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REPUBLIC OF ALBANIAMINISTRY OF HEALTH

A L B A N I A N S T R A T E G YF O RH E A L T H S Y S T E M A D A P T A T I O NI N T OT H E C L I M A T E C H A N G E

T I R A N A O C T O B E R 2 0 1 1

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F O R E W O R D S F O R T H E A U D I E N C EThe strategic document “Health System Adaptation into the Climate Change 2001-2021 “includes the strategic directions and the action plan for the period 2011-2021. This Strategywas part of the project “Protecting health from climate change. A seven-country initiative”implemented by the World Health Organization with the support of BMU Office in Germany , incollaboration with the Albanian Ministry of Health aiming to provide complete information onactivities to be undertaken by the Ministry of Health in the framework of Health SystemAdaptation into the Climate Change in Albania.

AKNOWLEDGEMENT

The initiative aims to protect health from climate change through addressing adaptation, strengtheningof health systems and building institutional capacity. The seven-country project is part of theInternational Climate Initiative (ICI). The German Federal Ministry for the Environment, NatureConservation and Nuclear Safety supports this initiative on the basis of a decision adopted by theGerman Bundestag.

WHO/Europe coordinated the projects, contributing to the implementation of the WHO regionalworkplan on climate change and health. It also provided technical assistance, guidance, training andexpertise. In each country, a multisectoral steering committee was established, and a projectcoordinator oversaw implementation at the national level. The coordinators were supported byWHO/Europe. All activities were implemented in collaboration with the BMU and the nationalGovernments of the seven countries.

The process for the drafting of the strategic document “Albanian Strategy for Health Adaptation intothe Climate Change Context” was supported and oriented by Dr Petrit Vasil ,Minister of Health

The document is a contribution of the group of experts from various areas under the coordination ofProf. Dr Pellumb Pipero. The information, evidence, the country and foreign experience as well as thesuggestions and recommendations of country and foreign experts were compiled by Dr Alban Ylliwith the support of Dr Gazmend Bejtja, Head of the Steering Committee and coordinated by Dr VasilMiho, Project Coordinator in the WHO Office in Tirana. Special thanks go to Jo Nurse from for herhighly appreciated technical assistance offered to the group and Bettina Menne for her crucial supportto the entire process, both from WHO/EURO Rome office.

The scientific editing and preparation for publication were done by Vasil Miho and VladimirGusmari.

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TABLE OF CONTENTSExecutive Summary ................................................................................................................................................. 54Introduction................................................................................................................................................................ 86CONTEXT................................................................................................................................................................. 1210METHODS AND PROCESS ................................................................................................................................ 1412Guiding principles and approaches for including specific objectives and interventions in theAlbanian Strategy ................................................................................................................................................ 1715Vision and Aims.................................................................................................................................................... 1917General Recommendations from Vulnerability reeport...................................................................... 1917Objectives................................................................................................................................................................ 2119Interventions/activities for each objective............................................................................................... 2422Matrix of the action plan, including timelines, roles and responsibility, performancemanagement, monitoring and evaluation ................................................................................................. 4037Implementation process and infrastructure ............................................................................................ 5046Aneex 1 (TOR of the Steering Group).Errore. Il segnalibro non è definito.Error! Bookmarknot defined.References .............................................................................................................................................................. 5147

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EXECUTIVE SUMMARYThe rise of the average temperature in the past 30 years in Albania is a signal thatshould alert everyone in Albania about the overwhelming threat of climate change.The rise in temperatures is expected to continue (up to 5oC by the end of thecentury) while the precipitation will decrease (up to 16% during the same period).Extreme weather events are becoming more and more frequent in Albania andpredictions for the future are even worse.The climate change has brought mild winters, which have favored the growth oftropical plants even in Albania, and made it possible for mosquitoes to appear inaltitudes above 400-500 m above the sea level (mosquitoes were present only inlower altitudes before the 1990s). Albania is then become subject to potentialdisease outbreaks such as Chikungunya, dengue, malaria and other diseases oftropical origin.

Climate change will further aggravate air quality related health problems in the majorcities of Albania, but in particular in Tirana. There is a clear evidence of theaggravation of the air pollution in Tirana accompanied with worsening of therespiratory consequences of groups of residents clearly exposed to such risks.The climate change will have an impact on water quality and quantity for humanconsumption in Albania. Reduced hydrological resources might affect the energyproduction, which is based to a large extent on hydro-power.An increase of frequency and intensity of heat-waves could be leading to additionalsummer heat related cardiovascular and respiratory deaths. Also, an increase ofextreme precipitation events could aggravate current problems already existing inthe area of water related diseases, accidents and injuries.More importantly, climate change effects on health may have an impact on inequitiesin Albania. This has direct implications especially for the Millennium DevelopmentGoal health targets to be achieved by 2015.There is a pressing need to adapt the existing capacities in health sector in Albaniain order to face the new challenges of climate change and its impact on health.The Albanian health adaptation and climate change strategy states the followingvision aims and objectives:Vision:

The health and wellbeing of the Albanian population are assured andimproved in a changing climate.

Aims: Strengthen health services and inter-sectorial system functions to improve

their response to the impacts of climate change in an appropriate manner.

Encourage healthy, energy- efficient behaviors in all settings and provideinformation on opportunities for mitigation and adaptation interventions, with aparticular focus on vulnerable groups through public awareness campaigns.

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Objectives: Raise public awareness, improve education and build capacities among

professionals on the possible effects of climate change on health.

Adapt the information system to make it appropriate for detection ofclimate change related risks and evaluate in time their effects in health.Encourage research and innovation related to health and climate change.

Integrate health prospective approaches and issues at all current and futureclimate change policies so to ensure potentiating of benefits and minimizingharms. Assure coordination between different stakeholders and differentsectors to increase efficiency.

Enhance the capacities of inter- sectorial monitoring systems to controlincreasing problems related to air pollution with special focus on particlesand ozone.

Increase the capacities, preparedness and coordination of the healthsystem with other systems in dealing with expected health problems inflictedby heat waves and extreme cold weather.

Improve collaboration and integration of health system into the nationalemergency structures responsible for floods and fires, landslides andother natural disasters inflicted by climate change

Adapt and integrate surveillance and control systems for selectedcommunicable diseases and vectors likely to be affected by climatechange.

Strengthen the health services and coordination of information systems forprevention and management of health problems inflicted by increasingexposure to pollens.

Bringing together different sectors for setting up a system for monitoringand prevention of health problems resulting from an increased ultravioletradiation.

Developing an action plan to improve energy efficiency in the healthsector based upon the energy assessment report.

In order to assure sustainability and longer term implementation of this strategy,Ministry of Health will continue to provide leadership while coordinating its work withother relevant Ministries, including Ministry of Environment, Ministry of Agricultureand Food, Ministry of Interior, Ministry of Education, Local governments, Universitiesand other implementing agencies. An inter-sectorial Steering Committee will besupervising the identified activities and will monitor the achievements. Appropriatestructure will be set up at the Ministry of Health to support this work. Meanwhile the

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action plan of the strategy will be integrated to the country’s budgeting priorities, andcoordinated with donor’s contribution and interventions.

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INTRODUCTIONRATIONALEThere are solid facts demonstrating that the climate in our planet is changing and isactually occurring. The humans have no other options but to adapt themselvestowards climate changes.

In its Third Assessment Report the UN’s Intergovernmental Panel on ClimateChange (IPCC) concluded that: ‘Overall, climate change is projected to increasethreats to human health, particularly in lower income populations “(1).

WHO, as well, in its report ‘Protecting Health From Climate Change’ states that‘climate change will affect, in profoundly adverse ways, some of the mostfundamental pre-requisites for good health: clean air and water, sufficient food,adequate shelter and freedom from disease’. The global climate is now changingfaster than at any point in human civilization, and some of the effects on health willbe felt in short term, while others are expected in long run. The most severe risks areto developing countries, with negative implications for the achievement of the health-related Millennium Development Goals and for health equity (2).

Climate change can affect human health directly (e.g., impacts of thermal stress,death/injury in floods and storms) and indirectly through changes in the ranges ofdisease vectors (e.g., mosquitoes), water-borne pathogens, water quality, air quality,and food availability and quality. The actual health impacts will be strongly influencedby local environmental conditions and socio-economic circumstances, and by therange of social, institutional, technological, and behavioral adaptations taken toreduce the full range of threats to health .(1)

Broadly, a change in climatic conditions can have three kinds of health impacts:

Those that are relatively direct, usually caused by weather extremes. The health consequences of various processes of environmental change and

ecological disruption that occur in response to climate change. The diverse health consequences – traumatic, infectious, nutritional,

psychological and other – that occur in demoralized and displacedpopulations in the wake of climate-induced economic dislocation,environmental decline, and conflict situations.

