyclone shelters, relocation efforts, and increasing connectivity of contribute to increases in a population’s resilience to both climate health facilities in high-risk areas. change impacts and the impacts of pollution. Mitigation, in addition to delivering long-term health effects Despite evidence both of the problems and their potential by reducing the level of GHG emission, would also have an imme- solutions, there has been little effort in most low- and low-middle diate impact on health outcomes due to lower pollution levels. income countries to increase the levels of community resilience A significant proportion of potential deaths could be avoided through interventions in health and other sectors to improve health with stringent climate mitigation, given air pollution’s role as outcomes. This historic trend is currently changing, and we may a co-emitted byproduct of fossil-fuel combustion. However, the be at a “tipping point” for health and climate change. remaining deaths are also avoidable through mitigation of black carbon and methane, the so-called short-lived climate pollutants or SLCPs (Rogelj et al., 2014). 57 Annex 2 Country-Identified Priority Actions for Climate Change and Health The following sections present excerpts from two country prioritizations. They have been translated into English, but are otherwise transcriptions of what is found in each document. A. Madagascar Nationally Determined Contributions (NDCs) (2016) Priority actions before 2020 1. Finalization and implementation of the National Adaptation Plan 2. Strengthen climate change adaptation mainstreaming in all strategic/framework documents 3. Multi-hazard early warning systems that mainly consider cyclones, floods, drought, and public health surveillance 4. Effective application of existing or newly established sectoral policies: flood and cyclone-resistant hydro-agricultural infrastructure standards, cyclone resistant building standards, flood-resistant terrestrial transport infrastructure standards, local climate hazard community guideline for water-sanitation-hygiene 5. Intensive awareness raising campaigns concerning the adverse effects of climate change and environmental degradation 6. Development of Resilient Agriculture Integrated Model pilot projects/programs (combination of watershed management, selected/adapted varieties, locally produced compost, rehabilitation of hydro-agricultural infrastructures, input access facilitation system, conservation agriculture, and agroforestry) or “climate-smart agriculture” 7. Promotion of intensive/improved rice farming system and rain-fed rice farming technique 8. Formulation and implementation of the national policy of the maritime territory of Malagasy, considering climate change 9. Formulation and implementation of the National Strategy for Integrated Water Resources Management 10. Evaluation of links between climate change and the migration of vector-borne diseases, malaria, and other emerging diseases as well as the evolution of acute respiratory infections, in order to identify remedial and/or corrective measures 11. Restoration of natural forests and reinforcement of habitat connectivity 12. Identification and sustainable management of climate refuge areas inside and outside protected areas 13. Contribution to the finalization of the “National Framework for Meteorological Services” for which Madagascar has committed itself to the World Meteorological Organization 59 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC B. Madagascar PNASS III. Integrated Health and Environmental Recommendations (2016) Surveillance I. Risk and Capacity Evaluation Desired outcome: Rapid, evidence-based decisions are made for the sound management of public health risks related to climate change Desired outcome: Risk factors for climate change are identified 1. Establish a baseline of health and nutritional status to triage 1. Conduct assessments of sensitive risk factors including levels relevant issues of risk to climate change for human health 2. Establish an integrated