technical report...4 technical report: vulnerability assessment of public health and health care...

Technical Report ___________________________________

Vulnerability Assessment

of Public Health and Health Care Systems to Projected Climate Change in Kathmandu, Nepal

2

Technical Report: Vulnerability Assessment of Public Health and Health Care Systems to Projected Climate Change in Kathmandu, Nepal

WHO Library Cataloguing-in-Publication Data

Technical report: vulnerability assessment of public health and health care systems to projected

climate change in Kathmandu, Nepal.

1.Delivery of Health Care. 2.Climate Change. 3.Public Health. 4.Nepal. I.WHO Centre for

Health Development (Kobe, Japan). II.World Health Organization. Regional Office for South-

East Asia.

ISBN 978 92 4 150783 7 (NLM classification: WA 30)

© World Health Organization 2015

All rights reserved. Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html), or to the WHO Centre for Health Development, I.H.D. Centre Building, 9th Floor, 5-1, 1-chome, Wakinohama-Kaigandori, Chuo-ku, Kobe City, Hyogo Prefecture, 651-0073, Japan (fax: +81 78 230 3178; email: [email protected]). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication.

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Technical Report

Vulnerability Assessment

of Public Health and Health Care Systems to Projected Climate Change in Kathmandu, Nepal

Submitted by:

Nepal Public Health Foundation

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Acknowledgements

I would like to express my deep sense of gratitude and thanks to Dr Gajananda Prakash

Bhandari (Principal Investigator) for his tireless effort to complete this project. He is now

working as a program director at Nepal Public Health Foundation.

I am grateful to Mr. Meghnath Dhimal, Research Officer, Nepal Health Research

Council, Mr Saraju Baidya, Senior Meteorologist from the Department of Meteorology

Hydrology for providing the climatic data and thankful to Mr Dhruba Raj Ghimire,

Statistical Officer from HMIS, DoHS, MoH for providing data related to diarrhoea in

Kathmandu.

Furthermore, I would like to extend my sincere thanks to the Chief of District Public

Health of Kathmandu, experts from Kathmandu Metropolitan City and experts from all

other organizations. I would like to express my thanks to Dr Roshan Shrestha from UN-

HABITAT Nepal for his commitment to support for implementation of recommendations

of this research in the near future.

Last but not the least, my sincere thanks goes to the World Health Organization Centre

for Health Development (WHO Kobe Centre), Japan for funding this research project

without which the project would not have started.

Thank you.

Dr. Mahesh K Maskey

Chair

Nepal Public Health Foundation

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Project Summary About the Project This technical report was the final product of a research project funded by the World Health Organization (WHO). This was a joint collaboration between the WHO Centre for Health Development (WHO Kobe Centre - WKC) and the WHO Regional Office for South-East Asia (WHO SEARO). The research project was carried out officially through the coordination of Dr Gajananda Prakash Bhandari, Principal Investigator and Program Director, Nepal Public Health Foundation. The research project provided a case study to address the knowledge gap on the impact of climate change and variability on Katmandu, Nepal. It was based on a generic research protocol entitled “Guidance for conducting assessments of health vulnerability and public health and health care interventions to address climate change” (WHO draft, 2010). Project Objectives The general objective of the research project was to establish the basis for an assessment of the vulnerability and adaptation status of the public health and health care system to projected climate change in Kathmandu, Nepal. The specific objectives were to: 1) to test the suitability of the guidance developed by WHO to evaluate the vulnerability of public health and health care system to climate change in urban settings; 2) To conduct a pilot study in the city of Kathmandu, Nepal to establish the basis for assessing the vulnerability of public health and health care system to climate change; and 3) to identify actions to protect the health of the population of Kathmandu, Nepal in the face of climate change. Project Team Members Dr Mahesh Kumar Maskey, Chair, Nepal Public Health Foundation (NPHF) Dr Gajananda Prakash Bhandari, Principal Investigator and Member, NPHF Mr Meghnath Dhimal, Research Officer, Nepal Health Research Council Mr Saraju Kumar Baidya, Expert, Department of Hydrology & Meteorology Ms Astha Joshi, Research Assistant, NPHF Project Peer Reviewers (WHO) Dr Jostacio M. Lapitan, Technical Officer, Urban Health Emergency Management, WHO Centre for Health Development (WHO Kobe Centre) Dr Abu Muhammad Zakir Hussain, Scientist, WHO Regional Office for South-East Asia (WHO SEARO)

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Table of Contents

TABLE OF CONTENTS………………………………………………………………………... 6 LIST OF FIGURES……………………………………………………………………………… 7 LIST OF TABLES……………………………………………………………………………….. 7 LIST OF ACRONYMS AND ABBREVIATIONS…………………………………………….. 8 EXECUTIVE SUMMARY………………………………………………………………………. 9 1. INTRODUCTION……………………………………………………………………………... 10 1.1 Background………………………………………………………………………………….. 12 1.2 Objectives……………………………………………………… 15 2. METHODOLOGY……………………………………………………………………………. 16 2.1 Consultative meeting.……………………………………………………………………… 16 2.2 Key Informant Interview.………………………………………………………………….. 17 2.3 Secondary information 17 3. RESULTS……….…………………………………………………………………………….. 18 3.1 Assessment of vulnerability of Kathmandu Valley using the WHO Guidance…….…………………………………………………………………………………….

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3.1.1 Identification and Orientation of Stakeholders for Assessment……………………… 18 3.1.2 Vulnerability to current climate variability and change.……………………………….. 19 3.1.3 Project the health impacts of climate change……..…………………………………… 31 3.1.4 Identification and prioritization of adaptation options to address current and projected health risks…………………………………………………………………………….

31

3.1.5 Identification of potential health risks of adaptation and mitigation measures implemented in other sectors, such as water resources, land use, and transport, and identification of possible interventions to reduce any identified risks……………………….

33 3.1.6 Implement, monitor, and evaluate the burden of climate-sensitive health outcomes and interventions to address these burdens, to ensure continued effectiveness in a changing climate……………………………………………………………

34 4. DISCUSSION……………………………………………………………………………......... 36 4.1 Suitability of the guidelines to be included in the assessment…………………...…….. 36 4.1.1 Identify stakeholders to be included in the assessment …………………..…………. 36 4.1.2 Describe vulnerability to current climate variability and change…..………………… 37

4.1.3 Project the health impacts of climate change….………………………………………. 38 4.1.4 Identify and prioritize adaptation options to address current and projected health risks………………………………………………………………………………………………...

38

4.1.5 Determine the potential health risks of adaptation and mitigation measures implemented in other sectors, such as water resources, land use, and transport, and identify possible interventions to reduce any identified risks………………………………...

38 4.1.6 Implement, monitor, and evaluate the burden of climate-sensitive health outcomes and interventions to address these burdens, to ensure continued effectiveness in a changing climate………………………………………………………………………………...

39 5. CONCLUSIONS AND RECOMMENDATIONS………………………………………….. 40 6. REFERENCES………………………………………………………………………………. 44 7. ANNEXES……………………………………………………………………………………. 47

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List of Figures

Figure 1 Map of Kathmandu .............................................................................................................................. 11

Figure 2 Annual Mean Temperature in Kathmandu ........................................................................................ 19

Figure 3 Decadal Average Temperature of Kathmandu ................................................................................. 20

Figure 4 Trend analysis for childhood diarrhoeal diseases (1997/8-2007/08).............................................. 50

Figure 5 Time series decomposition plot for minimum temperature ........................................................... 51

Figure 6 Time series decomposition plot for maximum temperature ........................................................... 52

Figure 7 Time series decomposition plot for precipitation level ................................................................... 53

List of Tables

Table 1 Essential Health Care Services (EHCS) in Nepal ............................................................................... 26

Table 2 Disease pattern among different age groups as perceived by convened experts ........................ 30

Table 3 Project Prioritization ............................................................................................................................. 32

Table 4 Policy and Plan of other than health sector ....................................................................................... 33

Table 5 List of Project Team Members ............................................................................................................. 47

Table 6 List of Stakeholders (Key Organizations: Climate Change & Health Nepal) .................................. 47

Table 7 List of Stakeholders identified by the project team .......................................................................... 48

Table 8 Name list of Key Informant Experts .................................................................................................... 50

Table 9 Projected data of diseases from 2011-2030 ....................................................................................... 50

Table 10 Seasonal factor of indicators according to months ........................................................................ 51

Table 11 Projected minimum temperature ....................................................................................................... 52

Table 12 Projected maximum temperature ...................................................................................................... 53

Table 13 Projected precipitation level .............................................................................................................. 54

Table 14 List of Priority project Scoring from Experts ................................................................................... 55

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List of Acronyms and Abbreviations

AIDS Acquired Immune Deficiency Syndrome ARI Acute Respiratory Infection COPD Chronic Obstructive Pulmonary Disease DPHO District Public Health Office EHCS Essential Health Care Services EPI Expanded Program on Immunization GIS Geographic Information System HIMS Health Information Management System HIV Human Immunodeficiency Virus IMCI Integrated Management of Childhood Illness IPCC Intergovernmental Panel on Climate Change IRS Insecticide Residual Spraying KII Key Informant Interview KMC Kathmandu Metropolitan City LSGA Local Self Governance Act MCA Multi-Criteria Analysis MOH Ministry of Health MDGs Millennium Development Goals NAPA National Adaptation Program of Action PM10 Particulate matter of 10 micrometers or less in aerodynamic

diameter SLTHP Second Long-Term Health Plan UN United Nations WHO World Health Organization WHO SEARO WHO Regional Office for South-East Asia WKC WHO Kobe Centre

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Executive Summary Introduction. In 2007, the Intergovernmental Panel on Climate Change (IPCC) predicted that global mean temperature will increase by between 1.0 and 6.5 degrees Centigrade within the next 90 years. Even more alarming, average annual temperatures are forecasted to increase by more than 1.0 degree Centigrade by 2029 and by more than 2.0 degrees Centigrade within 50 years in Nepal. Climate change, then, poses a potential significant and emerging threat to public health and would have direct and indirect effects on human health of people living in Kathmandu valley of Nepal, being one of the most vulnerable districts based on the climate change vulnerability index. Kathmandu was selected for a pilot vulnerability study of its public health and health care system in order to provide an evidence base that will have implications for local as well as national policy making. Objectives. The general objective of this pilot study was to establish the basis for an assessment of the vulnerability and adaptation status of the public health and health care system to projected climate change in Kathmandu, Nepal. The specific objectives were:

To test the suitability of the guidance developed by WHO to evaluate the vulnerability of public health and health care system to projected climate change in urban settings;

To conduct a pilot study in the city of Kathmandu, Nepal to establish the basis for assessing the vulnerability of public health and health care system to projected climate change; and

To identify actions to protect the health of the population of Kathmandu, Nepal in the face of projected climate change.