WHO states that ‘Besides environmental and economic damage, the ultimate impactof climate change represents a toll on our most precious resource - human lives andthe health’. Furthermore, it says that ‘addressing the impacts of climate change onpopulation health will be the responsibility of the health sector. Investing now inhealth protection and adaptation can improve resilience to climate change impacts’.(3) Climate change is one of several concurrent global environmental changes thatsimultaneously affect human health – often interactively. A good example is thetransmission of vector-borne infectious diseases, which is concomitantly affected by

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climatic conditions, population movement, deforestation and land-use patterns,biodiversity changes, freshwater surface profiles, and human population density.Climate change would cause increased heat-related mortality and morbidity,decreased cold-related mortality in temperate countries, greater frequency ofinfectious disease epidemics following floods and storms, and substantial healtheffects following population displacement from sea level rise and increased stormactivity (4).

For each potential impact of climate change, certain groups will be particularlyvulnerable to specific diseases or conditions. The vulnerability of a communitydepends on factors such as population density, level of economic development, foodavailability, income level and distribution, local environmental conditions, pre-existinghealth status, and the quality and availability of public health care (5).

Health effects are expected to be more severe for elderly people and people withpre-existing medical conditions. The groups who are likely to be most susceptible ofthe increasing risk of diseases are children and the poor, among them, especiallywomen (5). The major diseases that are most likely to happen due to climate changeare: diarrhea, vector-borne diseases, infections associated with under nutrition –which appear severely mostly in children living in poverty.

The IPCC Fourth Assessment Report (2007) states that the Mediterranean is a ‘hotspot’ for climate change. Even in the moderate climate change scenario, averagetemperatures are projected to increase from 2.2°C to 5.1°C, by the end of thecentury (6). In Albania the temperature is expected to increase with up to 5.3oCwithin the same period while the precipitation will decrease with up to 16% (seevulnerability report). Higher temperatures, lower water availability and increaseddesertification processes are expected by as early as mid-century.

Albania being in the Mediterranean area is subject to potential disease outbreaks oftropical origin such as Chikungunya, dengue, malaria and other diseases. Anincreased frequency of extreme weather events is being documented with significantimpact into the wellbeing of the affected populations. Climate change will furtheraggravate the air quality related health problems in the major cities of Albania, but inparticular in Tirana. An increase in annual temperature in the country is expected tobe accompanied by a decrease in precipitation. Water quality and quantity for humanconsumption is expected to worsen. Reduced hydrological resources will almostcertainly affect the energy production and the whole Albanian economy (AlbaniaVulnerability Report).

While mitigation of greenhouse gases provides a response mechanism for slowing,and perhaps eventually halting, the build up of greenhouse gases in the atmosphere,adaptation is another important response option. Such an action enhances theresilience of vulnerable systems, thereby reducing potential damages from climatechange and climate variability.

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Adaptation to climate change implies making modifications in our lives and in oursocieties including behavior, processes, technology, institutions, programs, andpolicies that address current or anticipated health effects of climate change.

The main goal of adaptation, from a public health prospective, is to prevent disease,injury, and death due to climate change and its negative effects on environmentalsystems, and communities (7).

The first line of the original UN Framework Convention on Climate Change(UNFCCC) highlights the need to avoid ‘adverse effects’; which it defines assignificant deleterious effects on ‘natural and managed ecosystems or on theoperation of socioeconomic systems or on human health and welfare’ (8).Addressing climate change should therefore be viewed as much as an effort toimprove human health and well-being as it is to protect the natural environment oreconomic development.

Strengthening of public health services needs to be a central component ofadaptation to climate change. A range of cost-effective health interventions arealready proven in many countries. The WHO report ‘Protecting Health from ClimateChange’ identifies some of them (2).

It seems to be an acute need for public health systems to strengthen their keyfunctions in order to address the new challenges posed by climate change.Reinforcing disaster risk reduction, early warning, and health action in emergencies,can help to ensure that people are better protected from the increasing hazards ofextreme weather and will help communities recover faster following a disaster.

Effective disease surveillance and control, becomes even more important underconditions of rapid environmental change and movement of people, disease vectorsand infections.

Enhancing water and sanitation services and household disinfection would reducediarrhea and, at the same time, lessen the health impacts from decreasing and morevariable water supplies. The size of benefits of such interventions is already muchlarger than the costs, and the threat of climate change makes these preventivehealth measures, an even more visionary investment.

Strengthening and increasing the coverage of basic key services in the healthsystem brings about another benefit: tackling the needs of the most vulnerablegroups, the ones who are the most at risk from the climate change.

In the climate change context, health sector and public health should be moreflexible, adaptable and their planning and management needs to be in continuoustouch with the changing environment.

Adaptive strategies intended to protect public health will be needed whether or notactions are taken to mitigate climate change. Building capacity is an essential

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preparatory step. Adapting to climate change will require more than financialresources, technology, and public health infrastructure. Education, awareness-raising and the creation of legal frameworks, institutions and an environment thatenables people to take well-informed, long-term, sustainable decisions are allneeded.

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CONTEXTThe process for building this strategy was preceded by the involvement of AlbanianGovernment in a number of international declarations focused on climate changeand health.

First, the Resolution issued by Sixty-first World Health Assembly, urges MemberStates to take decisive action to address health impacts from climate change,warning of its potential risks on human health. The resolution calls on the healthsector to upscale actions in adaptation projects to limit the impacts on climatechange on health (9, 10).

Second, following the Declaration of the Fifth Ministerial Conference on Environmentand Health of Parma, a European Regional Framework for Action was accomplishedduring 2009, in a number of policy dialogues and workshops organized in severalcountries including Albania (11, 12).

Albania has earlier ratified the United Nations Framework Convention on ClimateChange (UNFCCC) and Kyoto Protocol, accepting the importance of the problem ofclimate changes and the need to take effective measures to lower the causes ofthese changes. In the context of climate change and environment protection, anumber of policy documents are prepared including inter-sectorial environmentalstrategy 2007-2013, the national action plan (NAP) to address climate change, firstand second national communication for UNFCCC and the policy document of carbonfinancing in Albania, 2009 (13,14,15,16).

The health and climate change strategy development process was supported by aseven-country initiative of WHO/Europe and the German Federal Ministry for theEnvironment, Nature Conservation and Nuclear Safety (BMU) which aimed toprotect health from climate change through addressing adaptation, strengthening ofhealth systems and building institutional capacity. Other countries involved wereKazakhstan, Kyrgyzstan, the Russian Federation, Tajikistan, the Former YugoslavRepublic of Macedonia and Uzbekistan.

The overall goal of the project in Albania called “Protecting health from climatechange in Albania” was to strengthen the capacity of the country in understandingand acting upon the health risks of climate change.

The implementing process of the project, including the health and climate changestrategy has been led by an inter-sectorial Steering Committee chaired by Ministry ofHealth.

The technical works has been supported by a number of foreign experts, andconsultants, either from “WHO” or hired by this Organization, in close collaborationwith Albanians experts. (See the TOR of the Steering Group in the Annex 1).

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METHODS AND PROCESSPrior to, and parallel with the process of building this strategy a detailed analysis ofrisks to health and the specific vulnerabilities is carried out taking into account thenature of the problems and the size of the problems.

The results of this analysis are included in a detailed report which served as abackground document and includes all the facts which have allowed the prioritizationprocess.

The best experts operating in different sectors in the country were involved in theprocess of situation analysis and strategy building. Expertise was provided in almostall disciplines with relevance in climate change and health not only those under theadministration of the traditional health sector. These disciplines includedepidemiology, environment and health, physics, chemistry, biology, entomology,clinical medicine, emergencies and catastrophes, health system administration etc.

For more than one year a large number of individuals participated in workshops,conferences and other forms of forums, contributed with their discussions whileexchanging data, opinions and expertise in giving shape to this strategy.International expertise and WHO technical support was assured as well during theprocess and the leadership from Ministry of Health was of the paramountimportance.

Priorities, objectives and interventions were agreed upon in technical workshops ofthe working group and thereafter were approved in the steering committee.

Consensus was achieved upon a framework of priorities in Albania, in terms ofclimate change exposure, multi-sector impacts and health impacts as well as themost vulnerable populations. The results of this consensus are included in thescheme below and are the bases upon which, the objectives and interventions arefurther developed.

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-Frequent extreme weatherevents

-Air Quality

-Temperature increase,warming, heat and fire

-Sea level rise and precipitationchanges (erosions and flood:including coastal andavalanches)

-Air Pollution

-Environment habitat

-Agriculture and forest

-Land management

-Water management

-Waste water

-Food Safety

-Social and economic impacts;Housing, employment, welfare,migration

-Infrastructure (transport,communication, energy)

-Cardio-vascular diseases

- -Respiratory diseases andLund Cancers

-Water borne infections

-Food-borne diseases

-Vector borne and zoonosis

Infections

-Mental health problems

-Injuries

-Skin diseases

CLIMATE CHANGE EXPOSURE MULTISECTOR IMPACTS HEALTH IMPACTS

Vulnerable Populations:geographically,environmentally

Western regions, regarding thecoastal erosion and flooding

-Urban and industrial area

-Population living near to rivers

-Roma community

-Migrant populations

- Poor populations

-Elders, children, women,

Vulnerable Populations:Demographically, socio-economic, social inequality

Vulnerable Populations:Health status

-Chronic diseases anddisabilities

-Pregnant women, cardio-vascular and respiratorydiseases

-Immuno-deficent diseases

-Mental illness

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A number of specific recommendations resulted from the vulnerability analyses as ananswer to gaps and problems identified. These recommendations are reflected in theobjectives and interventions included in the strategy.