health and environment surveil- 2. Conduct descriptive modeling approaches to understand the lance system pertinent health risks, with a view to setting up a surveillance 3. Reinvigorate local early warning systems in the face of and early warning system climate change 3. Evaluate existing structures and programs by identifying capac- 4. Early detection of events related to climate change ity and gaps including technological needs for climate change 5. Use new technologies to strengthen the epidemiological surveillance system using satellite imagery II. Capacity Building 6. Conduct countrywide integrated surveillance of all climate- Desired outcome: Capacity for the effective management of public sensitive diseases (malaria, acute respiratory infections, diar- health risks related to climate change are made available rhea, plague, conjunctivitis, skin infection, malnutrition, etc.) 1. Prepare capacity-building plans specific to climate change 7. Create a platform at all levels to validate and disseminate adaptation to address identified weaknesses as a result of data resulting from environmental and disease surveillance capacity assessment for decision making 2. Train members of the GTSCC on assessment and manage- 8. Establish and operationalize early warning systems to control ment of public health impacts resulting from climate change climate change sensitive diseases including data management 3. Train national experts and civil society members in the 9. Implement the Global Framework for Climate Services adaptation of the health sector to climate change 10. Expand sentinel surveillance sites for fevers, including 4. Provide laboratories and research institutions with equip- climate observation stations ment and products: acquisition and deployment of appro- 11. Develop and update the risk and vulnerability mapping and priate technologies (satellite imagery, monitoring, health distribution of climate change-related diseases. and environmental monitoring, laboratory and research activities, etc.) 12. Collect and analyze data related to climate change 5. Train technicians at the level of the inter-sector institutions in IV. Response terms of response at all levels (event management of public health significance, epidemiology of interventions, etc.) Desired outcome: The critical situation of facing climate change 6. Create specific expertise on the links between health and is monitored the environment 1. Inform the population in time of any type of danger related 7. Expand anticyclonic health facilities to the climate catastrophes 8. Expand “FS” with WASH infrastructure 2. Taking care of climate change victims through treatment and prevention of target diseases 9. Strengthen the capacity of local communication stakehold- ers in “GRC” 3. Implement communication activities related to prevention, preparedness, and early warning of disasters 10. Strengthen the institutional capacity of the health system 60 Co u nt ry-Id entifie d Pr io r it y A ction s fo r Clim ate Ch a ng e and Health 4. Mobilize all healthcare and related actors in the event of VII. Coordination and Program Management disasters 5. Advocate with public and private partners to provide nutri- Desired outcome: Cross-sectoral coordination is effective at all levels tious food to disaster victims 1. Integrate climate-sensitive health risks into national disaster 6. Evaluate response activities risk reduction strategies and plans 2. Develop and implement climate change and health regulations V. Research 3. Incorporate environmental and sanitary standards into urban planning Desired outcome: Local knowledge on health risk factors sensitive to climate change fuel decision making 4. Institutionalize the “GTSCC” for the implementation of the PNASS 1. For all relevant institutions, integrate health and environmental research and action programming together 5. Integrate the climate change and health framework into the GRC, and the National Contingency Plan for Pandemics and 2. Develop and implement a climate change and health