Methodology. Quantitative data were accessed from the Management Division of the Department of

Health Services, Nepal for the health component (1997 to 2009) and from the Department of Hydrology

and Meteorology, Nepal for the climate component (1971 to 2009). On the other hand, qualitative data

were taken through key informant interviews and meeting discussions with relevant stakeholders. The

quantitative data were analyzed using statistical software (SPSS) and time series analysis while retrieved

qualitative data were analyzed manually. The study was conducted and completed within a year from

2011 to 2012.

Discussion. The document “Guidance for conducting assessments of health vulnerability and public

health and health care interventions to address climate change” (WHO draft, 2010) that was used to

guide the study was found suitable with some recommendations for improvement and/or refinement. For

example, in the very first step “identify stakeholders to be included in the assessment”, aside from

identification, the authors recommended that there should be a separate “orientation of stakeholders” –

sensitizing them and enhancing their understanding about climate change and vulnerability. In the third

step “Project the health impacts of climate change”, the authors found it difficult to differentiate the health

impacts in the absence and presence of climate change. Nevertheless, climatic data namely rainfall and

temperature as well as climate sensitive diseases (e.g., diarrhea) were projected until the year 2030. In

terms of actions, capacity building of human resources for carrying out vulnerability assessment and

response was deemed very important.

Conclusions and recommendations. The case study came up with a seven-point action plan in moving

forward with the use of the draft guide document in urban settings as follows: 1) Improving the specificity

of the guidance document; 2) Developing more detailed methodological steps; 3) Using checklists and/or

interview schedules; 4) Formulating alternative methods to cope with data inavailability; 5) Improving the

guidance document in terms of providing examples from developing country contexts; 6) Incorporating

standard research tools and methods; and 7) Engaging in capacity building programme as a prerequisite

prior to actual assessment work. Adaptation options identified to reduce vulnerability to projected climate

change were water, sanitation and hygiene measures; vector control through waste management; health

promotion and education; reduction of air pollution; and integrated disease surveillance and response;

Keywords: public health; climate change; urban health; vulnerability and adaptation assessment

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1. Introduction

1.1 Background

In 2007, the Intergovernmental Panel on Climate Change (IPCC) predicted that global

mean temperatures will increase by between 1.0 and 6.5°C within the next 90 years.

Even more alarming, average annual temperatures are forecasted to increase by more

than 1.0°C by 2029 and by more than 2.0°C within 50 years in Nepal. Climate change

poses a significant and emerging threat to public health. Climate change is expected to

have both direct and indirect impacts on human health of people living in Kathmandu

valley, Nepal.

Kathmandu is the capital and largest metropolitan city of Nepal. The city stands at an

elevation of approximately 1,400 meters in central Nepal surrounded by four major

mountains. It is inhabited by 671,846 (2001) people. It has a density of 13,225 per km2.

It is by far the largest urban agglomerate in Nepal, accounting for 20% of the urban

population in an area of 50.67 square kilometers.

Five major climatic regions have been deciphered in Nepal, out of which Kathmandu

valley falls under the Warm Temperate Zone (elevation ranging from 1,200–2,300

meters) where the climate is fairly pleasant. The average temperature during the

summer season varies from 28–30 °C whereas during the winter season the average

temperature is 10 to minus 1 °C. The rainfall which is mostly monsoon based (about

65% of the total concentrated during the monsoon months of June to August), has been

recorded as about 1,407 millimeters. On an average, humidity is 75%. These weather

parameters have been changing significantly probably due to global impact of climate

change.

Water supply in Kathmandu is derived from two sources, namely, surface water (rivers

and ponds) and groundwater; rainfall precipitation is the major contributor of these two

sources. Most of the drinking water source is from surface water of the Baghmati River.

However, the supply is insufficient and there is chronic shortage of water.

Water demand of the urban areas of Kathmandu valley is 170 million liters per day of

which only 50% is met during dry season and 80% during monsoon (NPC 2002). The

pressure on water quantity in Kathmandu has been increasing day by day due to the

rapid urbanization. There is an influx of people from other parts into the capital which

has aggravated the situation. In order to fill the gap of water supply, often the water

quality aspect has been ignored. In Kathmandu, most of the surface water and ground

water have been tapped for water supply.

http://en.wikipedia.org/wiki/Metropolis

http://en.wikipedia.org/wiki/Nepal

http://en.wikipedia.org/wiki/Humidity

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Figure 1 Map of Kathmandu

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Another important source of water supply in Kathmandu is the age-old stone spouts or

‘Dhungedhara’. Stone spouts are natural springs that were developed as sites for public

water consumption several hundred years ago. However, they are drying up gradually

over the years and the quality of 'stone spouts’ water is not satisfactory. All the samples

tested have shown positive for microorganisms. About 90% of samples showed excess

ammonia concentration; 60% of samples showed nitrate concentration. The water

quality of the different stone spouts showed that they are not spared from the

anthropogenic pollution (NGO Forum for Urban Water and Sanitation, 2008).

Water quality mainly of the accessible water bodies to the urban centers and dense

human settlement are extremely polluted. The degree of pollution of such water

depends upon season of the year and volume of water flowing in the rivers. Water

quality of all the rivers and streams of Kathmandu valley near to the densely populated

areas exhibit characteristics similar to that of raw sewage (NHRC 2009)

Realizing the basic need of public health in the city, in 1994 Kathmandu Metropolitan

City (KMC) launched a Community Urban Basic Health Service Program in the city.

Seven community urban health clinics at ward level and Medical Facility Section in the

Central level were established. An exclusive Public Health and Social Welfare

Department (PHSWD) was also established. As of date, 21 community urban health

clinics are functional and an Acupuncture Service Center has also been added. The

Ministry of Health has also launched several social mobilization and health education

awareness programs to ensure the welfare of citizens by educating and empowering the

people through mainstreaming women, children, youth, and older people.

Healthcare in Kathmandu is the most developed in Nepal. General and specialized

hospitals are located in the city centre. Nevertheless, frequent outbreaks of diseases

are reported to occur in Kathmandu valley. Outbreak of cholera in Kathmandu valley

was first reported in 1994 (Ise, et.al 1996).

Kathmandu city is susceptible to urban floods due to limited drainage system, frequent

blockage and heavy rainfall for short duration. The geological study in Kathmandu valley

shows that Kathmandu valley is prone to land subsidence (Sapkota T. 2009).

Kathmandu valley is also vulnerable to earthquakes (NSET 2003).

Air pollution is a serious problem in Kathmandu. Many studies over the last decade

(MOPE/UNEP/ICIMOD 2000; CBS 1994; MOPE 1998; Pokharel 1998; Kunwar 1999;

NESS 1999) have shown that ambient air in the Kathmandu Valley is heavily polluted

and not in accordance with international standards, and that the air quality is

deteriorating. This development has mainly been due to a rapid rise in the number of

petrol and diesel vehicles plying the streets. At the same time, continued emissions

from the many brick kilns, the dyeing industry, and other industries are important

contributors.

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In recent years it has been increasingly recognized that air pollution and climate change

are linked in several ways which in turn will lead to several health problems such as

increase in incidence of acute respiratory infections (ARI), chronic obstructive

pulmonary disease (COPD), and other diseases. Air pollutants also contribute to the

developing problem of climate change, although it is difficult to assess to what extent. At

the same time, climate change will itself have an impact on the pattern and extent of air

pollution and consequently to health. The increased concentration of greenhouse gases

in the atmosphere is associated with respiratory diseases and most vulnerable

populations will be the elders, children, women and patients of asthma and other

respiratory disorders. The hospital admitted COPD cases in Kathmandu valley correlate

with air quality data in Kathmandu valley. During December, January and February, the

24-hour average concentrations of particulate matter (PM10) exceed the National

Ambient Air Quality Standards (NAAQS) of 120 µg/m3 in the urban area (MOEST

2007).

Climate change is a significant and emerging threat to public health. (WHO 2011).

Several documents and literature on the issue of climate change and health have

already been published. It has been highlighted that infectious diseases like diarrhoea,

cholera and vector-borne diseases as well as respiratory diseases such as asthma,

bronchitis and chronic obstructive pulmonary diseases are likely to be affected the most

(WHO 2000; WHO 2003; Kovats 2003; Campbell-Lendrum 2007). The health impact of

climate change is obvious in the context of Nepal as a country and Kathmandu as a city.

It is estimated that 84.6% of the total diarrhoeal deaths and 47.95% of the total enteric

fever deaths can be attributed to unsafe water supply and sanitation in Kathmandu

valley (NHRC/WHO 2006). Kathmandu has an acute shortage of drinking water

(Shrestha MN 2010). Ultimately, shortage of water in Kathmandu might be reasonably

attributed to climate change due to increase in temperature and decrease in rainfall

(Bhandari et al. 2010).

Changes in climate are likely to lengthen the transmission season of important vector-

borne diseases (like dengue and malaria) and to alter their geographic range, potentially

reaching regions that lack either population immunity or a strong public health

infrastructure. One to two degree Celsius increase in temperature of Kathmandu valley

may make a huge difference in the life cycle of the insect and the parasites. The first

outbreak of dengue occurred in Nepal in 2006. The cross-sectional entomological

survey conducted in 2006 identified the presence of Aedes aegypti in 5 major urban

areas of terai (low-land) regions bordering with India.