Two other approaches were followed for developing the strategy:

There are in Albania already in place a range of systems and routine activities whichcan contribute to the challenge of climate change and its health consequences, suchas communicable diseases surveillance, monitoring of drinking water and air inurban areas, specific public health communication structures, etc (17,18) (seevulnerability report as well). Many parts of the strategy builds up on these toolsadapting them and adding new measures as necessary or meet the needs ofdifferent communities.

The other approach is the timing and prioritization of activities, to begin withmeasures that bring immediate health benefits anyway, or that promote long-termecological and economic sustainability, irrespective of their contribution to adaptation(19, 20). For example, investments in improved sanitation and water treatmentbased upon the latest climate change vulnerability analysis would yield immediatehealth added values while also stimulating health of communities and civicinfrastructure against future climatic stresses.

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GUIDING PRINCIPLES AND APPROACHES FOR INCLUDING SPECIFICOBJECTIVES AND INTERVENTIONS IN THE ALBANIAN STRATEGYThe strategy covers only areas of intervention which would have an impact onadaptations and health. It doesn’t aim at a larger picture which includes mitigation ofgreenhouse gases for example. Other national policy documents cover those areas.

While mitigation of greenhouse gases provides a mechanism for slowing, andperhaps eventually halting, the build-up of greenhouse gases in the atmosphere,adaptation is another important response option. Such an action enhances theresilience of vulnerable systems, thereby reducing potential damages from climatechange and climate variability.

Two main approaches are being used in the process of strategy development forsetting up priorities, objectives and specific interventions:

The precautionary principle. It is a risk management principle applied whena potentially serious risk exists, but significant scientific uncertainty alsoexists. Rio Declaration on Environment and Development as Principle 15,states: “Where there are threats of serious or irreversible damage, lack of fullscientific certainty shall not be used as a reason for postponing cost-effectivemeasures to prevent environmental degradation.” (21)

The “benefit-cost” principle, weighting the expected benefits and costs of aproposed action (7). It means efficiency - evidence for electivity of theintervention/policy and financial soundness/ cost electivity. Size/impact of therisk and cost effectiveness of the interventions have been in mind, such as:

Size of population at risk of harm

Likelihood of the harm

Wider gains including health, from the intervention

Potential harm from intervention

Timescale of risk: short, medium, long- term

The benefit-cost criterion emphasizes the efficient use of scarce resources –but does not deal with equity. Nor does it deal well with consequences thatare displaced into the future, and therefore, by economic convention, oftendiscounted. Climate change has the potential for catastrophic outcomes in thedistant future, the “present value” of which would be small if discounted.

To deal with issues not answered by these basic approaches, Albanianadaptation strategy incorporates another set of crucial principles andcharacteristics:

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The usual public health ethics considerations are applied: respect forautonomy and justice;

Includes a variety of measures, long-and short-term, anticipatory and reactive,targeted and general. Some measures aim to prevent harm by limiting oravoiding exposure, while others focus on building adaptive capacity orstrengthening coping ability;

Is multidisciplinary in its approach, gathering knowledge and expertise frommany disciplines of public health and coordinating among different agencieswithin the health system;

Is aiming to fit into broader public health objectives such as, diseasemonitoring and surveillance, health promotion, prevention of illnesses andaltering unhealthy behaviors, fighting poverty and inequity and building publichealth infrastructure;

Takes into account wider environmental and social problems that could affecthuman health;

Looks carefully at protecting especially vulnerable groups including children;

Includes measures to treat unavoidable illnesses or injuries resulting fromclimate change;

Distributes costs and benefits equally among all members of society;

Respects basic constitutional rights of individuals and communities includingfreedom of choice;

Shares common ground with regional strategies on the field of healthprotection in an environment challenged by climate change (i.e. Parma 2010,WHO climate and health work plan, Climate change and human health - risksand responses" WHO UNEP and WMO etc).

Aims at making health sector the responsible contributor to society mitigationefforts. As health sector activities and infrastructure is energy intensive,reducing the health sector environmental footprint, can play a significant rolein reducing global greenhouse gas emissions.

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VISION AND AIMSVision

1. The health and wellbeing of the Albanian population are assured andimproved in a changing climate.

Aims

The strategy aims to:

Strengthen health services and inter-sectorial systems to improve theirresponse to the impacts of climate change in an appropriate manner.

Encourage healthy, energy-efficient behaviors in all settings and provideinformation on opportunities for mitigation and adaptation interventions,with a particular focus on vulnerable groups through public awarenesscampaigns.

GENERAL RECOMMENDATIONS FROM VULNERABILITY REPORT Raise the public awareness about individual contributions in the emission of

greenhouse gases, for example: use of diesel cars, etc.

Raise the public awareness in order to participate in the discussion of urbanplanning and industrial areas.

Raise the public awareness in order to respect the rules for environmentalprotection.

General population: Everyday advices on air pollution levels, and raise theawareness. The Albanian population at large needs to become more aware ofthe climate change phenomena and their public health consequences.

Include environmental education in the school curricula.

The measures envisaged by the Inter-sectorial Environmental Strategy to mitigateclimate change include the following:

Change of legal basis: legal framework for energy efficiency in new buildings; legal framework for energy efficiency of household equipment.

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Establishment of economic incentives:

setting the carbon tax; creation of a grant or subsidy scheme for energy efficiency.

Reduce GHGs released by transport and energy:

review of the transport strategy in accordance with the provisions of thestrategic environmental assessment for the improvement of road transportinfrastructure;

introduction of vehicles with low levels of emissions; review the strategy for the energy sector in accordance with the provisions of

the strategic environmental assessment to enable the promotion of renewableenergy sources.

Awareness campaign to reduce the amount of greenhouse gases:

promotion of energy efficiency in industry; improvement of thermal isolation and reducing unnecessary use of power for

heating or cooling systems in houses; promotion of solar heating systems.

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OBJECTIVESThe objectives answer mainly to priority areas and problems identified in vulnerabilityanalysis. They reflect principles described above and are followed by specificactions.

Ten objectives will guide the Albanian government in the following years when tryingto protect health of its population from the imminent climate changes and attemptingto successfully adapt to the new conditions: The objectives can be categorized in twogroups. The first three ones are horizontal and crosscut with the other objectives;the other seven can be considered as vertical and focus more deeply in one priorityarea, climate change exposure, health determinants and health impact.

Working group is aware that the content of objective 9 (protecting health fromexcessive ultraviolet radiation) is not to be strictly considered part of global climatechange which occurs in the troposphere. However, this objective was included in thestrategy considering its relevance for public health and the opportunity provided byclimate change and health strategy to tackle such a subject.

1. Raise public awareness, improve education and build capacities amongprofessionals on the possible effects of climate change on health.

2. Adapt the information system to make it appropriate for detection ofclimate change related risks and evaluate in time their effects in health.Encourage research and innovation related to health and climatechange.

3. Integrate health prospective, approaches and issues at all current andfuture climate change policies so to ensure potentiating of benefits andminimizing harms. Assure coordination between different stakeholdersand different sectors to increase efficiency.

4. Enhance the capacities of inter-sectorial monitoring systems to controlincreasing problems related to air pollution with special focus onparticles and ozone.

5. Increase the capacities, preparedness and coordination of the healthsystem with other systems in dealing with expected health problemsinflicted by heat waves and extreme cold weather.

6. Improve collaboration and integration of health system into the nationalemergency structures responsible for floods and fires, landslides andother disasters inflicted by climate change

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7. Adapt and integrate surveillance and control systems for selectedcommunicable diseases and vectors likely to be affected by climatechange.

8. Strengthen the services and coordination of information systems forprevention and management of health problems inflicted by increasingexposure to pollens.

9. Bringing together different sectors for setting up a system formonitoring and prevention of health problems resulting from anincreased ultraviolet radiation.

10.Developing an action plan to improve energy efficiency in the healthsector based upon the energy assessment report.

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INTERVENTIONS/ACTIVITIES FOR EACH OBJECTIVEThe following categories/models of activities and actions are included in the strategy:

o Improved, continuous and systematic data collection for surveillance(Surveillance & monitoring; early warning systems, forecasting, healthindicators)

o Coordination mechanisms (within health sector and inter-sectorial)

o Information of public, raising awareness

o Risk assessment & communication

o Improvement of health structures and standards (apart fromsurveillance)

o Training of professionals and skills development

o Research on climate change and health impact

Generally, activities and actions aim at achieving a specific objective, under whichthey are listed. Nevertheless, in many cases they contribute to other objectives aswell. This is especially the case for three crosscutting or horizontal objectives 1, 2and 3.

In this section those actions which are associated with objective 1 (apart of theobjective within which they are categorized) are marked with the number 1. Thoseassociated with objective 2 with number 2 and so on.

Activities for objective 1: Raising public awareness, improving educationand building capacities among professionals on the possible effects ofclimate change on health.