research Major Epidemics program 6. Advocate for a continuing government allocation of resources 3. Disseminate research findings for the adaptation of public health to climate change 4. Disseminate the PNASS and the Vulnerability Assessment 7. Integrate climate, health, and environmental linkages into and Health Sector Adaptation Study curricula at all levels 5. Review the research already undertaken on the adaptation of 8. Implement the interministerial convention to facilitate access public health to climate change to and improve the availability of climate change data 6. Use new technologies for the collection, transmission, pro- 9. Carry out working information sessions with stakeholders: cessing, and analysis of data Department of Health, other departments 7. Integrate data and information related to climate change and 10. Advocate at the four institutions and at the level of the health into existing information systems ministerial departments 8. Organize inter-sector information exchange between research 11. Create a partnership platform for the exchange of experiences institutes and health practitioners in climate change adaptation planning processes 9. Advocate for the creation of a scientific discipline formed 12. Mobilize resources for the implementation of activities around health and meteorology (biometeorology) related to climate change VI. Monitoring and Evaluation 13. Advocate with local authorities for the creation of income- generating activities to reduce inequality in access to basic Desired outcome: PNASS monitoring and evaluation activities social services, especially at the expense of vulnerable groups are carried out such as the poorest strata, the elderly and the disabled, 1. Identify the process, output, impact, and indicators for the pregnant women and children under five, malnourished program children, people without health centers and WASH infra- structure, people living in areas exposed to hazards during 2. Monitor and evaluate PNASS activities periods of crisis (post-epidemic and post-cyclone) 3. Strengthen existing monitoring and evaluation systems to 14. Keep all stakeholders informed on issues of change climate integrate climate change and health and health 4. Supervise stakeholders 5. Incorporate information from follow-up activities 6. Organize periodic reviews of the program 7. Conduct community outreach regarding communication 61 annex 3 Climate Change and Health Stakeholder Consultation Agendas and Participant Lists Consultation 1 CHANGEMENT CLIMATIQUE ET SANTÉ À MADAGASCAR Consultation Technique 1 Hotel Carleton, Antananarivo, 9 June 2017, 8h30–13h00 PROGRAMME 0800–0830 Accueil des participants 0830–0915 Introductions 5m Bienvenue Dr. Voahirana Rajoela, Banque Mondiale 20m Contexte Madame DGS Dr. Ihanta, Ministère Auto-présentation des participants de la Sante 5m L’approche du climat et la santé à la Banque Mondiale Dr. Timothy Bouley, Banque Mondiale Les objectifs de la réunion 5m Vue d’ensemble de l’investissement santé à la Banque Ms. Jumana Qamruddin, Banque Mondiale à Madagascar Mondiale 5m Contribution du Madagascar à l’expérience Dr. Joy Guillemot, OMS/OMM internationale en sante et climat 5m L’importance de l’environnement et les approches Dr. Christopher Golden, Harvard écosystémique pour la santé et le nutrition School of Public Health 0915–1030 Session Technique: Risques Climatique à Madagascar 10m Les tendances climatiques observées et les futurs Dr. Zo Andrianina Rakotomavo, changements climatiques à Madagascar Direction Général de la Météorologie 10m Questions et réponses 10m Les impacts et priorités pour la gestion des risques BNGRC catastrophes liées au climat 10m Questions et réponses 1030–1045 Pause-Café 63 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC 1045–1130 Session Technique: Sante et climat à Madagascar—aléas, actions, et priorités 15m Résultats de l’étude: Evaluation de la vulnérabilité et de l’adaptation Dr. Norohasina Rakotoarison, Service de Santé du secteur santé au changement climatique à Madagascar