Similarly, entomological survey conducted in 2009 has revealed the presence of Aedes

aegypti in Kathmandu (Gautam et al. 2009). Previously A. aegypti was not recorded in

Nepal. The presence of A. aegypti in these districts may be attributed to climate change

as explained by shifting pattern of vectors from low land to high hills. Vector borne

diseases that have important public health implications in the national context include

malaria, kala-azar, lymphatic filariasis, Japanese encephalitis and — more recently —

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dengue. Malaria, once believed to be confined to the forest and forest-fringe areas of

the terai and inner terai regions is now distributed over almost 65 districts of the country.

Japanese encephalitis, first identified in 1978, is now present in 24 districts. Kala-azar

was not a problem up to 1980 but is now present in 12 districts of eastern and central

terai regions. One of the reasons for increasing prevalence of the disease and

geographical spread might be climate change. The increased temperatures and change

in precipitation pattern due to the climate change may have created conducive

environment to mosquitoes breeding. More research is needed to discern the attribution

of health impacts to climate change.

In order to respond to the emerging threats due to climate change and protect the

vulnerable population, Nepal Government has prepared the National Adaptation

Program of Action (NAPA), which is a requirement under the United Nations Convention

on Climate Change for all Least Developed Countries (LDCs) party. NAPA has covered

the six major thematic areas which include public health, water resources and energy,

urban settlement and infrastructure, agriculture and food security, forest and

biodiversity, and climate induced-disaster. The NAPA process has been able to

convene wide stakeholder involvement from different sectors. It has also provided a

broad base of prioritized adaptation response measures across various sectors

important to the livelihood of the climate vulnerable populations in Nepal. This can be

used as a platform for the development of climate change adaptation response strategy

at national level and is important in formulating policies on climate change for urban

settlements like Kathmandu.

As part of the NAPA process, a series of the climate change vulnerability assessments

at the district level was conducted. The vulnerability assessment report states that due

to data limitations, use of expert judgment particularly in assigning weight to the various

climate indicators is necessarily subjective (MOE 2010). The overall vulnerability of the

districts of Nepal as gleaned from GIS–based vulnerability maps developed by NAPA

project team shows that Kathmandu is one of the most vulnerable districts based on

climate change vulnerability index (MOE, 2010). Being most vulnerable urban area and

capital of the country, Kathmandu is taken for a pilot study for vulnerability of public

health and health care system in Nepal to pave the way for evidence that will have

implications for local and national policy making.

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1.2 Objectives

The general objective of this pilot study is to establish the basis for an assessment of

the vulnerability and adaptation status of the public health and health care system to

projected climate change in Kathmandu, Nepal.

The specific objectives are:

To test the suitability of the guidance developed by WHO to evaluate the

vulnerability of public health and health care system to projected climate change

in urban settings;

To conduct a pilot study in the city of Kathmandu, Nepal to establish the basis for

assessing the vulnerability of public health and health care system to projected

climate change; and

To identify actions to protect the health of the population of Kathmandu, Nepal in

the face of projected climate change.

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2. Methodology

2.1 Consultative Meeting

Nepal Public Health Foundation after getting ethical approval from Nepal Health

Research Council formed a team of researchers to complete the given project. The

team included Chairman of Nepal Public Health Foundation, Environment Health

Researcher from Nepal Health Research Council, Principal Investigator of the project

and a research assistant (Name list is given in Annex I).

The first important task was to define and identify stakeholders to be involved

throughout the assessment process. Stakeholders, as used in this pilot study, are

defined as ‘a group or organization with an interest, statutory responsibility, or practical

role in developing and implementing climate change adaptation strategies and related

initiatives.’

The involvement of relevant stakeholders was critical in order to assess vulnerability of

public health and health care system to climate change and develop adaptation

measures. Ultimately, the main objective was to enhance the capacity of stakeholders in

the city to respond to climate change impacts. This included raising awareness by

orienting them on climate change and its effect on health; process of vulnerability

assessment of public health and health care system due to climate change which were

adopted from the draft WHO guidelines; their involvement during all phases of

vulnerability assessment and later planning and implementation of adaptation

measures.

The project team discussed in a preliminary meeting and initiated listing of stakeholders

to convene the first consultative meeting. After consultation with the NAPA public health

thematic group and other experts (WHO, UN HABITAT), a list of stakeholders was

developed. At first different levels of stakeholders were defined which included

stakeholders at national level and stakeholders for Kathmandu city. As there were very

few stakeholders involved at city level (only Kathmandu Metropolitan Office) all other

stakeholders working in the area of climate change and health at National level were

listed (Annex II).

The identified stakeholders were then communicated through telephone and emails for

their participation in the first consultative meeting. An official invitation letter was also

sent to all.

The first consultative meeting was conducted at the meeting hall of Nepal Public Health

Foundation on 3 November 2010 to orient participants on climate change and the

vulnerability of health and health system. The names of the participants and few other

invitees were listed in Annex III. The second and third consultative meetings were held

on 2 December 2010 and 10 January 2011 respectively, with active participation from

stakeholders as listed in Annex III.

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2.2 Key Informant Interview (KII)

In-depth key informant interviews were conducted with key personnel of municipality,

government departments, academia, NGOs, and related agencies. Interview guidelines

were designed for this purpose, which is attached in Annex IV. The name and affiliation

of key informant interviewer is given in Annex V.

2.3 Secondary Information

Relevant national, regional, and local level documents (including policy documents,

NAPA reports, national communication reports to UNFCCC from government and non-

government organizations were searched, to find out the climatic and health situation of

Kathmandu city. The final NAPA report prepared by Ministry of Environment in

September 2010 was thoroughly reviewed, and public health adaptation and other

sector adaptation programs were identified and listed out. Similarly, the vulnerability

assessment findings of health due to climate change conducted in other countries were

reviewed.

Health related data on diarrhea were accessed from Management Division of

Department of Health Services. The monthly number of cases of diarrheal diseases was

accessed for a ten-year period from 1997 to 2009. The obtained data were verified by

visiting the Kathmandu district public health office (DPHO). The inconsistent data were

then discussed with the statistical officer of DPHO leading into a consensus after

verification from primary data collection sheet. Similarly, climatic element data were

accessed from Department of Hydrology and Meteorology (DHM). The data were

accessed from 1971 to 2009. The data obtained from DHM were monthly records on

minimum and maximum temperature and total rainfall.

Data management

Qualitative data (from key informant interview and meeting discussions) were taken in

both written format and record format using tape recorder. On the same day, the

recorded data were transcribed and matched with written data. Informed consent was

taken from all the participants. Ethical approval was also taken from Ethical Review

Board of Nepal Health Research Council.

Data analysis

Retrieved qualitative data through meeting and key informant interview were analyzed

manually. The quantitative data were analyzed using statistical software (SPSS) and

time series analysis.. Before forecasting, the seasonal components were analyzed for

all the indicators (minimum temperature, maximum temperature and precipitation) using

month as a seasonal component. The trend analysis was carried out using

depersonalized data since January 1971. For forecast, the projected trend component

was multiplied with seasonal component.

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3. Results

3.1 Assessment of Vulnerability of Kathmandu valley using the WHO

Guidance

3.1.1 Identification and Orientation of Stakeholders for Assessment

The process of stakeholder identification was explained in the methodology section

(Chapter 3).

The first consultative meeting was mainly focused on the orientation of stakeholders on

climate change and its impacts on health and draft WHO guidelines to conduct

vulnerability assessment of public health and health system to climate change.

The meeting started with the self-introduction of the participants and during introduction

they also briefly mentioned about their possible roles in the vulnerability assessment.

The principal investigator (PI) of the project, Dr. Gajananda Prakash Bhandari,

presented an introduction to climate change and health focusing on the project, its

objectives and outcomes. Then, Mr. Meghnath Dhimal introduced the WHO draft

guidelines on vulnerability assessment of public health and health system to the

participants.

In the first presentation, Dr. Bhandari gave an introduction on climate change and briefly

explained about climate change as an additional stressor to human health on top of the

existing burden of communicable and non-communicable diseases including its direct

and indirect impact. He also added the role of extreme events on public health and

health care delivery system. The presentation also focused on impacts of climate

change on malnutrition and food security. The presentation further continued with

discussion on Nepal Government's response to climate change from signing the United

Nations Framework Convention on Climate Change on 12 June 1992 to initiation of Pilot

Programme Climate Resilience (PPCR). Further, Dr Bhandari explained about the

evolution of this project (i.e., vulnerability assessment on public health and health care

system) and from consultative meeting to develop research protocol on climate change

held in Kolkata, India (2009) to a consultative meeting held in New Delhi (2010) to refine

the developed research protocol. At the end of the presentation, he discussed the

objective of the vulnerability assessment project and briefly explained about the

framework for vulnerability and adaptation assessment.

Mr Meghnath Dhimal started his presentation with restating the introduction of the

project, its objective and framework for vulnerability and adaptation assessment due to

climate change. The methodology was explained to the participants in a stepwise

manner such as consultative meeting with stakeholders, review of relevant documents,

key informant interview and testing suitability of the WHO draft guidelines. He also

explained the sources of data required to complete the project which were from the

Department of Hydrology and Meteorology for climate data and Department of Health

Services for health related data on quantitative measurement whereas qualitative

19


information was taken by reviewing relevant literature and also from stakeholders

meeting and key informant interview. Expected outcome was also explained before

going to the steps of the WHO draft guidelines on vulnerability and adaptation

assessment.

The steps of the WHO draft guidelines (Annex IX) were explained in detail to the

participants.

3.1.2 Vulnerability to current climate variability and change

Information from a series of consultative meetings and key informant interviews was

used to describe the distribution and burden of climate-sensitive health outcomes by

vulnerable population and areas. The findings are as follows:

Climate Change in Kathmandu from quantitative data analysis

In Nepal, studies based on the data from 1975 to 2005 show that the mean temperature

of the country is increasing steadily at a linear rate of 0.04°C/year (Baidya et. al 2007).

This rate is relatively much higher than the mean global rate. Moreover, the cities are

warming faster than surrounding outskirts as a result of the urban heat island effect and

the country sides/villages are also warming as well. The temperature in Katmandu is

increasing at a linear rate of 0.05°C/year (Fig. 2); higher than the all Nepal rate at

0.04°C/year (Baidya et al. 2007).