Rationale

A better understanding of the effects of the climate change on health wouldcatalyze action in the form of adaptation measures, facilitate socialacceptance and system support for adaptation and mitigation actions andprovide elements to the population on how best protect themselves.

A better understanding of the risks and effects of climate change on health willmotivate and facilitate both behavioral change and societal support for actionstaken to reduce greenhouse gas emissions. Improved awareness will helphealth-sector professionals to provide leadership in supporting rapid andcomprehensive strategies for mitigation and adaptation that will both improvehealth and reduce vulnerability(2).

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A number of mechanisms could be enabled to strengthen awareness. Theserange from the inclusion of climate change into health promotion activities,with particular care for vulnerable groups (elderly, infants, chronic diseases,pregnant women etc) during summer and winter time; the active involvementof school children and young people in designing promotional activities andcapacity building among health professionals including preparation of specificcurricula for them.

Stakeholders should be engaged throughout an assessment process. Acommunication strategy must ensure access to information, presentation ofinformation in a usable form, and guidance on how to use the information.Risk communication is a complex, multidisciplinary, and evolving process.Often information has to be tailored to the specific needs of risk managers inspecific geographic areas and demographic groups. This requires closeinteraction between information providers and those who need the informationto make decisions.

Instruments and materials already produced by international specializedagencies may be taken as models to be adapted at national level.

Information must be directed to families, communities, as well as local andcentral governments, inhabitants living in small communities as well as bigmetropolis such as Tirana District.

Specific actions/activities

1.1. Produce a set of information and training materials in Albanian, includingfactsheets, policy briefings and training manuals for professionals;

1.2. Organize public awareness and education campaigns for general publicon the linkages between climate and health, actions to contribute in adaptionand to reduce carbon footprint;

1.3. Organize school based education campaigns on the linkages betweenclimate and health, actions to contribute in adaption and to reduce carbonfootprint;

1.4. Develop short courses, in the frame of continuous education, for primaryhealth care doctors and nurses related to health and climate change;

1.5. Review curricula and introduce themes and modules dedicated to healthand climate change, into the public health and medicine post graduatecourses;

1.6. Develop and run awareness-raising and advocacy campaign aiming toput health at the centre of the climate change mitigation and adaptationagenda for central and local policy makers;

1.7. Set up and/or strengthen civil society networks with interests andexpertise in the climate change and health issues.

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Activities for objective 2: Adapting the information system to make itappropriate for detection of climate change related risks and evaluate intime their effects in health. Encouraging research and innovation relatedto health and climate change

Rationale

Good evidence requires good data. The climate varies spontaneously, as wellas in response to human influences, and, in turn, climate is only one of manydeterminants of population health. Therefore, assessing the health impacts ofclimate change poses challenges. Further, the process of climate change isdetectable only over decades, and the resultant health impacts will besimilarly slow to emerge (7).

Monitoring to assess climate-change impacts on health therefore requires thatdata-collecting process be associated with analytical methods able to quantifythe climate-attributable.

The principal criteria for selecting diseases and settings for monitoring shouldinclude the following: Evidence of climate sensitivity, significant public healthburden and practicality.

On the other hand, a successful policy-focused assessment of the potentialhealth impacts of climate change should include: 1) a multidisciplinaryassessment team; 2) responses to questions asked by all stakeholders; 3)evaluation of risk management adaptation options; 4) identification andprioritization of key research gaps; 5) characterization of uncertainties andtheir implications for decision-making; and 6) tools that support decision-making processes.

As mentioned above a number of activities which target the achievement ofthis objective are already listed under other objectives in this strategy. Hereare identified a few more, while, some indicator of monitoring are furtherdeveloped.


2.1. Review and adapt the national research strategy on health, eitherincluding among priorities climate change and health, or integrating it withother priorities. Assure during this process multi-institutional and multi-disciplinary collaboration, acknowledging the importance of participationresearch experts and institutions other than health ones.

2.2. Finalize the health information strategy shaping it in the health andclimate change context. Allow during this process for introduction of healthimpact indicators specifically related to climate and weather such as excessheat morbidity.

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2.3. Integrate/adapt the following indicators into existing surveillance, earlywarning or monitoring systems:

On the subject of vector borne health conditions;

CCHF and Hemorrhagic fever with renal Syndrome Visceral and Cutaneous Leishmaniasis West Nile Fever Leptospirosis

On the subject of vectors;

Ticks: Ixodes, Hyaloma (to further be specified) Mosquitoes Aedes Albopictus mosquitos Annopheles mosquitoes Phlebotomes Rodents (to further be specified)

On the subject of food and water born health conditions;

Salmonellosis

On the subject of heat waves/extreme weather;

Heat Exposure Excess Heat Mortality Excess Heat Morbidity

On the subject of air pollution;

Particles Ozone (troposphere)

On the subject of health conditions induced by pollens;

Asthma Hay fever

Activities for objective 3: Integrate health prospective, approaches andissues at all current and future climate change policies so to ensurepotentiating of benefits and minimizing harms. Assure coordinationbetween different stakeholders and different sectors to increase efficiency.

Rationale

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Climate change can no longer be considered simply an environmental ordevelopmental issue. A greater appreciation of the human health dimensionsof climate change is necessary for the development of effective policy.

Distribution of health risks from climate change is diverse, widespread, long-term and inequitable. This makes imperative actions in partnership with arange of actors across society: the health sector, environment, agriculture,security, education as well as community representatives and political leaders(2, 22).

Human health needs to be placed at the centre of environment anddevelopment decisions. There is a growing opinion that the naturalenvironment should be valued not just for its own sake, but for the “goods andservices” that it provides to support human societies; and that economicdevelopment is not an end in itself, but a means to improving human lives. Itis essential that the same reasoning be applied to climate change. Theultimate aim of mitigation and adaptation, and related development decisions,should be the protection and improvement o human well-being.

The 2007 IPCC report shows that the costs of many mitigation interventionswould be partly or wholly compensated for by health benefits (6). They shouldtherefore be valued and provided with incentives as much for protectinghealth as they are for protecting the climate.

Direct health benefits are an important and neglected political and publicargument in support of climate mitigation. The health co-benefits of manymitigation decisions are more local and immediate than the long-term andglobally distributed benefits of reduced damage to the global climate. Forexample, the motivation of city mayors to promote cleaner energy andtransport to reduce deaths from urban air pollution, or of individuals to walkand cycle to work to improve their cardiovascular health conditions, is likely tobe at least as strong as their motivation to take these actions in order toreduce greenhouse gas emissions.

The health community should play a more active role in the design ofgreenhouse gas mitigation policies. The health implications of the variousmitigation measures vary widely. Failure to select the most health-enhancingactions would be a lost opportunity for society, and would reduce the returnbenefits on investment in greenhouse gas mitigation. Some measures,however, can also bring health risks. Unless carefully managed, these maycause health damages, which would also have the side-effect of underminingsupport for action on climate change.


3.1. Set up an interdisciplinary committee on climate change and healthissues to be headed by director of policies and planning in Ministry of Health.

29

3.2. Design a full or part time technical position for climate change and healthunder Directory of Public Health. The position must be responsible forcoordination and communication purposes within health sector and with otherMinistries and agencies.

3.3. Propose review and adaptation of national policies and standards ondomestic use of cleaner heating and cooking energy sources.

3.4. Propose review and adaptation of national policies and standards forhousing insulation and other construction standards. Use BE standards asreference.

3.5. Propose adaptation at national and/or municipal level of policies for moreeffective urban transport systems. Advocate for less use of individual cars andmore urban facilities for cycling and walking.

3.6. Review and adapt national nutritional/food guidelines in order to advocatefor a more balanced diet and the reduction of daily consummation of saturatedfats and meat.

3.7. Advocate for continuation of the family planning policy. Identify of theapproaches for the increase of coverage with family planning services for thelarge proportion of women with unmet needs.

3.8. Advocate for better road standards and stronger regulations for drivers inorder to reduce accidents.

Activities for objective 4: Enhancing the capacities of inter-sectorialmonitoring systems to control increasing problems related to air pollutionwith special focus on particles and ozone.

Rationale

The concentration of air pollutants in the atmosphere is highly dependent onthe weather, particularly for those pollutants that result from photochemicalreactions. Temperature, wind, solar radiation, atmospheric moisture, venting,and mixing affects both emissions of ozone precursors and production ofozone. Because ozone formation depends on sunlight, concentrationstypically are highest during the summer months (24).

Climate change is expected to alter the concentration and distribution of thesepollutants in the atmosphere. Certain weather patterns enhance thedevelopment of the urban heat island (23), the intensity of which may beimportant for secondary chemical reactions within the urban atmosphere,leading to elevated levels of some pollutants, mainly to troposphere ozoneconcentrations.

30

This could have important health consequences, especially for those sufferingfrom chronic respiratory diseases. Ozone is a powerful oxidant that has beenassociated with reduced lung function, exacerbation of chronic respiratorydiseases and increases in respiratory hospital admissions and mortality withsome evidence of a synergistic effect between high temperature and ozone.