et Environnement, Ministère de la Santé Publique 15m Plan d’action national d’adaptation du secteur santé au changement Dr. Norohasina Rakotoarison, Service de Santé climatique à Madagascar (PNASS) et Environnement, Ministère de la Santé Publique 15m Questions et réponses 1130–1245 Les perspectives multisectorielles 15m Interventions et recommandations des autres secteurs et ministères Les participants du gouvernement 30m Discussion avec les représentants internationaux Les participants des organisations internationaux 30m Discussion et recommandations des participants sur 3 thèmes: 1. Les vulnérabilités prioritaires et opportunités de l’investissement qui adresse le climat, environnement, et sante 2. Les lacunes dans les connaissances et les actions 3. Les connections entre les organisations et les partenaires à Madagascar qui travaillent sur le climat, environnement, et sante 1245–1300 Résumé et prochaines étapes 1300–1400 Déjeuner 1400–1600 Séance technique avec le groupe de travail en santé et changement climatique Participants N° Nom et Prénom Fonction et Entité E-mail 01 RAKOTOARISON Norohasina Point Focal Santé Environnement norohasinarakotoarison@gmail.com SSEnv/MSANP 02 RAZAFINDRAMO Lalao Madeleine Equipe Technique Service de Santé razafindramavolalaomadeleine@gmail.com et Environnement Membre GTCS 03 TOMBOARISENDRA Annah Equipe Technique Service de Santé tannahangela@gmail.com et Environnement 04 RASAMINANJA Rado Mahafaly Equipe Technique Service de Santé Radomafal15@gmail.com et Environnement 05 RAMAHAVONJY Voahangy SSE/DSFa/MSANP ramahavonjyvoahangy@gmail.com 06 RAKOTOMAVO Zo Andrianina DGM yandrianina@yahoo.fr 07 RAKOTOARISOA Alain AT/DVSSE arissoa@gmail.com 08 Jeremie TOUSSAINT PAM-WFP Jeremie.toussaint@WFP.org 09 RAZAFIARISOA Jean Michel 10 QUANSAH Nat Ethnobotanist nat.quansah@yahoo.fr SIT Study Abroad +261 33 73 392 84 11 ROBINSON Harinoro Magistrat miganoor@yahoo.fr DEpi/MINJUS 12 RASOLONJATOVO Nathalie Journaliste GAZETIKO rasoaminah@yahoo.fr 13 Tahina Faniry NARI-VONJY Statisticien IPM fanirynarivony@pasteur.mg 64 Clim ate Ch an ge a n d H e alth Sta kehold er Consu ltation Agend a s and Pa rticipant Lists 14 RAJOELINA Cedric ONE cedric@pnue.mg Cadre en Evaluation Environnementale 15 MIORAMALALA Sedera Aurélien Medécin Sedera_2008@hotmail.fr DLP, MSANP 16 ANDRIAFENOMIARISOA Lantoniaina Hery MEEF/BNCCC lantoniainaherisoa@yahoo.fr Collaborateur Technique 17 ANDRIAMBOAVONJY Andrien BCC MinSanP docteur.adrien@yahoo.fr D.G 18 RAJOELA Voahirana HNP Santé BM vorajoela@worldbank.org 19 NELY Alphonse José SLMEN/MSANP josenely@yahoo.fr 20 GEOFFREY GASPARD PHOTOGRAPHE/FILMMAKER geoffreygaspard@yahoo.com FOUNDER INSTAGRAMERS MADAGASCAR 21 RAHAMIHANTANIARIVO MSP/DGS dgs@sante.gov.mg 22 RATSITORAHINA Maherisoa MSP/DVSSE mahery@pasteur.mg 23 RANDRIAMASIARIJAONA Harinelina SNUT/DSFa snut@sante.gov.mg 24 RAVAOARINOSY Vololoniaina Aimée MSP/DLP ravaoaim@yahoo.fr 25 RALAIVELO Mbolatiana INSTN ludgekely@yahoo.fr 26 ANDRIAMARO Luciano CI landriamaro@conservation.org 27 ANDRITSAINA Bao Zahana bao.andritsaina@gmail.com 28 RAKOTOARIMANANA Haingoaritiana Equipe Technique Service de Santé rhaingoaritiana@yahoo.fr et Environnement MSANP 29 RANDRIANASOLO Ravo Responsable base de données Service micaravo@rocketmail.com de Santé et Environnement MSANP 30 VOLOLONIAINA NIVOARISOA Medecin du SURECA manuelachristophere@gmail.com Manuela Christophere Membre du GTCC MSANP dsureca@yahoo.com 31 RAMIAKAJATO Mavoarisoa Huguette Membre du GTSC ramia_hugsahondra@yahoo.fr 32 RAZAFINDRALAMBO Niry Secrétaire DGS rakotobeniry@gmail.com 33 Hakeem Angulu Student of Harvard hangulu@college.harvard.edu 34 TATA Venance MSANP/DPS/SSEnv tata_ssenv@yahoo.fr 35 RAZAKAMAHEFA Sergio MSANP/DPS/SSEnv ihangyjedidia@yahoo.fr 36 JOY GUILLEMOT WHO/WMO-GENEVE Jshumake-guillemot@wmo.int 37 TIMMY BOULEY World Bank tbouley@worldbank.org 38 JUMANA QAMRUDDIN WORLD BANK 39 RAJERISON Faraniaina MSANP/DPS/SSEnv rajerisonfaraniaina@yahoo.fr 40 RAHOLIJAO Nirivololona MTM/DGM/GTSC niriraholijao@gmail.com 41 RAMIANDRISOA Voahanginirina