Temperature is increasing, and all the seasons are warming in Kathmandu valley.

Decadal average temperature of Kathmandu since 70’s reveals that each decade is

warmer than the previous one (Fig. 3). The first 5 year mean temperature of the 21st

century is warmer than any of the previous decades. The rate of warming also varies,

which is higher in winter compared to other seasons. Besides change in the mean

temperature, widespread changes in extreme temperatures have also been observed. Cold

days, cold nights have become less frequent, while hot days, hot nights have become more

frequent (Baidya et al. 2007).

Figure 2 Annual Mean Temperature in Kathmandu

y = 0.0545x + 17.642

R2 = 0.7214

16.0

16.5

17.0

17.5

18.0

18.5

19.0

19.5

20.0

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

Year

Te

mp

era

ture

(°C

)

20


Figure 3 Decadal Average Temperature of Kathmandu, Nepal, 1971-2005

21


Stakeholder’s Perception towards climate change (Pattern of rainfall and temperature):

Information from multiple sectors is required to understand the impact of climate

change. Climate change is gradually taking place and its impacts are being felt and

responded to by the people. There are visible changes in the climatic conditions and

events since 1971. Climate change is happening and slowly developing associated

changes in the natural environment. Rainfall is erratic and does not occur in sufficient

amounts as needed. Monsoon rain is delayed and the time of rainfall is shifting, and it

was perceived by the Kathmandu population that it does not rain as it used to rain. The

average temperature is experienced to be increasing every year in Kathmandu,

experienced at every season across the years. The maximum temperature of

Kathmandu has even reached to 38 °C which is relatively high considering its

geographical location.

Trend of extreme climatic events (heat stress, severe cold, flooding, landslide in periphery of Kathmandu, drought, high winds):

The significant problem or burden of heat waves and heat stress are not known in

Kathmandu valley. Kathmandu is not highly vulnerable to floods and landslides but the

future danger and possibility of occurrence of such events cannot be ignored or

neglected. Small floods sometimes are recorded in Kathmandu. Due to the increasingly

drier days and seasons, the problem of drought will add another burden to the well-

being of the people. In the near future, if such climatic event would occur (like delayed

monsoon and flooding) then Kathmandu has to be prepared as it would be at risk for

floods and landslides.

Prevalence of disease and illness (Vector borne, water borne, worm infestation, malnutrition):

With the observed increasing temperature in Kathmandu, vectors such as mosquitoes

are getting favourable environment for breeding and development and hence are able to

transmit the vector borne diseases. Japanese Encephalitis (JE) is seasonally endemic

to Kathmandu valley with an incidence of 2.1/100,000 and the case fatality rate of 20%

during monsoon in 2006. The existence of JE transmission in the valley is also

supported by a report by Darsie and Pradhan and an ecologic study conducted in 2001

(Environmental Health Project, unpublished report) that provided clear evidence of the

presence of JE vectors in the Kathmandu valley (Darsie & Pradhan 1990; Partridge et

al. 2007). The entomological survey conducted by Gautam et al. in 2009 reported the

vector Aedes aegypti from different locations of Kathmandu able to transmit Dengue

Hemorrhagic Fever. There was an outbreak of dengue in a nearby district adjoining

Kathmandu (Sharma 2010) which was the first outbreak in Nepal. So far, Kathmandu

valley has been declared as a malaria free area. These diseases (JE and Malaria) were

only found in terai and low altitude regions but are shifting their presence to places at

higher altitude (Dhimal & Bhusal 2009). Similarly, the prevalence of water-borne

diseases (diarrhoeal diseases such as cholera and enteric fever) are also increasing in

22


Kathmandu. The burden of climate sensitive health outcomes are being recorded and

reported in health institutions of Kathmandu.

Outbreak/ Epidemic of disease

Epidemic of cholera was recorded in Kathmandu Valley in 1994 (Ise et al. 1996). But it

should be noted that there is no outbreak of any diseases in the recent years. . Due to

the availability of health institutions and early treatment, fortunately, no disease

outbreak has been recorded or reported recently.

Quality and Quantity of supply drinking water (possible causes):

The quality of drinking water is relatively poor and not drinkable in Kathmandu (Katuwal

and Bohara 2011). The present drinking water if consumed without treatment at

household level may cause diarrhoeal diseases and other health problems. The daily

demand of water for increasing population cannot be fulfilled (Prasai et al. 2007). There

is scarcity in the source of water, and pipeline distribution of water has leakage and

most of the pipelines from which the water reaches to the household level is cross-

connected to drainage system (Warner et al. 2008). The present source of water is not

sufficient to fulfill the daily needs for water of Kathmandu people. The possible reason

for the decrease in the level of water at source may be secondary to the increased

population with decreased rainfall in the last decades as seen in other parts of the

country (Bhandari 2011).

Climate change and health Program in KMC

Climate change has been talked a lot at national level and the focal point has been the Ministry of Environment in

Nepal. There are no activities focusing on climate at local level in Kathmandu Metropolitan City (KMC). Despite

limited resources, KMC is making its best efforts for improvement of environment in Kathmandu. Air pollution of the

Kathmandu valley is of great concern to people followed by waste management. In order to reduce the air pollution of

Kathmandu, KMC is promoting greenery development. In coordination with the Ministry of Forest and Soil

Conservation, the concept of urban forestry is envisioned. However, it is difficult to translate the concept into practice

because of limited space in KMC. Further, KMC has not conducted any health research and survey on health impacts

of climate change. If certain areas are identified by research or vulnerability assessment, KMC is willing to implement

program/s for addressing those health risks towards decreasing vulnerability. In parallel, KMC is providing primary

health care services through its health centers and clinics, albeit in few places of Kathmandu. In summary, the topic

on the health impacts of climate change is totally new for the people of KMC and KMC needs appropriate technical

and financial support to respond to this issue.

Executive Officer, Kathmandu Metropolitan City

23


Sanitation and hygiene in relation to skin & water related diseases (possible

causes and effects):

The significant improvement in personal hygiene and environmental sanitation cannot

be maintained with low supply and less availability of water at the individual level. Slum

dwellers, for example, even don’t use toilets and they practice open defecation. Solid

waste management is also poor that contributes to diarrhoeal diseases, skin diseases,

and other infections. Most Kathmandu residents suffer from some form of skin problems

like itching, dermatitis and allergy. This is supported by the data published by DoHS in

Annual report (Pandey S 2006; MoHP 2009).

Awareness of Climate Change among the Municipality Staff

The awareness about climate change and its impacts is very low among the staff of environmental department in

Kathmandu Metropolitan City (KMC). We had allocated small fund for climate change related activities in last fiscal

year but this fund could not be utilized. The budget has also been allocated for this year which has yet not been

utilized. Solid waste management is a key problem in Kathmandu valley. The open burning of solid wastes in street

corners including premises of government offices is common which needs to be stopped through awareness and

interaction with informed stakeholders. In the absence of elected Mayors in Kathmandu Metropolitan City, community

demanded programs are not in priority in annual program of Kathmandu Metropolitan City. There are no studies

about health impacts of solid waste on the public. Nevertheless, waste handlers, though the metropolitan city, are

provided three months extra salary as compensation and receive free health check up. In order to be aware about

climate change and its impacts, the general public inclusive of the vulnerable people of Kathmandu, any climate

change program should be integrated with solid waste management awareness. For this, about two thousand two

hundred employees of KMC should be sensitized and oriented on climate change and its health impacts. The first

step for protecting the people of Kathmandu from climate change is to make them aware about possible impacts of

climate change.

Environmental Engineer Environment Department, KMC

Pollution level in Kathmandu and respiratory disorders:

Unplanned urbanization, increasing population, polluting vehicles and industries have

started degrading the environment in Kathmandu valley (Jha PK 1995). The pollution in

addition to increasing temperature and decreasing rainfall may have affected the health

of individuals as well. In Kathmandu, air pollution has reached that level that it has

adverse impacts on health. A study suggests that rate of particulate matter pollution in

Kathmandu has reached 11.41 percent point per year. At the same time, there is a

positive relationship between ARI and PM10 level. In an average, a one percent point

increase in PM10 results in about 0.54 percent point increase in the number of inpatient

ARI cases (Sarraf A. 2005). Common colds, asthma, pneumonia, and other respiratory

problems are also directly associated with increased air pollution.

24


Health Problems and Health Services in KMC

The urbanization pattern in Kathmandu valley is very rapid with conversion of arable land into building areas. The

number of old vehicles is high. The operation of old vehicles along with massive construction activities warm up the

temperature of Kathmandu valley. The drainage system in Kathmandu is not planned well and sewers are directly

mixed in rivers without any treatment. The roads are not paved. Primary health care service is being provided to

inhabitants of Kathmandu. Vector borne diseases are emerging in Kathmandu. In order to control Filariasis, mass

drug administration program was launched. Similarly, vaccination program for Japanese Encephalitis was also

launched. Control program for dengue and malaria is also an urgent countermeasure in Kathmandu. Acute

Respiratory Infection (ARI), diarrhoea, gastritis, skin diseases and hypertension are the most common health

problems reported from health centers in Kathmandu. In order to maintain healthy setting in Kathmandu for protecting

the health of the people, the government should have construction and urbanization policies and these policies

should be implemented effectively. The registration of new vehicles should be controlled and old vehicles should be

banned to improve the air quality of Kathmandu so that the burden of ARI can be reduced by about 50%. Though the

Local Self Governance Act 1999 has given full mandate for governance of the Kathmandu Metropolitan area, it has

not been enforced effectively in the absence of the elected Mayors due to political instability. In order to protect the

health of people from changing environment and climate, the local government should be aware about health impacts

of such changes. Alone, the Kathmandu Metropolitan City cannot cope with this problem. It needs altogether joint

efforts of all sectors and stakeholders. The first step for this will be coordination and sensitization.

Chief, Public Health Department, KMC

The climate change impacts and climate sensitive diseases in Kathmandu can be

summarized as follows:

Water borne diseases: diarrhoea, dysentery, typhoid, giardiasis, amoebiasis,

gastritis, hepatitis. The incidence of these diseases is increasing every year

(Bhandari 2011).