Building appropriate monitoring systems of air pollution is a crucial first stepfor influencing sustainable clean air policies. Air monitoring has been atraditional function of public health institutes as part of the health system.


4.1. Increase coverage with air monitoring stations in capital Tirana andselected large cities. Assure that most at risk areas are covered first (2).

4.2. Adapt national standards and protocols for air pollution measurementaccording to those of European Union Standards. Introduce the concept ofpopulation weighted average exposure.

4.3. Provide training for professionals operating in public health system atdifferent levels on air monitoring standards, instruments and practice. SupportDirectories of Public Health with training, information and expertise.

4.4. Set up coordination mechanisms between health sector, environmentagencies, meteorological institutes and local municipalities for data utilizationand public information (3).

4.5. Introduce appropriate instruments for timely and systematically informingcommunities on air pollution, including bulletins, websites, and city screens(1).

4.6. Conduct more research on indoor air quality and use the data for policychanging advocacy and public advice (1, 2).

4.7. Adapt health sector policies for using ‘cleaner’ technologies for transport,facility heating systems and energy management (3).

Activities for objective 5: Increasing the capacities, preparedness andcoordination of the health system with other systems in dealing withexpected health problems inflicted by heat waves and extreme cold weather

Rationale

The risk of heat related mortality can be increased especially among peoplewith cardiovascular problems, those with pre-existing cardiovascular,respiratory and renal diseases, diabetes, neurological disorders and

31

psychiatric illness, those having more than one chronic condition, those withproblems of self-sufficiency and is especially affected by indoor temperatureconditions. Elderly people are primarily affected.

Heat can have a different impact from locality to locality dependent onenvironmental, socioeconomic, and behavioral patterns. Cities and urbanareas tend to be hotter than rural areas (25). This is a result of the heatreflection from hard surfaces and the heat from buildings and vehicles (23)(the so-called ‘heat island’ effect).

The mortality rates during heat waves rises progressively as temperaturesincrease.

A more adapted system to heat waves would mean an early warning systembased on reliable meteorological forecasting better monitoring systems foridentifying vulnerable individuals and communities, appropriate preventionmeasures in school and work settings, equipment of emergency and primaryhealth care facilities with appropriate quality standards and infrastructure etc.


5.1. Set up a seasonal and sentinel early warning system based in heat-bornconditions. To be selected a number of syndromes, a group of reportinghealth facilities, periodicity, and responsibilities for data management andpublic information (2).

5.2. Establish a multi-sectoral cooperation mechanism of health sector,meteorological institutes and environmental protection agencies (3).

5.3. Set up a steering committee within the health sector, for actions to controlheat waves/other extreme weather impacts on health, to assure resourcesharing, information, skills exchange.

5.4. Set up standards and protocols for special measures to be taken byclinicians and administrators for patients with special needs in a heatwave/other extreme weather situation.

5.5. Provide training sessions to selected health professionals, includingprimary health care doctors, nurses and emergency care specialists on heatwaves/other extreme weather links to health and emergency management (1)

5.6. Prepare materials in the Albanian language for older people, people withchronically conditions including cardiac and cerebral conditions, and children,with information on self care and health care seeking during a heat wave (1).

5.7. Inform communities at higher risk timely and systematically aboutpossible heat waves, most vulnerable categories and advice about preventionand health care access (1).

32

5.8. Adapt health sector policies for health facility construction allowing for thenecessary ‘cooled’ rooms for most at need patients and sustaining moreenergy saving buildings (3).

Activities for objective 6: Improving collaboration and integration of healthsystem into the national emergency structures responsible for floods andfires, landslides and other natural disaster under the influence of climatechange.

Rationale

It is expected that because of climate change more extreme weather eventssuch as flooding and fires will be experienced in the future. There is evidencethat globally, natural disaster impacts have been increasing. An analysis hasfound a tripling in the number of natural catastrophes in the last ten years,compared to the 1960s. The increasing trend in natural disasters is partly dueto better reporting, partly due to increasing population vulnerability, and mayinclude a contribution from ongoing global climate change.

Developing countries are poorly equipped to deal with such disasters inflictedby weather extremes. In poor countries, the impacts of disasters can limit oreven reverse improvements in social development. Even under favourableconditions recovery from major disasters can take decades.

Though earthquakes are considered as the gravest disasters affectingAlbania, in the past years the frequency of flooding has caused considerabledamage especially to property, environment, and the wellbeing of inhabitants.

During these past two decades the number of forest fires in Albania hasincreased as well, and so have the affected areas. The unfavorablecombination of climatic conditions (high summer temperatures whichcontinued for a long period), coupled with careless human activity havecaused fires in forests, which in many cases endangered inhabited areaseven putting human lives in danger.

Population, government and policy makers need to become more aware ofthese phenomena and their public health consequences.

Based on the experience of these past years, the impact of emergency cases,their frequency as well as the need to increase the security level for thecommunity, the private and public properties and the environment, then theneed to make legislative, structural changes and intensify the preventionmeasures, is much more evident.

33


6.1. Finalize the health sector crisis management Policy based on theassessment of existing gaps and capacities, and propose adaptations to thecurrent disaster management legislation (3).

6.2. Set up disaster-related institutional structure in the health sector andassure integration with other sectors (3). Design the necessary components;management programs for: risk reduction, crises preparedness, coordinationand partnership, crises health education, public information, and monitoring &evaluation.

6.3. Preparation of operational practices, procedures and protocols for thecontinuity of essential medical services:o Prevention and control of communicable diseases and immunization,o Mother and child health care and reproductive health,o Mental health and psycho-social support,o Water safety and Sanitation,o Treatment for chronic and non-communicable diseases,o Diagnostic capacities,o Blood donation and safetyo Nutrition & food safety

6.4. Prepare guidelines and training modules on health crises planning andmanagement. Include issues such as security of staff, volunteers, emergencyprocurement, distribution of essential pharmaceuticals, and equipment.

6.5. Set up and integrate an early warning system with attention to floods,fires, landslides and other disasters influenced by climate change. Prepareprotocols, for assessment, definitions reporting channels and feed-back (2).

Activities for objective 7: Adapting and integrating surveillance and controlsystems for selected communicable diseases and vectors likely to beaffected by climate change.

Rationale

The best approaches to control communicable diseases including theemerging ones are based on systematic surveillance, early detection ofoutbreaks as well as primary prevention of exposure to infectious agents andvectors through public health measures (27, 28, and 29).

Effective infectious disease surveillance and control is becoming moreimportant in the context of environment change and population movement.Rapid and accurate disease notification, in compliance with InternationalHealth Regulation standards can be considered a good base for planningdisease control (26).

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Combining health, veterinary and entomological surveillance as well asdevelopment of one health concept including health professionals, veterinaryspecialists, entomologists, biologists, chemists, environmental and socialscience specialists can further improve the chances for success in this field.

The decrease in absolute numbers observed in the burden of some infectiousdiseases in Albania, such as gastroenteritis, is mostly explained by thedecrease of the fertility levels on the Albanian population and the changingdemographic profiles. The determinants of the diseases remain there (i.e.amortized aqueduct systems, large gaps in pest control) and the prospect ofthe climate change will certainly worsen them. Furthermore there is clearproof of increasing risks for re-emergence of some vector born diseases(malaria) and emergence of some others (chikungunya).

This objective can be further developed into four more specific objectives.

Specific sub-objective 7.1: Strengthening the early warning/syndrome basedsurveillance of selected communicable conditions (ALERT system)


7.1.1. Adapting the ALERT instrument and infrastructure as well as itsreporting tools, based in the International Health regulation Concept (2).

7.1.2. Training the epidemiologists on the new instruments and tools

7.1.3. Review regulations and clarify the responsibilities for Public healthauthorities, Food Authorities and local governments in outbreak investigationafter an ALERT report (3).

Specific sub-objective 7.2: Improvement of public health laboratory system inthe country and better integration of prevention, diagnosis and treatmentservices for communicable diseases


7.2.1. Review and adapting the guidelines and standards relating to PublicHealth laboratories in Albania.

7.2.2. Build common policies/guidelines for Public Health Laboratories,Primary Health Care and Hospitals for outbreak management, in order toavoid miscommunication, responsibility gaps and to increase accountabilityand transparency to public.

7.2.3. Set up a modern quality assurance system for Public HealthLaboratories reporting system with the Institute of Public Health providingleadership and technical support.

35

Specific sub-objective 7.3: Adapting vector control and pest control systemsin the country, able to face exposures to emerging and re-emerging vectorsand agents


7.3.1. Adapt an integrated policy document addressing vector and pest controlin Albania, under the coordination of Institute of Public health and Institute ofFood Safety and Veterinary and under the auspices of Ministry of Health.Include in this document relevant standard protocols and guidelines as well asjoint surveillance mechanisms (3).

7.3.2. Support with training and information Directories of Public Health atlocal level and individual Municipalities on issues concerning vector borndisease and vector and pest control.

7.3.3. Adapt the existing surveillance systems on vector born diseasesallowing for more active and population based mechanisms, including sero-prevalence surveys, case based and diseases specific, or vector specificsurveillances and mapping (2).