MTM/DGM/GTSC voahangy_ramiandrisoa@yahoo.com 42 RAMIARAMANANA Hanitra BNGRC sp.bngrc@bngrc.mg hanitra.ramiara@gmail.com 65 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC 43 RAKOTOSEHENO Elisaha CPGU elisharak@gmail.com 44 RAKOTOARISON Anthonio IPM anthonio@pasteur.mg 45 RANDRIAMANALINA Julot CPGU rjulotherman@gmail.com 46 VONJY ANDRIANJAKA Journaliste TARATRA rajaobelinavonjy@yahoo.fr 47 ENRIQUE Paz Chef Santé epaz@unicef.org 48 Sylvie CHAMOIS Responsable Nutrition schamois@unicef.org 49 Elia Wisch ewisch@unicef.org 50 Janus HAZA CRS James.hazen@crs.org 51 Julien Rougerie USAID jrougerie@usaid.org 52 Lessie Snaza USAID jsnaza@usaid.org 53 ONTSANIAINA Iantsatiana iantsaniaina@gmail.com 54 ANDRIAMAMPIANINA Manda mandalinaocent@gmail.com 55 LIVANANDRASANA R.S. DPS/MSANP livanomena@gmail.com 56 RAMINOSOA Malala OMS Madagascar raminosoav@who.int 57 RAZANATSIMBA Fabiola DRES/MPMP fabmi2001@yahoo.fr 58 Amelia Midgley World Bank ameliamidgley@gmail.com 59 Chris Golden golden@hsph.havard.edu 66 Clim ate Ch an ge a n d H e alth Sta kehold er Consu ltation Agend a s and Pa rticipant Lists Consultation 2 CHANGEMENT CLIMATIQUE ET SANTÉ À MADAGASCAR Consultation Technique 2 Hotel Carlton, Antananarivo, Mercredi 4 Octobre, 8h30–16h30 Les objectifs de la réunion Présenter et valider le rapport de diagnostic de Madagascar, y compris ses recommandations pour appuyer le gouvernement de Madagascar à améliorer la résilience face aux impacts sanitaires du changement climatique. Résultats attendu Finaliser la conception des interventions de la Banque mondiale sur le climat et la santé décrites dans le rapport. 0830–0900 Accueil des participants 900–0915 Introduction Madame DGS Dr. Ihanta, Ministère de la Santé Bienvenue Tour de table des participants 0915–930 Progrès sur la diagnostic du climat et la santé à la Banque Mondiale Dr. Timothy Bouley, Banque mondiale Les objectifs de la réunion et processus 930–1000 Diagnostic Global—une approche pour l’évaluation des risques et Dr. Kris Ebi, University of Washington l’investissement dans des systèmes de santé adaptés au changement climatique. 1000–1015 Questions et réponses sur les 2 présentations 1015–1030 Pause-Café Session Technique 1: Aperçu des Risques Climatique à Madagascar 1030–1130 Résultats de l’étude: Aperçu de la vulnérabilité et le secteur santé à Dr. Chris Golden, Harvard University Madagascar Questions et réponses 1130–1230 Session Technique 2: Interventions bas-carbon dans le secteur de la santé Présentation de les interventions recommandées Dr. Timothy Bouley, Banque mondiale Questions et réponses 1230–1330 Déjeuner 1330–1445 Session Technique 3: Approches résilientes dans le secteur de la santé Présentation des approches recommandées pour la résilience Dr. Joy Guillemot, OMS/OMM Groupes de travail: • Nutrition • WASH • Maladies Vectorielles • Catastrophes • Capacité du Système Sanitaire Questions et réponses 1445–1500 Pause-Café 67 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC 1500–1600 Session Technique: Interventions Multi-sectorielle Présentation des interventions recommandées pour les autres secteurs Dr. Joy Guillemot, OMS/OMM Groupes de travail: • Agriculture • Assainissement et eau • Infrastructure, Energie, Transport • Gestion des catastrophes naturelles Questions et réponses 1600–1630 Conclusion Dr. Timothy Bouley, Banque mondiale Liste des participants N° NOM FONCTION ENTITÉ E-mail 1 RAMINOSOA Malala HIP OMS Bureau Pays raminosoav@who.int 2 TATA Venance Chef du Service Service de Santé et tata_ssenv@yahoo.fr Environnement/Ministère de la Santé Publique 3 RAZAFINDRAMAVO Lalao Co-coordinatrice du GTCS Service de Santé et razafindramavolalaomadeleine@gmail.com Madeleine Environnement/Ministère de la Santé Publique 4 RAMORASON Technicienne Service de Santé et rvelonanja@gmail.com Nomenjanahary Velonanja Environnement/Ministère de la Santé Publique 5 ANDRIANARIVELO Technicien Service de Santé et maminiiaina@yahoo.fr Maminiaina Roland Environnement/Ministère de la Santé Publique 6 RANDRIANASOLO Ravo Responsable de Base de