Air pollution-related health effects: respiratory diseases like acute respiratory

infection (ARI), bronchitis and asthma are in increasing trend.

Vector borne diseases: Japanese encephalitis and Dengue.

Nutritional, mental and others: include malnutrition, mental health diseases and

non-communicable diseases which have an increasing trend.

The potential vulnerable populations in Kathmandu

The potential vulnerable population varies with population characteristics, geographical

location, settlement types, and occupational groups, social, political and cultural

situations. Though vulnerable population is given in the guidance document, the

vulnerable population in the context of Kathmandu through consultative meeting by

stakeholders and also using NAPA public heath thematic group report was identified as

follows:

Children and women especially pregnant;

25


Elderly people;

Squatters population;

Slum dwellers;

Dwellers of flood plain, river banks and hill slopes;

Internally Displaced Persons (IDPs) - due to political, socioeconomic, natural

factors;

Rag pickers and child workers;

Street Children;

Indigenous habitants of Kathmandu; and

Prisoners.

Policies and Plans

In 1991, the country adopted its first National Health Policy, aimed at improving the

health conditions of the people through extending access and availability of primary

health care system. The policy addressed all measures such as provision of preventive,

curative, and promotive, as well as rehabilitative services. It has also emphasized on

environmental sanitation in promoting public health. The country initiated its first long

term health plan for 15 years from 1975 to 1990. It now has its Second Long-Term

Health Plan (SLTHP) formulated by the Ministry of Health and Population for 20 years

from 1997 to 2017. The aim of the SLTHP is to improve overall health of the people,

particularly those whose health needs are often not met. Its priority is for health

promotion and prevention activities based on primary health care principles, as well as

on identified Essential Health Care Services (EHCS), which are essential clinical and

curative services for the appropriate treatment of common diseases (Table 1). EHCS

has also defined Ayurved and other traditional systems of medicine separately.

26


Table 1. Essential Health Care Services (EHCS) in Nepal

Main Interventions* Health Problems Addressed

Appropriate treatment of

common diseases and injuries

Common Diseases and injuries

Reproductive health Maternal and peri-natal health problems including other RH issues

The expanded programme on

immunization (EPI) and HB

Vaccine

Diphtheria, Pertussis, TB, Measles, Polio, Neonatal Tetanus, Hepatitis B

Integrated Management of

Childhood Illness (IMCI)

Diarrhoeal Disease, Acute Respiratory Infection (ARI), Protein Energy Malnutrition (PEM), Measles and Malaria

Nutritional supplementation,

enrichment, nutrition education

and rehabilitation

PEM, Iodine Deficiency Disorders, Vitamin A Deficiency, Anaemia, Cardiovascular Disease Prevention, Diabetes, Rickets, Perinatal Mortality, Maternal Morbidity, Diarrhoeal Disease, ARI

Prevention and control of

blindness

Cataracts, Glaucoma, Pterygium, Refractive Error, and other Preventable Eye Infections

Environmental sanitation Diarrhoeal Disease, Acute Respiratory Infection, Intestinal Helminthes, Vector Borne Diseases, Malnutrition

School health services Diarrhoeal Disease, Helminthes, Oral Health, HIV, STDs, Malaria, Eye and Hearing Problems, Substance Abuse, Basic Trauma Care

Vector borne disease control Malaria, Leishmaniasis, Japanese Encephalitis

Oral health services Oral Health

Prevention of deafness Hearing Problems

Substance abuse, including

tobacco and alcohol control

Cancers, Chronic Respiratory Disease, Traffic Accidents

Mental health services Mental Health Problems

Accident prevention &

rehabilitation

Post Trauma Disabilities

Occupational health Chronic Respiratory Disease, Accident, Cancers, Eye and Skin Diseases, Hearing Loss

Emergency preparedness Natural and Human-made disasters

Source: DoHS (2010), *Main Interventions are listed in priority order

27


These programs are implemented in Kathmandu through the District Public Health

Office, Kathmandu. Though these programs are not planned targeting to climate

change, they will directly or indirectly help to reduce the vulnerability due to climate

change on public health and health care system.

These programs have focused on prevention, promotion and treatment aspects of

health. The likely reproductive health issues might be attributed by climate change

(highlighted but not sufficient evidences) such as prolapsed uterine and other STDs

which can be timely diagnosed and treated under reproductive health program.

The effective implementation of EPI and Hepatitis B vaccine can prevent vaccine

preventable diseases which are likely to be increased due to climate change. In order to

prevent the vector borne diseases, Kathmandu District Public Health Office has

conducted vector control programs using insecticide residual spraying (IRS),

administering JE vaccine and Mass Drug Administration (MDA) to all inhabitants of

Kathmandu for preventing people from JE. However, the DPHO still does not have

programs for controlling Dengue in Kathmandu, the vector and cases of which have

already been reported from Kathmandu valley.

The Integrated Management of Childhood Illness (IMCI) will help to reduce morbidity

and mortality from diarrhoea and malnutrition. This effective program in Kathmandu

might help to reduce vulnerability due to climate change amongst the most vulnerable

groups of children.

Environmental sanitation programs are also implemented which help to reduce the

morbidity and mortality of diarrheal diseases, acute respiratory infections, vector borne

diseases and malnutrition. These health problems are expected to increase due to

change in temperature and rainfall patterns. Hence, ensuring effective implementation

of environmental sanitation programs will reduce the environmental burden of these

diseases as well as likely impacts of climate change.

Mental health programs help to reduce the psycho-social problems and mental stress

which is also expected to be increased due to climate change as it affects the livelihood

of people, with extreme climatic events such as droughts and floods.

School health program raises the awareness among the students about diarrhoeal

disease, vector borne diseases and these in turn might help to reduce the burden of

diseases due to climate change

In summary, the effective implementation of essential health package will address the

health problems which are likely to be affected by climate change directly or indirectly.

The Interim Constitution of Nepal-2007 has adopted a free health care policy by which

every citizen shall have the right to basic health services free of costs with special

attention given to poor, vulnerable and marginalized people as a safety net.

28


National Health Sector Plan II (2010-2015) gives more emphasis on integrated

approach of health service and also to environmental issues and climate change and its

health impacts. This is the first plan of health sector which addresses the issue of

climate change to control infectious diseases in Nepal. In this plan, likely impacts of

climate change on communicable diseases control and impact on other diseases have

been prioritized and strategy has been developed such as empowering the capacity to

respond the health impacts of climate change, raising public awareness and

coordinating with other line agencies for mitigating the health impacts of climate change.

The Three Year Approach Paper (2010/11-2013/14) aims to make the development

plans of Nepal climate resilient. The National Planning Commission has attempted to

make the development plans of Nepal climate change resilient involving climate change

experts and making it compatible with Pilot program on Climate change resilient (PPCR)

which is funded by World Bank and implemented by the Ministry of Environment.

However, this is still under process.

The Millennium Development Goals (MDGs) related to health sector that Nepal has to

meet by 2015 are: Goal 4: reduce child mortality, Goal 5: improve maternal health, and

Goal 6: combat HIV/AIDS, malaria and other diseases.

Local Self Governance Act of 1999

Section 96 of the Local Self Governance Act (LSGA) of 1999 stipulates the functions,

duties, and responsibilities of municipalities which also includes Kathmandu

Metropolitan City: “Section 96, Functions, Duties and Power of Municipality: In addition

to executing or causing to be executed, the decisions and directions of the Municipal

Council, the functions and duties to be performed by the Municipality mandatory in the

municipality area shall be as follows:

1. Physical Development:

a. Frame land-use map of the Municipality area and specify and implement

or cause to be implemented, the industrial, residential, agricultural,

recreational areas, etc.

b. Prepare housing plan in the area of Municipality and implement or cause

to be implemented the same.

c. Develop, or cause to be developed, green zones, parks and recreational

areas in various places in the Municipality area.

2. Water resources, Environment, and Sanitation:

a. Conserve rivers, streams, ponds, deep water, wells, lakes, stone water-

taps etc. and utilize or cause to be utilized them properly.

b. Assist or cause to be assisted, in environment protection acts by

controlling water, air and noise pollution to be generated in the

Municipality area.

29


c. Protect or cause to be protected the forests, vegetation and other natural

resources within the Municipality area.

d. Carry out and manage or cause to be carried out and managed the acts of

collection, transportation and disposal of garbage and solid wastes.

3. Health Services:

a. Open, operate and manage or cause to be operated and managed health

posts and sub-health posts within the Municipality area.

4. Industry and Tourism

a. Act or cause to act as a motivation to the promotion of cottage, small and

medium industries in the Municipality area.

b. Protect, promote, expand and utilize or cause to be protected, promoted,

expanded and utilized, natural, cultural, and tourist’s heritage within the

Municipality area.

5. Miscellaneous:

a. Determine and manage places for keeping pinfolds and animal slaughter

house.

b. Protect barren and government-owned unregistered (Ailani) land in the

Municipality

c. Frame by-laws of the Municipality and submit it to the Municipal council.

d. Carry out necessary functions in managing and responding to natural

disasters.

e. Maintain inventory of population, houses, and land within the Municipality

area.

f. Update the block numbers of the houses in the Municipality area.

g. Carry out or cause to be carried out other acts relating to the development

of the Municipality area.

6. However, these mandates provided by the Act are not fully implemented in

absence of elected Mayor and other members in the Metropolitan City.

Disease Pattern

The trends of disease pattern among different age groups 1995 and 2010 were

discussed and the perceptions of experts are listed in Table 2. A disease pattern 15

years ago in 1995 and now in 2010 is shown in Table 2.