7.3.4. Develop training for health professionals on vector born diseasesprevention and control.

7.3.5. Build better capacities at Institute of Public Health for entomologicallaboratory and entomological research (2)

7.3.6 Review legislation and identify legislative gaps and needs on the area ofvector and pest control. Advocate with relevant stakeholders, includingMinistry of Health for new legislation (3).

Specific sub-objective 7.4: Strengthening the systems of control for food-borne and water-borne diseases through monitoring, surveillance andsanitation


7.4.1. Set up an early warning surveillance system for potable water quality.Build the necessary legal frame, instruments and technology for it (2).

7.4.2. Train public health professionals including administrators, hygienists,laboratory and administrators on the new system.

7.4.3. Continuously assure the quality of the new surveillance and the feed-back reports related to it, including reports for administrators, policy-makersand public.

36

7.4.4. Set up joint surveillance systems for food born diseases and food safetyin coordination between Institute of Public Health and Institute for Food Safetyand Veterinary (2, 3)

7.4.5. Support Food Authority with training and instruments in strengtheninglocal laboratory capacities for food safety and risk assessment.

7.4.6. Evaluate the most at risk communities in sanitation standards amongcommunities in Albania. Prepare a report on this and communicate thefindings to the relevant stakeholders including public

7.4.7. Support Municipalities and Local Directories of Public Health withguidelines and expertise on sanitation of households, neighborhoods, andother settings. These activities should be carried out systematically andcontinuously.

7.4.8. Review and identify gaps and needs in national regulation forwastewater utilization. Set up monitoring system for wastewater utilization (2,3).

Activities for objective 8: Strengthening the services and coordination ofinformation systems for prevention and management of health problemsinflicted by increasing exposure to pollens.

Rationale

Climate change could have caused an increase in the duration of the pollenseason by means of earlier onset of spring pollen season in the northernhemisphere. A warmer climate increases the risk of proliferation of new plantswith well-known allergenic pollens like ragweed, etc. Pollens that are grown intemperatures more than usual could possibly have stronger antigenicity.

The increase in atmospheric CO2 concentration, along with global warming,also enhances the production of pollen.

An increase in heavy thunderstorms on summer days in the grass pollenseason, increase the chance of asthma exacerbations.

Furthermore, rapidly changing climate could have altered the interactionbetween air pollutants and respiratory allergens, thus increasing the morbidityin pollen-sensitive asthmatics.

Pollen monitoring and forecasting systems has proven to be useful for allergysufferers, medical professionals and the pharmaceutical industry. Increasingskills and awareness of health professionals and advising public can be someactions to be followed to successfully adapt against this increasing healththreat.

37


8.1. Review and adapt the health system registries relating to pollen inducedconditions, including asthma and hay fever. Carry out a feasibility analysisregarding a case based asthma surveillance. Carry out a population basedsurvey on pollen-specific allergies (2).

8.2. Increase the sites of pollen monitoring in Albania and adapt theinstruments and standards for pollen forecasting system (2). Put in placepublic information component as part of the system (1).

8.3. Develop training materials for health professionals and organize coursesfor family doctors, and pediatricians on issues concerning climate change,pollens and pollen induced conditions.

8.4. Develop and distribute brochures for allergy sufferers and leaflets forcommunities on climate change, pollens and pollen induced conditions (1).

Activities for objective 9: Bring together different sectors for setting up asystem for monitoring and prevention of health problems resulting from anincreased ultraviolet radiation.

Rationale

Most of the incoming solar ultraviolet radiation is absorbed by stratosphericozone. Ozone absorbs especially the biologically more damaging, shorter-wavelength, radiation. A number of industrial halogenated chemicals such asthe chlorofluorocarbons (CFCs – used in refrigeration, insulation and spray-can propellants) and methyl bromide, while inert at ambient earth-surfacetemperatures, react with ozone in the extremely cold polar stratosphere. Thisdestruction of ozone occurs especially in late winter and early spring.

Recent assessments by the United Nations Environment Program projectincreases in skin cancer incidence and sunburn severity due to stratosphericozone depletion1 for at least the first half of the twenty-first century (andsubject to changes in individual behaviors). Other conditions, their risk isincreased by UV are acute and chronic diseases of the eyes.

Furthermore, ultraviolet radiation exposure causes both localized and whole-body immune-suppression.

Any public health messages concerned with personal ultraviolet radiationexposure should consider the benefits (such as vitamin D production, bonehealth and mental health) as well as the adverse effects (7). Nevertheless, thepopulation must be aware and alert to the potential increase in someparticular risks to health posed by stratospheric ozone depletion.

38


9.1. Prepare and distribute informative materials for primary health careprofessionals in order to raise their skills and awareness concerning climatechange and risks of ultraviolet radiation (1).

9.2. Design and implement appropriate communication tools for general publicconcerning risks of ultraviolet radiation in the climate change context (1).Specific attentions must be given to some categories such as children,agriculture workers, etc.

9.3. Support research and monitoring on time and space trends of ultravioletradiation and ultraviolet radiation exposure (2).

9.4. Set up inter-sector mechanisms with public health institutions, physicssciences institutes and centers to assure exchange in information andexpertise (3).

Activities for objective 10: Develop an action plan1 to improve energyefficiency in the health sector based upon the energy assessment report.

Rationale

The process of energy efficiency and the better performance of healthinstitutions in this regard is relatively new in the country and the interventionsto assist this process have only recently been adapted, regulated andstandardized by law. The involvement of Albania in this process is just in timeas a great need for the implementation of the idea “Think globally and actlocally”. For this reason a study is conducted by public health professionalsof the country not only for the assessment of the situation in health careinstitutions but also to provide knowledge and direction in the facilitation ofan action plan .( see the publication "Assessment of Energy Efficiency inHealth Facilities in Albania and Piloting of an Efficiency Plan for HealthCare Facilities”)


10.1.Actions should be taken by the Ministry of Health and local authorities to investin order that all internal environments of the hospitals have a good thermo-insulation. It should include a partial reconstruction of the buildings for betterservices , to increase the efficiency and to decrease the costs. It is recommended

1 The detailed action plan for this vast objective will be done in a second phase

39

that internal doors and joint doors are opened and closed automatically and thedamaged doors, windows, glasses, etc, should be repaired.

10.2.There should be a continuous control and maintenance of the hospitalbuildings. Investments should be foreseen to install devices aiming to measure thewater, electric energy and fuel consumption in the buildings. The continuous controland repair of the water and plumbing system should be assured in every sanitarydevices and equipment. The installation of the automatic valves will save the waterconsumption, but also will eliminate the wall humidity. During the reconstruction ofthe buildings, it is important to carry out the thermo-insulation of the external wallsof the building, of the terrace and of the floor. A system should be installed in orderto check the parameters of microclimate of the internal hospital environment whichshould be monitored at least twice per year, in winter and summer.

10.3.Measures should be taken to improve the lighting system like flux and intensity,in order to have a system according to the standards, able to guarantee an optimalsight during the work process. The damaged bulbs should be replaced withfluorescent ones in line with the decree of the Council of Ministers.

10.4.A strategy for the improvement of the infrastructure of the institutions should bedrafted . It should include a partial reconstruction of the building in order to servebetter, to increase the efficiency and to decrease the costs. It is recommended tointervene in:

a) Reconstruction of the heating system which includes: the replacementof damaged boilers, replacement and thermo-insulation of damaged radiators,replacement and thermo-insulation of pipes and of the automatic regulationsystem.

b) Modernization of lighting system

c) Replacement of windows and doors

d) Installation of the solar panels

e) Measurements and control of fuel, water and electric energy

consumption

10.6. The surgery and intensive care rooms need considerable investments inconditioning system (HVAC) in order to guarantee proper microclimatic conditionsand increase the efficiency of the energy.

10.7. Measures are to be taken to make possible that furnaces work 24 hours a dayto guarantee uniform heating.

40

MATRIX OF THE ACTION PLAN, INCLUDING TIMELINES, ROLES ANDRESPONSIBILITY, PERFORMANCE MANAGEMENT, MONITORING ANDEVALUATIONObjective 1. Raising public awareness, improve education and build capacitiesamong professionals on the possible effects of climate change on health ($828 000)

Activities Timeline Responsibility OutcomeIndicators/results

Budget000/USD1.1 Produce a set ofinformation andtraining materials inAlbanian

2011-2013

Ministry of Health(MoH), Institute ofPublic Health (IPH)

Set of materialsproduced andapproved by MoH

$24

1.2. Organize publicawareness andeducation campaignsfor general public

2011-2021

MoH, IPH 1 campaign per year $500

1.3 Organize schoolbased educationcampaigns

2011-2021

MoH, Ministry ofEducation andScience (MES), IPH

50 schools per yearare covered witheducation activities

$210

1.4 Develop courses,doctors and nursesrelated to health andclimate change.

2012-2021

MoH, IPH, Faculty ofMedicine (FM)

3 courses per yearorganized

$68

1.5 Review curriculaand introduce

2012-2014

FM, IPH Report of curriculaanalysis is prepared

$4

41

themes and modulesdedicated to healthand climate change

and the proposedchanges areapproved

1.6 Develop and runawareness-raisingand advocacycampaign for centraland local policymakers.

2012-2021

MoH, Ministry ofEnvironmentProtection (MEP),other Ministries,Local Governments

1 combined advocacycampaign per yearcovering central andlocal decision makers

$0

1.7 Set up and/orstrengthen civilsociety networks

2012-2015

MEP, responsblestructure near PrimeMinister, civil societygroups

2 conferences for thefirst 3 years; awebsite and/or journalof the network set up.