Service de Santé et micaravo@rocketmail.com Données Environnement/Ministère de la Santé Publique 7 ANDRIANJAFINIRINA Chef du Service de la DGM/DEM njafys@yahoo.fr Solonomenjanahary météorologie opérationnelle 8 RAHANTAMALALA Mirana Médecin de santé publique Service de surveillance rmiranaando@gmail.com épidémiologique/DLP/MSANP 9 MIORAMALALA Sedera Médecin de santé publique Service de lutte antivectorielle/ sedera_2008@hotmail.fr Aurélien DLP/MSANP 10 RAKOTOMANANA Chef d’Unité Epidémiologie/SIG IPM fanja@pasteur.mg Fanjasoa 11 RAKOTOMAVO Zo Chef du Service DGM/DRDH yandrianina@yahoo.fr des Recherches 12 RAHOLIJAO Nirivololona CHWG Co-chair DGM niriraholijao@gmail.com 13 MAHAZOASY Nestor Responsable du Système ONN n.mahazoasy@gmail.com d’Information 14 ANDRIAMAMPIANINA Stagiaire Service de Santé et mandalinnocent@gmail.com Manda Narindra Chercheur en Communication Environnement/Ministère de la Santé Publique 68 Clim ate Ch an ge a n d H e alth Sta kehold er Consu ltation Agend a s and Pa rticipant Lists N° NOM FONCTION ENTITÉ E-mail 15 ONJANIAINA Iantsatiana Stagiaire Service de Santé iantsaniaina@gmail.com Chercheur en Communication et Environnement/Ministère de la Santé Publique 16 Amelia MIGLEY Specialiste du climate World Bank amidgley@worldbank.orf 17 Kristie EBI Chercheuse University Washtington krisebi@uw.edu 18 Timothy BOULEY Specialiste du climate-santé World Bank tbouley@worldbank.org 19 Joy SHUMAKE Specialiste du climate-santé WMO jshumake-guillemot@wmo.int 20 Chris GOLDEN Chercheur Université de Harvard Chrisgolden05@gmail.com 21 RAMIHANTANIARIVO DGS MSANP ihantaher@gmail.com Herlyne 22 RALISON Paul Directeur Général de l’Ecologie MEEF pralison@yahoo.fr 23 BAO Directeur MEEF 24 ANDRIAFENOMIARISOA Equipe technique BNCCC/MEEF lantoniainaherisoa@yahoo.fr Hery 25 RAKOTOARISON Point focal en Santé et MSANP norohasinarakotoarison@gmail Norohasina Environnement .com 69 Annex Overview of New World Bank Framework 4 for Strengthening Systems at the Human-Animal-Environment Interface (One Health Operational Framework) Health disasters like Ebola in West Africa, H5N1 Avian Influenza in Asia and Europe, and Zika virus in Latin America have significantly harmed both health and economies. Many of these countries afflicted by diseases of pandemic potential also face a persistent burden of endemic diseases such as rabies, Lassa virus, and brucellosis, and are challenged by bacteria increasingly resistant to antibiotics. These disease threats compound poverty and obstruct development. Ecosystem alteration, climate change, and inadequate biosecurity are also disproportionately present in the developing world, and exacerbate existing and emergent disease risk. Strong, environmentally considerate, public health systems are needed to prevent, reduce, and man- age risks to humans, animals, and the environment and are critical to achieving the World Bank twin goals of ending extreme poverty and boosting shared prosperity. The “One Health” concept recognizes these connections and promotes coordination to better understand and manage risks. This approach can help countries achieve progress on national and global priorities including poverty alleviation, economic growth, food security, health, and well-being toward achievement of the SDGs. One Health: What It Is and Why It Matters Public health challenges at the human-animal-environment interface are inherently multi-sectoral, and therefore warrant whole-of-society solutions. The One Health concept recognizes the connections between humans, animals, and the environ- ment and promotes coordination to better understand and manage risks. By improving understanding Box A4.1: Humans, Animals and the Environment: What Are the Connections? • Pandemic and epidemic threats: Over 60 percent of infectious diseases in humans are of animal origin; e.g., Avian Influenza, Ebola, MERS-CoV, and Rift Valley fever viruses, even HIV/AIDS. Changes in land use, climate, food production, trade, and travel are among the drivers of disease emergence and spread. • Antimicrobial resistance: There is evidence of adverse human health consequences due to re- sistant microorganisms resulting from nonhuman usage of antimicrobials, including in animal agriculture. Improper waste management from manufacturing and application may also enable environmental dissemination of residues and resistant strains. • Loss of ecosystem services: Land degradation often results in loss of ecosystem services that support human health and agriculture (e.g., safe water and food, pest control, disaster resilience). 