30


Table 2. Disease pattern among different age groups as perceived by convened experts

Diseases 1995 2010

Male Female ≤ 5 y/o Male Female ≤ 5 y/o

o Diarrhoea - - √ √ √ √

o Typhoid - - - √ √ √

o Hepatitis √ √ √

o Cholera √ √ √

o Pneumonia √ √

o Hypertension √ √

o Diabetes √ √

o Anaemia √

o Cataract √ √

o Allergic Rhinitis √ √

o Asthma √ √ √

o Bronchitis √ √ √ √

o Malnutrition - √

o Skin Disease - - √ √

o Cancer √ √

o Psychological Disease √ √

Note: dash (-) indicate diseases were seen, but not many

31


3.1.3 Project the health impacts of climate change

Many tertiary care hospitals including private hospitals exist in Kathmandu but only the

public health institutions report to the National Health Information Management System

(HIMS). Hence, only the trends of diarrhoea and ARI were carried out using 10-year

HIMS data from public hospitals. The study revealed that the trend of childhood

diarrhoeal diseases (Yt = 11301+771.1t) is increasing. The increase in childhood

diarrhoeal diseases is 771 cases per year. Similarly, ARI trend is also increasing (Yt

=5456.5+2712.9t). The increase in ARI is 2,713 cases per year. The projected trend of

diarrhoeal diseases and ARI is given in Annex VI.

The study revealed that the trend of minimum temperature (Ft=10.71+0.004t) and

maximum temperature (Ft=23.56+0.0068t) are increasing (Annex VII). However, the

increasing trend in both the minimum and maximum temperature is different. The

increase in maximum temperature is 0.0070C/ month and in minimum temperature is

0.0040C/ month after taking consideration of seasonality factor (Annex VII).

Similarly, the trend of precipitation level is decreasing (Ft=188.26-0.0288t). The

decrease in precipitation level is 0.03 mm per month after seasonal adjustment. The

study revealed the projected minimum temperature (> 220C) during monsoon period,

which may lead to increase burden of diarrhea and vector borne diseases (Annex VII).

3.1.4 Identification and prioritization of adaptation options to address

current and projected health risks

Multi-criteria analysis (MCA) technique was used to prioritize and select adaptation

measures. While using MCA the following measures were taken:

Adaptation options were scored against selected criteria;

Quantitative scored against selected criteria; and

Discussion and consensus was done through a multidisciplinary team.

There were altogether 10 criteria considered and each criterion was defined within

NAPA context as follows:

Strategic value – (poverty reduction, national plan, policy, local development

program)

Ease - (prevailing know how and skill, ease for funding)

People’s participation - (generate people’s participation, cash/kind, meet

immediate need of people)

Cost-Benefit - (deliverables likely to have cross-sectoral benefits)

32


Cost-Effectiveness - (minimum cost, investment, operation and maintenance /

life cycle cost, the quality of providing, 1.value for money 2. Maximum output for

minimal input)

Sustainability - (impact on the existing resources base, sustainability /

continuity with little or no compromise in the capital-investment, economic

source, quality, ability of maintaining functions of services undermined on a

continuous basis)

Acceptability - (compatibility with technical expectations of end users and

acceptance by local community to adapt)

Technical Feasibility - (can be successfully implemented)

Coverage – (access to water and sanitation sources)

Relevancy – (appropriateness)

As shown in Table 3, each criterion is given equal marks/points and the grading of the

marks will be in 1 to 5 scale which is very poor to very high. The total marks obtained

by each project are listed. To make it comparable, total marks obtained is multiplied by

100 as shown in the equation given below. In this case the higher the score, the higher

the project's priority.

Table 3 Project Prioritization

Pro

ject

Str

ate

gic

va

lue

Ea

se

Pe

op

le's

pa

rtic

ipa

tion

Reso

urc

e

Cost-

effe

ctive

Su

sta

ina

bili

ty

Mu

ltip

le

Be

nefit

Acce

pta

bili

ty

Fea

sib

ility

Cove

rag

e

A

B

C

D

E

NB: Score for each criterion is 1 to 5 (1= Very Poor, 2=poor, 3=Medium, 4= High, 5= Very High). The

higher the score higher the project's priority

The scores obtained from experts are given in Annex VII. The recommended adaptation

projects in terms of priority are as follows:

Managing safe drinking water with adequate quantity to the inhabitants of

Kathmandu;

Maintaining environmental sanitation including proper solid waste management

in Kathmandu for reducing nuisance and destroying the breeding places of

diseases vectors;

33


Organizing public awareness and advocacy program on climate change and

urban health;

Management of air pollution for reducing respiratory disease in Kathmandu

valley; and

Implementing Integrated Diseases Surveillance including vector borne diseases

in Kathmandu valley.

3.1.5 Determination of potential health risks of adaptation and mitigation

measures implemented in other sectors, such as water resources, land

use, and transport, and identification of possible interventions to reduce

any identified risks

In order to determine the potential health risks and benefits of adaptation and mitigation

measures implemented in other sectors, sectoral policies were reviewed and their

implication on public health is identified. The following table gives an overview of it.

Table 4 Policy and Plan of sectors other than the health sector

S N Policies Health aspects Climate change aspects

1. National Shelter Policy 1996.

Unmanaged shelter construction can create conducive environment for climate sensitive diseases.

Construction of apartment for filling the increasing shelter demand in urban areas without conducting environmental impact assessment may cause environmental degradation.

2. Urban sanitation and drinking water policy 2066 (2009).

Long time extraction of groundwater may degrade groundwater reservoirs, causing the various health hazards like arsenicosis, gastro-intestinal and skin diseases.

Regular extraction of groundwater to fill demand of drinking water may create the problem of land subsidence and change in local climate.

3. National Urban policy 2064 (2007).

The promotion of industrial infrastructure can produce high concentration of solid waste and gases in urban areas. There has not been any specific provision to control and manage urban waste, which has become a serious cumulative health hazard in cities of Nepal like Kathmandu, Biratnager and Nepalganj.

There is lack of mitigation awareness and practice to reduce greenhouse gas emission by industries in urban areas.

34


The identified adaptation projects on other thematic areas in NAPA other than public

health are equally important to public health because health is a cross-cutting issue and

has co-benefits to other sectoral programs like water and sanitation, nutrition, disaster

response, protection of aromatic plants, urban environment improvement and other

areas of work. For example, rainwater harvesting identified by the water and energy

group of NAPA as a community–based adaptation option increases domestic water

supply and improve sanitation; early warning system identified by the climate-induced

disaster group reduces human injury and deaths; agricultural diversification increases

food availability as well as livelihood options and all of these adaptation projects

contribute to ensuring nutrition and well-being.

3.1.6 Implement, monitor, and evaluate the burden of climate-sensitive

health outcomes and interventions to address these burdens to ensure

continued effectiveness in a changing climate

The burden of climate-sensitive health outcomes differ with specific diseases. The

burden of Japanese Encephalitis and Dengue in Kathmandu valley are considerably low

whereas the burden of diarrhoeal diseases such as Cholera and Typhoid Fever are

considerably high.

This is one of the most challenging tasks to implement, monitor and evaluate

intervention to address these burdens for urban settlements (such as Kathmandu) of a

developing country like Nepal. Firstly, question arises on ownership of proposed

programs because of frequent transfer of officials in ministry and department due to

political instability in the country. Secondly, continuous support or allocation of budget is

less likely in the near future by national government or external development partners

on programs to respond to health risks due to climate change. Thirdly, lack of

institutional and human resource that specifically address the issue of climate change

still persist. There are no separate sections or units to deal with climate change in line

ministries and their departments and staff have already been overburdened with their

existing responsibilities. However, the new program can be integrated with ongoing

program such as Control of Diarrhoeal Diseases (CDD). For this, sensitization and

orientation of staff including capacity building is most needed.

In order to monitor the progress of interventions, we need to have long term

supervision, monitoring and evaluation with standard indicators setup for baseline

scenario. In order to ensure the continuity of the program and maintain the

effectiveness, political commitment is needed so that it can be mainstreamed in national

policies and programs. Lastly, implementation of the intervention will be in the public

health system and the people in the urban areas most of the times prefer to visit private

health institutions where monitoring and evaluation is not easy until now. So, a strategy

of Public Private Partnership would be an important approach to ensure continued

effectiveness of the intervention to address climate-sensitive health outcomes.

35


The UN-HABITAT Nepal has committed some fund for implementation of adaptation

strategies for one of the municipalities in Kathmandu Valley as an outcome of

recommendations given by this research project; and a new research on Vulnerability

and Assessment of Climate change in relation to water and sanitation will be conducted

in the same municipality.

36


4. Discussion

4.1 Suitability of the Guidelines developed by WHO in Nepalese Context

The Guidance document for Conducting Assessments of Health Vulnerability and Public

Health and Health Care Interventions to Address Climate Change drafted by WHO was

reviewed by experts and the same document was discussed in series of stakeholder

meetings. The WHO draft guidance used is given in Annex IX.

The observation and judgment in steps of vulnerability assessment in the context of

urban setting (in Kathmandu, Nepal) are as follows:

4.1.1 Identify stakeholders to be included in the assessment

Identifying stakeholders is a very important step for qualitative assessment of

vulnerability due to climate change. Stakeholders contribute significantly to understand

current vulnerability and to identify necessary adaptation measures to improve public

health and health care interventions. At the same time, their involvement in the

assessment process will educate them about the risks of climate change and motivate

them to continue the adaptation process after the assessment.

However, identifying stakeholders for inclusion in the assessment process and ensuring

effective stakeholder engagement, specifying their roles and responsibilities; and

ensuring their continued involvement is a challenging task in an urban setting of Nepal.

This is partially due to frequent transfer of experts within government organizations,

overburden of work and the reality that there are no designated personnel in line

ministries and departments to look after climate change issues. Most important thing to

note is that, sensitization and understanding of climate change and vulnerability is

needed among the stakeholders. For this, orientation to stakeholders at first is needed.

So, after identification of the stakeholders, a special session or a meeting must be

conducted to orient them on climate change and its effects on human health. The first

point of the WHO guidance must also include the term “orientation of stakeholders”

apart from “identifying stakeholders”.

37


4.1.2 Describe vulnerability to current climate variability and change

The diseases surveillance system is poor in Kathmandu and other sectors' indicators

are also not properly reported. In the absence of quantitative data, qualitative

techniques can be used to describe the burden of climate sensitive diseases. Many

climate sensitive diseases such as malaria, diarrhea and malnutrition are reported since

decades and intervention programs are in place. Because of health care interventions,

the burden has been reduced and at the same time, the burden would have increased

due to the effects of climate change. Even with the use of quantitative techniques, the

effectiveness of health care interventions and attribution of climate change for diseases

are difficult to assess.