$22

Objective 2. Adapt the information system to make it appropriate for detection of climatechange related risks and evaluate in time their effects in health. Encouraging researchand innovation related to health and climate change ($28 000)

Activities Timeline Responsibility Indicators Budget2.1. Review andadapt the nationalresearch strategy onhealth

2015 MoH, MES, Agencyof Research andInnovation (ARI),IPH, UniversityHospital Center(UHC),University/Academia

Strategy reviewedand approved

$3

2.2. Finalize thehealth informationstrategy shaping it inthe health andclimate changecontext.

2011-2014

MoH, IPH, UHC,Health insuranceInstitute (HII),Institute of Statistics(INSTAT) ect

Strategy approved $18

2.3. Integrate/adaptindicators intoexisting surveillance,early warning ormonitoring systems.

2012-2014

MoH, IPH, UHC Adapted surveillancetools approved byMinister

$6

Objective 3. Integrate health prospective, approaches and issues at all current and futureclimate change policies so to ensure potentiating of benefits and minimizing harms.Assure coordination between different stakeholders and different sectors to increaseefficiency ($29 000).

42

Activities Timeline Responsibility Indicators Budget3.1.-3.2. Set up aninterdisciplinarycommittee andstructure forcoordination

2012 MoH Structure approved byMinister of Health

3.3. Propose reviewand adaptation ofnational policies andstandards ondomestic use ofcleaner heating andcooking energysources.

2014-2016

MoH, otherMinistries

Analysis reportprepared. Draftregulation proposed.Policy approved

$7

3.4. Propose reviewand adaptation ofnational policies andstandards forhousing insulationand otherconstructionstandards.

2016-2018

MoH, otherMinistries


$7

3.5. Proposeadaptation atnational and/ormunicipal level ofpolicies for moreeffective urbantransport systems.

2016--2021

MoH, otherMinistries, LocalGovernment


$7

3.6. Review andadapt nationalnutritional/food

2012 MoH, IPH, Ministryof Agriculture andFood (MAF),

Guidelines reviewedand adapted

$3

3.7. Advocate forcontinuation of thefamily planningpolicy.

2012-2021

MoH, IPH,Directories of PublicHealth (DPHs)

Periodical report oncoverage with FPservices produced.Conferencesorganized yearly

$0

3.8. Advocate forbetter road standardsand strongerregulations fordrivers in order toreduce accidents

2012-2021

Ministry of Interior(MI), MoH, Ministryof Transport andInfrastructure (MTI),ect.

Situational reportprepared. Standardsreviewed andregulations approved

$5

Objective 4. Enhancing the capacities of inter-sectorial monitoring systems to controlincreasing problems related to air pollution with special focus on particles and ozone.

43

($1,757 000)

Activities Timeline Responsibility Indicators Budget4.1. Increasecoverage with airmonitoring stations incapital Tirana andselected large cities

2011-2021

MoH, MEP, IPHselected DPH s 5 cities with more

than 100 000inhabitants fullycovered

$1,600

4.2. Adapt nationalstandards andprotocols for airpollutionmeasurementaccording to those ofEuropean Union.

2012-214

MoH, MEPEnvironment Agency(EA), IPH

Standards adapted

$18

4.3. Provide trainingon air monitoring

2011-2021

MoH, IPH, DPH s 1 course per yearorganized/20 personstrained

$13

4.4. Set upcoordinationmechanisms

2014 MoH, MEP, IPH, EA, Institute ofMeteorology (IM),Municipalities.

Inter-agencyagreement signed

$2

4.5. Introduceinstruments forinformingcommunities on airpollution.

2013-2021

MoH, MEP, IPH, EA,IM, Municipalities Template of the

bulletin is prepared.Bulletins are issuedquarterly. One website set up.

$0

4.6. Conduct moreresearch on indoorair quality and usethe data for policychanging advocacyand public advice.

2014-2021

MoH, IPH, PolitecnicUniversity (PU)

One survey in twoyears. Reportspublished

$120

4.7. Adapt healthsector policies forusing ‘cleaner’technologies fortransport, facilityheating systems andenergy management

2015-2016

MoH

Policy documentprepared. Signed byMinister

$4

Objective 5. Increasing the capacities, preparedness and coordination of the healthsystem with other systems in dealing with expected health problems inflicted by heat

44

waves and extreme cold weather ($476 000)

Activities Timeline Responsibility Indicators Budget5.1. Set up aseasonal andsentinel earlywarning systembased in heat-bornconditions.

2012-2014

MoH, UHC, IPH,selected regionalhospitals

Guidelines/standardsprepared. 50 Sentinelcentersselected/professionalstrained

$10

5.2. Establish amulti-sectoralcooperationmechanism of healthsector,meteorologicalinstitutes andenvironmentalprotection agencies

2013 MoH, UHC, IPH, IM,EA

Inter-sectorialagreement signed.

$4

5.3. Set up a healthsteering committee,for actions to controlheat waves/otherextreme weatherimpacts on health.

2014 MoH, UHC, FM, IPH

Order of Ministerissued.

5.4. Set up standardsand protocols forclinicians andadministrators

2012-2013

MoH, UHC, FM

Standards/guidelinesprepared.

$4

5.5. Provide trainingsessions to selectedhealth professionals.

2013-2021

MoH, UHC, FM 3 courses per yearorganized. At least 70health professionalstrained

$4

5.6. Preparematerials in Albanianfor high risk groupson self care andhealth care seekingduring a heat wave.

2012 MoH, UHC, IPH

50 000 leaflets peryear

$100

5.7. Informcommunities timelyand systematicallyabout possible heatwaves.

2012-2021

MoH, IPH

1 media campaign peryear

$350

5.8. Adapt healthsector policies for

2015-2016

MoH Relevant policyprepared and signed

$4

45

health facilityconstruction.

by minister

Objective 6. Improving collaboration and integration of health system into the nationalemergency structures responsible for floods and fires, landslides and other naturaldisaster under the influence of climate change ($19 000)

Activities Timeline Responsibility Indicators Budget6.1.-6.2. Finalize thehealth sector crisismanagement policyand set upinstitutional structurein health sector

2012-2013

MoH, MI, OtherMinistries

Policy documentprepared. Legislativeamendmentsproposed.

$4

6.3.-6.4 Prepareoperational practices,guidelines andtraining modules onhealth crisesplanning andmanagement

2013-2014

MoH Protocols, plans andtraining modulesprepared.

$6

6.5. Set up andintegrate an earlywarning system.

2013-2015

MoH, MI, otherMinistries

Tools of reportingsystem aproved. 100persons in selectedagencies trained.

$9

Objective 7. Adapting and integrating surveillance and control systems for selectedcommunicable diseases and vectors likely to be affected by climate change ($2,508000)

Activities Timeline Responsibility Indicators Budget7.1.1. Adapting theALERT instrumentand infrastructure

2012 MoH, IPH New tools andinfrastructure ofsurveillance prepared

$100

7.1.2. Training theepidemiologists 2013-

2014

MoH, IPH, DPH 50 epidemiologistsare trained in twoyears

$7

7.1.3. Reviewregulations andclarify theresponsibilities.

2013 MoH, IPH, DPH

Regulation/standards

$4

46

prepared

7.2.1. - 2.2.3Enhance thestandards of PublicHealth laboratories.

2012-2015

MoH, IPH, DPH

Guidelines/standardsprepared

$16

7.3.1. Adapt anintegrated policydocumentaddressing vectorand pest control inAlbania.

2012-2013

MoH, MEP. MAF,IPH, Institute of foodsafety and veterinaryresearch (ISUV), AE,Local Government,MI.

Policy documentprepared

$8

7.3.2. Support withtraining andinformationDirectories of PublicHealth andMunicipalities.

2013-2021

MoH, IPH, DPH,Local Government

5 training per yearorganized, covering atleast 100 people

$260

7.3.3. Adapt theexisting surveillancesystems on vectorborn diseases.

2013-2021

MoH, IPH, DPH New surveillancetools prepared. 1sero-prevallencesurvey in two yearsand 1 mapping in 3years.

200

7.3.4. Developtraining for healthprofessionals onvector born diseasesprevention andcontrol.

2012-2015

MoH, IPH, ISUV,Univesity

5 courses organizedand 100 healthprofessionals trained

$260

7.3.5. Strengthencapacities at Instituteof Public Health forentomologicallaboratory andentomologicalresearch.

2013-2021

MoH, IPH 20 days/work forinternational experts.12 month/personstrained abroad. Newtechnology installed.Consumablesassured

$930

7.3.6 Reviewlegislation andadvocate for newregulation on thearea of vector and

2012-2015

MoH, IPH, ISUV,DPH s, otherMinistries Amendments or a

draft law prepared

$16

47

pest control.