71 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC Figure A4.1: One Health model, as used by the World Bank. Human Health Systems Collaboration Collaboration One Health Collaboration Animal Health Environmental Collaboration Systems Health and Management Systems of animals and/or ecology, it informs risk management and can are highly cost-effective not only for reducing pandemic and prevent disease threats. Its application can also reinforce other antimicrobial resistance risks, but also endemic diseases. health objectives, such as maternal and child health, food and nutrition security, pollution management, and sanitation. One Health Can Help Advance An increasing number of countries are taking measures to Other Development Priorities develop One Health coordination mechanisms to support multi- sectoral surveillance, laboratories, risk assessment, communication, Strengthening public health systems for the benefit of humans, and policy development activities. animals, and environmental health can also help protect agricultural production and ecosystem services, ranging from food and nutrition Why Invest in One Health? security to disaster resilience and ecotourism; all of which contribute to economic development and are critical foundations for growth. In addition to direct health benefits, the economic argument for One Health is integral to the success of multi-sector national action investing in One Health is compelling (Figure A4.2). plans for health security, to address antimicrobial resistance, and While economic impacts are considerable, investments in capac- for disaster risk reduction. It can optimize pandemic preparedness ity to mitigate risk are still very limited.10 One Health strategies planning and enhance climate change vulnerability assessments. This multi-sector approach is endorsed by international agencies (e.g., the WHO-World Organization for Animal Health-Food and Agriculture Organization tripartite agreement and recent decisions 10 Annual investment of approximately US$1.9–3.4 billion to raise human and on health and biodiversity by the UN Biodiversity Convention that animal health system capacity in World Bank client countries is expected to return specifically recognize the value of One Health for mainstreaming upward of $30 billion per year in avoided losses. This is a high return on investment even if only a portion of pandemics are prevented, while also generating gains for biodiversity to help protect species and ecosystems). agricultural production and control of endemic diseases (World Bank 2012). 72 Ove rv iew of N ew W or ld B ank Fr amewo r k fo r Str engthening Sys tems Figure A4.2: Examples of economic impacts of infectious disease outbreaks in nonhealth industries. Estimates represent medical and nonmedical costs; icons depict highly affected industries. Examples of Economic Impact of Infectious Disease Outbreaks: Non-Health Industries $50 bn SARS H1N1 China, Hong Kong, Worldwide $40 bn Singapore, Canada $45–55 bn $30–50 bn Estimated Cost $30 bn HSN1 Avian Flu Worldwide $30 bn $20 bn Zika, Latin America & the Caribbean $10 bn $7–18 bn Ebola West Africa $10 bn 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Tourism and Agriculture Travel public events Mining Figures are estimates and are presented as relative size. Based upon BioEra, World Bank, and UNDP data. Chart updated by EcoHealth Alliance. One Health Operations at the World Bank Interface (“One Health Operational Framework”) now builds on this experience and