Though general vulnerable group populations are identified in this document,

vulnerability differs in the urban context of Nepal because of high socio-economic and

ethnic diversity.

A wide range of programs and activities exist to control the health burdens. It is

important to understand the strengths and weaknesses of these programs, as well as

their flexibility for addressing the additional health risks of climate change. However,

there are many ministry/department, NGOs, and others who have responsibility,

individually or jointly for these programs. In the absence of coordination, it is very

difficult to judge the effectiveness of interventions. For example, ministries/departments

of health typically have responsibility for vector borne disease surveillance and control

programs. Other programs, such as disaster risk response activities, may be joint

activities across ministries/departments (including health, emergency management, and

others) and NGOs, such as the International Federation of Red Cross. The focal

persons for climate change and other cross cutting issues are not designated in most of

the institutions. It is quite difficult to invite and involve representatives from all relevant

organizations and institutions to understand what is working well, what could be

improved, and the capacity of the program to address possible increases in incidence or

changes in geographic range of the health outcome of the concern. This problem can

be resolved by allocating enough time for consultation and meetings.

Nepal Government has periodic short plans such as interim plans as well as long term

sectoral plans such as Second Long Term Health Plan (1997-2017) which helps to

analyze the planned future program and activities. Besides these, the Nepal

Government has already prepared the National Adaptation Program of Action (NAPA)

and is in the process of developing Local Adaptation Program of Action (LAPA),

Strategic Program on Climate Change Resilience (SPCR) which gives guidance of

future direction of adaptation works in Nepal. In Kathmandu, which is the capital of

Nepal, no budget is allocated for climate change related activities in its regular budget

except very few about US$ 2,000 for raising awareness on climate change in

Kathmandu Metropolitan City. Based on the present burden of climate sensitive

diseases and the adaptation programs, vulnerability of health care interventions can be

assessed qualitatively.

38


4.1.3 Project the health impacts of climate change

This step includes (1) describing how the current burden of climate-sensitive health

outcomes is likely to change over the coming decades irrespective of climate change;

and (2) estimating the possible additional burden of adverse health outcomes due to

climate change; which can be done qualitatively or quantitatively. In the context of

Kathmandu only qualitative projection is possible. The Initial National Communication

report prepared for UNFCCC in 2004 had also adopted qualitative techniques for

vulnerability assessment. The Second National Communication report to UNFCC is in

process of preparation while the NAPA vulnerability assessment team has projected the

climate change scenario for Nepal, no data specific to Kathmandu valley are available.

It is quite difficult to differentiate the health impacts in the absence and presence of

climate change. However, climatic data namely rainfall and temperature as well as

climate sensitive diseases (e.g., diarrhea) were projected until 2030 (Annex VII - Table

11, Table 12 and Table 13.).

4.1.4 Identify and prioritize adaptation options to address current and

projected health risks

This step is very pertinent and based on expert judgment, findings from retrospective

studies and expert consultation, adaptation options can be identified and prioritized. For

this, multi criterion analysis as used in NAPA preparation can be pursued. It is difficult to

have a summary of the costs and benefits of each option in the absence of quantitative

data.

4.1.5 Determine the potential health risks of adaptation and mitigation

measures implemented in other sectors, such as water resources, land

use, and transport, and identify possible interventions to reduce any

identified risks

Climate change mitigation and adaptation decisions taken in other sectors can have

important implications for public health which can be accessed through stakeholders'

consultation and expert judgment. Conducting health impact assessments in

collaboration with stakeholders from other sectors can identify adaptation and mitigation

options. The Government of Nepal has constituted the Climate Change Council under

the chairmanship of Prime Minister on 23 July 2009. The Council, a high-level

coordinating body, will:

Provide coordination, guidance and direction for the formulation and

implementation of climate change-related policies;

Provide guidance for the integration of climate change-related aspects in the

long-term policies, perspective plans and programs;

Take necessary measures to make climate change a national development

agenda;

39


Initiate and coordinate activities related to additional financial and technical

support to climate change-related programs and projects; and

Also initiate and coordinate for additional benefit from climate change-related

international negotiations and decisions.

However, there is no climate change coordination in Kathmandu district level.

4.1.6 Implement, monitor, and evaluate the burden of climate-sensitive

health outcomes and interventions to address these burdens, to ensure

continued effectiveness in a changing climate

This is pertinent step for the rescue of vulnerable population. However, it is a

challenging task as we enter in the implementation phase. Continuous financial

commitment is required to evaluate the impact of interventions programs after

implementation. It is quite difficult to identify good indicators to allow the follow-up and

to observe the effects of the interventions chosen.

40


5. Conclusions and Recommendations

The cause-and-effect chain from climate change to changing disease patterns can be

extremely complex and includes many non-climatic factors, such as wealth, distribution

of income, provision of medical care, and access to adequate nutrition, clean water and

sanitation. Therefore, the severity of impacts actually experienced will be determined

not only by changes in climate but also by concurrent changes in non-climatic factors

and by the adaptation measures implemented to reduce negative impacts.

A number of possible climate change-related impacts on human health are directly or

indirectly induced by climate change in Kathmandu, Nepal. In the absence of

quantitative estimation, it is difficult to assess disease burden of climate sensitive health

outcomes due to climate change and attribution of climate change on health of people

of Kathmandu are difficult. However, vulnerability of population can be determined using

both quantitative and qualitative techniques. The vulnerability assessment tool drafted

by WHO as a guidance (Annex IX) was used for testing the suitability of guidance for

evaluating the vulnerability of public health and health care to climate change, to

establish the basis for assessing the vulnerability of public health and health care to

projected climate change and finally to identify the actions to protect the health of

vulnerable population in Kathmandu, Nepal in the face of projected climate change.

Populations, subgroups and systems that cannot or will not adapt are more vulnerable,

as are those that are more susceptible to weather and climate changes. Understanding

a population’s capacity to adapt to new climate conditions is crucial to realistically

assessing the potential health effects of climate change. In general, the vulnerability of a

population to a health risk depends on factors such as population density, level of

economic development, food availability, income level and distribution, local

environmental conditions, health status, and the quality and availability of health care.

These factors are not uniformly distributed across settings or communities or across

time, and differ based on locality, demography and socio-economic factors. Hence, it is

quite difficult to assess the vulnerability of particular location from public health point of

view without considering other sectors.

41


The inavailability of valid data of long duration, poor disease surveillance systems and

lack of awareness about health impacts of climate change among stakeholders made

the vulnerability assessment of public health further difficult. As urban settlement of

developing countries like Kathmandu is already suffering from triple burden of disease

(i.e., infectious diseases, non-communicable diseases and injuries/road traffic

accidents), the local government often ignores the attribution of climate change on

these diseases despite its projected impact on health of the people.

Climate change rarely acts in isolation and health impacts of climate change cannot be

seen in isolation. Changes in the incidence and/or geographic range of infectious

diseases, malnutrition and psycho-social problems arise from the interaction of changes

in temperature, precipitation and other climatic variables with underlying vulnerabilities.

These vulnerabilities include the effectiveness of disease surveillance and control

programs, coordination with allied sectors, access to healthcare, educational status in

the communities, economic status, equity and social cohesion. Poorest of the poor are

always worst hit by climate change. Climate change acts to multiply these and other

stressors that affect population health.

The primary health concerns associated with climate change are that the health impacts

already exist and it’s difficult to convince policymakers about these. Therefore,

vulnerability and adaptation should identity the evidence base and modify current and

planned programs to reduce the burden of climate sensitive health outcomes to ensure

that current and future vulnerabilities due to actual and projected climate change are

effectively addressed.

In order to make the vulnerability assessment task realistic and precise in the context of

urban settings of developing countries, what would be required would be: a mapping of

stakeholders - their sensitization/orientation on vulnerability and adaptation assessment,

their participation throughout the assessment process which needs to be ensured;

review of existing programs and policies which is critical - their effectiveness and the

documentation of lessons learnt are very crucial; and ample negotiations and effective

communication with stakeholders which is a must. Capacity building of human

resources for carrying out the vulnerability assessment using available data is also

equally important. Very few people are technically competent to conduct such an

important task in Kathmandu, Nepal.

42


The specific conclusions and recommendations for use of draft guidelines in urban

settings are summarized as follows:

1. The guidance document is generic in content and guidance; and needs to be

specific with some examples. While reviewing literature, the document “ECDC

Technical Document Climate change and communicable diseases in the EU

Member States”, Handbook for national vulnerability, impact and adaptation

assessments was found to be more specific. Hence, it is suggested to make such

type of specificity but in the context of urban settings of developing countries;

2. There is a need to develop methodological steps in further detail. For example, if

a step is to project the future health impacts, then, it is better to clearly mention

methods and software to use for projection of climate change as well as

concerned climate-sensitive health outcomes (e.g., diseases);

3. It is easier if research tools are included such as a checklist or interview

guidelines which will be used for collecting data for assessment;

4. A few alternatives need to be developed in context of data inavailability;

5. The document should have sufficient examples from developing countries so that

it is easy to be replicated in other similar settings;

6. If there are standard tools and methods, then it’s easy to compare the findings of

vulnerability assessment of different settings or countries; and

7. There is a need to have capacity building programs such as training before the

inception of vulnerability assessment work.

The adaptation options to reduce the vulnerability of people in Kathmandu, Nepal

recommended by key stakeholders and concluded by key informant interviews are as

follows:

1. Managing safe drinking water with adequate quantity to the inhabitants of

Kathmandu;

2. Maintaining environmental sanitation including proper solid waste management

in Kathmandu for reducing nuisance and destroying the breeding places of

diseases vectors;

43


3. Organizing public awareness and advocacy program on climate change and

urban health;

4. Management of air pollution of Kathmandu valley for reducing respiratory disease

in Kathmandu Valley; and

5. Implementing integrated disease surveillance including vector-borne diseases in

Kathmandu valley.