7.4.1. Set up an earlywarning surveillancesystem for potablewater quality.

2012-2013

MoH, IPH, DPH Order of ministerissued. New toolsprepared. Informationtechnology installed

7.4.2. Train publichealth professionals.

2013-2014

MoH, IPH, DPH At least 100 publichealth professionalstrained

$26

7.4.3. Continuouslyassure the quality ofthe new surveillanceand the feed-backreports related to it.

2014-2021

IPH

Template of the reportis prepared. Reportsare issued weekly

$1

7.4.4. Set up jointsurveillance systemsfor food borndiseases and foodsafety

2012-2014

MoH, IPH, ISUV,Food Authority (FA),MAF

Standards/guidelinesprepared. Informationtechnology installed.Information sharedmonthly

$300

7.4.5. Support FoodAuthority withtraining for foodsafety laboratoriesand risk assessment.

2013-2018

IPH, ISUV, FA, UHC,University

Training materialsprepared. At least 150lab professionals andfood inspectorstrained. Labtechnology installed.

$0

7.4.6. Evaluate thecommunities onsanitation standards

2012-2013

MoH, IPH, DPH, One survey carriedout in the first twoyears. A conferenceorganized

$33

7.4.7. SupportMunicipalities andLocal Directories ofPublic health onsanitationcontinuously

2013-2021

MoH, IPH, DPH,Local Government

5 trainings per yearorganized. At least100 persons per yeartrained

$59

7.4.8. Identify gapsand needs in nationalregulation forwastewaterutilisation. Set upmonitoring systemfor wastewater

2014-2021

MoH, IPH, MAF,Regulation/standardsprepared. Monitoringsystem operational inat least two regions inthe first two years

$304

48

utilisation.

Objective 8. Strengthen the services and coordination of information systems forprevention and management of health problems inflicted by increasing exposure topollens ($733 000)

Activities Timeline Responsibility Indicators Budget

8.1. Review andadapt the healthsystem registriesrelating to polleninduced conditions.Case basedsurveillance analysisand survey onpollen-specificallergies.

2015-2017

MoH, IPH, UHC,University

Analysis of the gapsof the existinginformation systemprepared. Report onallergies prepared.

$4

8.2. Increase thesites of pollenmonitoring inAlbania. Publicinformation.

2015-2021

University/Academia,MoH, MEP

4-6 new stationsinstalled. Instrumentsstandardized andadopted.

$600

8.3. Develop trainingmaterials for healthprofessionals andorganize courses.

2015-2021

MoH, UHC Curricula prepared.40 ToT trained

$9

8.4. Develop anddistribute brochuresfor allergy sufferersand leaflets forcommunities

2015-2021

MoH, IPH, UHC,DPHs

Materials prepared.1 000 copiesavailable in each HCevery year. 10 000distributed every year

$120

Objective 9. Bring together different sectors for setting up a system for monitoring andprevention of health problems resulting from an increased ultraviolet radiation ($766 000)

9.1. Prepare anddistribute informativematerials for PHCprofessionals.

2012-2013

MoH, IPH, UHC,University/Academia

Brochures preparedand 2000 copiesdistributed

$2

9.2. Design andimplement

2013-2021

MoH, IPH, UHC,University/Academia

One campaignorganised every year.

$463

49

appropriatecommunication toolsfor general public.

50 000 leafletsdistributed

9.3. Supportresearch andmonitoring.

2015-2021

ARI, MEP,University/Academia

At least one large(national) researchproject designed andfinanced

$300

9.4. Set up inter-sector mechanisms.

2015 MoH,IPH, MEPUniversity/Academia

Agreement signed $2

Total $7,145

50

IMPLEMENTATION PROCESS AND INFRASTRUCTUREIn order to assure sustainability and longer term implementation of this strategy,some immediate steps should be taken and a set of structures and recourses needsto be in place.

First, the most appropriate way must be identified to link this strategy with othernational policy documents, to fit it into the legal framework of country and the highestpolitical ownership possible.

Second, the existing steering committee which was responsible for the project‘Protecting health from climate change in Albania’ needs to be reorganized, in termsof terms of reference. It has to be assured better and more sustainable presentationfrom relevant structures in ministries other than Ministry of Health such asDesignated National Authorities under Ministry of Environment and Department forEmergencies Control under Ministry of Interior.

Third, it must be considered a priority for Ministry of Health designation ofperson/structure, responsible for monitoring, reporting and other activities which willsupport delivery of the interventions planed in the strategy

Finally, the action plan of the strategy needs to be integrated with country’s middleterm budgeting priorities, while coordination instruments responsible for influencingdonor financing (i.e. annual donor conferences organized by Ministry of Health orMinistry of Environment) must be presented with the priorities included in thestrategy.

Annex 1

The ToR of National Steering Committee

Participants in this committee are encouraged to:

-orient local WHO office in Tirana on the components of the project

-guide the development (assist in developing) a detailed plan of the project

-guide the development of health plan for adaptation to climate

-guide the activities needed for capacity building

-advise researchers / institutes who will be involved in assessing the health impact of climate change

- facilitate the availability of data and information for the purpose of this project

- advise on the policy involvement of the adaptation plan within the institutes themselves

The Steering Committee will meet three times a year

51

REFERENCES1. UN s Intergovernmental Panel on Climate Change. Third Assessment Report 2001.

2. Protecting health from climate change. Connecting Science, Policy and People. WHO 2009.

3. WHO. Human health and climate change. www.who.int/ globalchange/health_policy/ climate_change_talks. (Accessed March 2011)

4. McMichael A et al. Climate change. In: Ezzati M et al., eds. Comparative quantification ofhealth risks: global and regional burden of disease due to selected major risk factors. Geneva,World Health Organization, 2004.

5. Confalonieri U et al. Human health. In: Parry ML et al., eds. Climate change 2007. Impacts,adaptation and vulnerability. Cambridge, Cambridge University Press, 2007, (Contribution ofWorking Group II to the Fourth Assessment Report of the Intergovernmental Panel on ClimateChange).

6. UN s Intergovernmental Panel on Climate Change. Fourth Assessment Report (2007)

7. Climate change and human health - risks and responses. Published by WHO in collaborationwith UNEP and WMO (2003)

8. United Nations (1992). United Nations Framework Convention on Climate Change. New York,United Nations

9. WHO. World Health Assembly resolution WHA61.19 on climate change and health (2008)..

10.WHO. Climate change and health. Report by the Secretariat(2008)..

11.Fifth Ministerial Conference on Environment and Health “Protecting children’s health in achanging environment” Parma, Italy, 10–12 March 2010

12.Protecting health in an environment challenged by climate change: European RegionalFramework for Action. WHO Europe. EUR/55934/6 Rev.1. 19 February 2010

13.Inter-sectorial environmental strategy of Albania 2007-2013

14.The Albanian national action plan (NAP) to address climate change,

15.First / Second Albanian national communication for UNFCCC

16.The policy document of carbon financing in Albania, 2009

17.MoH (2007). Health system strategy 2007-2013. Ministry of Health of the Republic ofAlbania. Tirana: Albania

18.Nuri, B., Tragakes, E. (2002). Health care systems in transition: Albania.Copenhagen:European Observatory on Health Care Systems

19.McMichael et al. (2009). Climate change: a time of need and opportunity for the health sector.Lancet, 374.

20.Haines A, et al. (2009). Public health benefits of strategies to reduce greenhouse-gasemissions: overview and implications for policy makers. Lancet, 374.

21. Report of the United Nations conference on environment and development.

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Rio de Janeiro, 3-14 June 1992). un.org/documents/ga/conf151/aconf15126-1annex1.htm(Accessed March 2011)

22.Menne et al. (2007). Protecting health in Europe from climate change.Copenhagen, WHORegional Office for Europe

23.Aniello C et al. Mapping micro-urban heat islands using Landsat TM and a GIS. Computers &Geosciences, 1995.

24.Cohen A et al. Urban air pollution. In: Ezzati M et al., eds. Comparative quantification ofhealth risks: global and regional burden of disease attributable to selected major risk factors.Geneva, World Health Organization, 2004.

25.Hales S, Edwards S, Kovats R. Impacts on health of climate extremes. In: McMichael AJ etal., eds. Climate change and health: risks and responses. Geneva, World Health Organization,2003.

26.International health regulations. Geneva, World Health Organization, 2007(http://www.who.int/gb/ebwha/pdf_files/WHA58/WHA58_3-en.pdf)

27.WHO guidelines for the safe use of wastewater, excreta and grey water, 3rd.Geneva, World Health Organization, 2006.

28.Hutton G, Haller L. Evaluation of the costs and benefits of water and sanitation improvementsat the global level. Geneva, World Health Organization, 2004.

29.Global strategic framework for integrated vector management. Geneva, World HealthOrganization, 2004 (http://whqlibdoc.who.int/hq/2004/WHO_CDS_CPE_PVC_2004_10.pdf).

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