provides guidance to help optimize One The World Bank has worked for over a decade to promote and Health operations. operationalize One Health approaches, supported by country part- ners, technical institutions, international organizations, and devel- How to Invest in One Health opment funders. The World Bank has established a considerable knowledge base on the topic, with reports and studies addressing Defining the scope, identifying entry points, and mapping stake- various One Health dimensions, such as People, Pathogens, and holders are key first steps to understanding relevant actors and Our Planet, the Investing in Climate Change and Health series, and identifying gaps to address hazards. Each sector has its own Drug-Resistant Infections: A Threat to Our Economic Future. This contributive tools and guidance resources; stronger multi-sector analytical work has underpinned country operations like the Global coordination can better harness existing efforts and generate Program for Avian Influenza and Human Pandemic Preparedness knowledge that could otherwise not be yielded from single sectoral and Response, and the Regional Disease Surveillance Systems approaches. As public health systems are dynamic and require Enhancement program. The Operational Framework for Strength- continuous feedback loops, implementation may occur at differ- ening Public Health Systems at the Human-Animal-Environment ent stages based on resources and priorities, but should reinforce 73 M a da g a s c ar C LIM AT E C H A N G E A N D H EA LTH DIAG N OS TIC overall public health systems strengthening to reduce resource One Health Operational Framework intensive responses. Comparative Advantage Tips for One Health Operations 1. Supports this process and establishes a stepwise, how-to methodology for applying One Health in development opera- • Starting points for One Health vary by context, disease, and tions. It outlines activities and interventions to target disease objectives.  Public health systems must be agile enough to threats at the human-animal-environment interface, highlight- address all hazards; to do this, countries need strong human, ing mechanisms for institutional and technical implementa- animal, environmental health/management systems and tion to build more collaborative public health systems. It coordination between them to even determine which sectors emphasizes elements that are critical to include in projects, are relevant to understand and manage risk. including specific country requests for national priority issues. • One Health approaches should be built into project design It presents steps and provides technical guidance for actions from the onset. Engaging all relevant stakeholders early and capacity that can be taken at the country level along the on helps optimize project success by developing a common prevent-detect-respond-recover spectrum. understanding of issues and joint solutions to address them, 2. Embeds One Health economic and development considerations anticipating risks, targeting key gaps and reducing duplication, into an applied approach to policy and lending. and facilitating relevant coordination channels. 3. Provides examples of successful One Health projects that can • Wildlife and environmental health services should be sys- be borrowed from and replicated. tematically included when considering national investments 4. Creates a platform for engagement amongst international in public health systems. organizations, development lending institutions, and national • There is a growing body of operational experience and governments. tools among the World Bank and key technical partners that 5. Finally, the One Health Operational Framework encourages provide solid grounds to develop sound One Health operations.  greater technical engagement and high-level political support • Communication is a key priority for One Health approach to mainstream One Health considerations into development understanding and implementation. 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