44


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7. Annexes

Annex I

Table 5 List of Project Team Members

S.N Name Organization

1. Dr. Mahesh Kumar Maskey Chair, Nepal Public Health Foundation

2. Dr. Gajananda Prakash Bhandari

Member, Nepal Public Health Foundation

3. Mr. Meghnath Dhimal Research Officer, Nepal Health Research Council

4. Mr. Saraju Kumar Baidya Expert, Department of Hydrology & Meteorology

5. Ms. Astha Joshi Research Assistant, Nepal Public Health Foundation

Annex II

Table 6 List of Stakeholders (Key Organizations: Climate Change & Health Nepal)

S.N Government Organization NGOs Multilateral

1. Department of Hydrology & Meteorology/MEST

ENSECT WHO

2. Ministry of Health and Population REDCROSS UNEP

3. Department of Water Induced Disaster Prevention

Care Nepal UNFPA

4. National Trust for Nature Conversation

Plan International

ICIMOD

5. Department of Soil Conservation WWF

6. Biogass Sector Partnership Nepal (BSP)

IUCN

7. Local Government Bodies: (District & Municipality)

AAEPC

8. Department of Urban Development Winrock

International

9. Tribhuwan University World Bank

10. TU Teaching Hospital ADB

11. Nepal Health Research Council

48


Annex III

Table 7 List of Stakeholders identified by the project team

S.N Name Organization

1. Mr. Saraju Kumar Baidya Department of Hydrology &

Meteorology/MEST

2. Mr. Meghnath Dhimal Member, NAPA Public Health Thematic

Group

3. Dr. Baburam Marasini Ministry of Health and Population

4. Dr. G.D. Thakur Epidemiology & Disease Control Division,

DoHS

5. Mrs. Sharda Pandey Ministry of Health and Population

6. Mr. Rabin Man Shrestha Chief, Environment Management Division,

Kathmandu Metropolitan City

7. Ms. Sarita Shrestha Maskey Senior Divisional Engineer, Department of

Urban Development

8. Mr. Jagannath Aryal Department of Environment, Tribhuwan

University

9. Dr. Bandana Pradhan TU Teaching Hospital

10. Dr. Nirmal Kandel WHO, Nepal

11. Mr. Namraj Khatri WHO, Nepal

12. Dr. Roshan Shrestha UNHABITAT Nepal

13. Mr. Apar Paudel Plan International

14. Dr. Basu Dev Pandey Tropical Hospital, Kathmandu

15. Mr. Nagmindra Dahal Ministry of Environment

16. Dr. Suresh Mehata Biostatistics, Nepal Public Health

Foundation

17. Dr. Mahesh K Maskey Chair, Nepal Public Health Foundation

18. Mr. Nawa Raj Sapkota Nepal Pollution Control and Environment

Management Center (NEPCEMAC)

19. Dr. Bijaya Thapa (invitee) School of Public Health, B.P.Koirala

Institute of Health Sciences

20. Dr. Bijaya Khanal (invitee) School of Public Health, B.P.Koirala

Institute of Health Sciences

21. Dr. Gajananda P Bhandari Nepal Public Health Foundation

49


Annex IV

Key Informant Interview Guidelines

1. Perception towards climate change (Rainfall pattern, pattern of temperature change)

2. Trend of extreme climatic events (heat stress, severe cold, flooding, landslide in

periphery of Kathmandu, drought, high winds)

3. Prevalence of disease and illness (Vector borne, water borne, worm infestation,

malnutrition).

4. Outbreak/ Epidemic of disease

5. Quality and Quantity of supply drinking water (possible cause).

6. Sanitation and hygiene in relation to skin diseases and water related diseases

(possible causes and effects).

7. Pollution level in Kathmandu and respiratory disorders.

8. Existing policies and strategies to deal with above mentioned problems.

9. Awareness level of community.

10. Availability of health services and coverage.

11. Effectiveness of existing programs and policies.

12. Disaster and emergency preparedness plan and strategies.

13. IEC/BCC programs.

14. Need of new program and policies.

50


Annex V

Table 8 Name list of Key Informant Experts

S.N Name Designation/Organization

1 Mr. Rabin Shrestha Engineer, Kathmandu Metropolitan City

2 Dr. Baburam Marasini Chief, Health Sector Reform Unit, MoHP

3 Mr. Saraju Vaidya Meteorologist, Department of Hydrology and Meteorology

4 Mr. Sarita Shrestha Maskey

Head, Dept. of Urban Development and Building Construction

5 Dr. Suresh Mehta Epidemiogy & Biostatistics, Nepal Public Health Foundation

6 Mr. Ngamindra Dahal Expert, Climate Change, Ministry of Environment

7 Mr. Namraj Khatri Environment Unit, World Health Organization

8 Dr. Bandana Pradhan Associate Professor, Institute of Medicine

9 Prof. Dr. Sarad Onta Head, Dept. of Community Health, Institute of Medicine

10 Mr. Apar Paudel Environment unit, Practical Action Nepal

Annex VI

Figure 4 Trend analysis for childhood diarrhoeal diseases (1997/8-2007/08)

Table 9 Projected data of diseases from 2011-2030

Year Diarrhoea ARI

2011 21325 33119

2012 22096 35247

2013 22868 37375

2014 23639 39503

2015 24410 41631

2016 25181 43759

2017 25952 45887

2018 26723 48015

Yt = 11301 +771.1t

0

5000

10000

15000

20000

25000

0 2 4 6 8 10 12

51


2019 27494 50142

2020 28265 52270

2021 29036 54398

2022 29807 56526

2023 30579 58654

2024 31350 60782

2025 32121 62910

2026 32892 65038

2027 33663 67166

2028 34434 69294

2029 35205 71421

2030 35976 73549

Annex VII

Table 10 Seasonal factor of indicators according to months

Month Min. temperature Max. temperature Precipitation

Jan 0.20 0.73 0.11

Feb 0.37 0.83 0.16

Mar 0.66 0.99 0.23

Apr 0.98 1.11 0.47

May 1.31 1.12 0.96

Jun 1.58 1.14 1.87

Jul 1.67 1.11 3.18

Aug 1.65 1.13 2.85

Sep 1.52 1.10 1.88

Oct 1.12 1.04 0.27

Nov 0.65 0.92 0.01

Dec 0.29 0.79 0.02

Figure 5 Time series decomposition plot for minimum temperature

Ft = 10.71 + 0.00402t

0.00

5.00

10.00

15.00

20.00

25.00

Jan-7

1

Jan-7

3

Jan-7

5

Jan-7

7

Jan-7

9

Jan-8

1

Jan-8

3

Jan-8

5

Jan-8

7

Jan-8

9

Jan-9

1

Jan-9

3

Jan-9

5

Jan-9

7

Jan-9

9

Jan-0

1

Jan-0

3

Jan-0

5

Jan-0

7

Jan-0

9

52


Table 11 Projected minimum temperature

Year Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2011 2.53 4.68 8.35 12.40 16.58 20.01 21.15 20.91 19.27 14.20 8.24 3.68

2012 2.54 4.70 8.38 12.45 16.65 20.08 21.23 20.99 19.34 14.25 8.28 3.69

2013 2.55 4.71 8.41 12.50 16.71 20.16 21.31 21.07 19.41 14.31 8.31 3.71

2014 2.56 4.73 8.44 12.54 16.77 20.24 21.40 21.15 19.49 14.36 8.34 3.72

2015 2.57 4.75 8.48 12.59 16.84 20.31 21.48 21.23 19.56 14.42 8.37 3.74

2016 2.58 4.77 8.51 12.64 16.90 20.39 21.56 21.30 19.63 14.47 8.40 3.75

2017 2.59 4.79 8.54 12.69 16.96 20.46 21.64 21.38 19.71 14.52 8.43 3.76

2018 2.60 4.80 8.57 12.73 17.03 20.54 21.72 21.46 19.78 14.58 8.46 3.78

2019 2.61 4.82 8.60 12.78 17.09 20.62 21.80 21.54 19.85 14.63 8.49 3.79

2020 2.62 4.84 8.64 12.83 17.15 20.69 21.88 21.62 19.93 14.69 8.53 3.81

2021 2.63 4.86 8.67 12.87 17.21 20.77 21.96 21.70 20.00 14.74 8.56 3.82

2022 2.63 4.88 8.70 12.92 17.28 20.85 22.04 21.78 20.07 14.79 8.59 3.83

2023 2.64 4.89 8.73 12.97 17.34 20.92 22.12 21.86 20.15 14.85 8.62 3.85

2024 2.65 4.91 8.76 13.02 17.40 21.00 22.20 21.94 20.22 14.90 8.65 3.86

2025 2.66 4.93 8.80 13.06 17.47 21.07 22.28 22.02 20.29 14.96 8.68 3.88

2026 2.67 4.95 8.83 13.11 17.53 21.15 22.36 22.10 20.37 15.01 8.71 3.89

2027 2.68 4.96 8.86 13.16 17.59 21.23 22.44 22.18 20.44 15.06 8.75 3.90

2028 2.69 4.98 8.89 13.21 17.66 21.30 22.52 22.26 20.51 15.12 8.78 3.92

2029 2.70 5.00 8.92 13.25 17.72 21.38 22.60 22.34 20.59 15.17 8.81 3.93

2030 2.71 5.02 8.95 13.30 17.78 21.46 22.68 22.42 20.66 15.23 8.84 3.94

Figure 6 Time series decomposition plot for maximum temperature

Ft = 23.56 + 0.0068t

0

5

10

15

20

25

30

35

Jan-7

1

Jan-7

3

Jan-7

5

Jan-7

7

Jan-7

9

Jan-8

1

Jan-8

3

Jan-8

5

Jan-8

7

Jan-8

9

Jan-9

1

Jan-9

3

Jan-9

5

Jan-9

7

Jan-9

9

Jan-0

1

Jan-0

3

Jan-0

5

Jan-0

7

Jan-0

9

53


Table 12 Projected maximum temperature


2011 19.59 22.28 26.58 29.81 30.08 30.63 29.83 30.37 29.57 27.97 24.75 21.26

2012 19.65 22.34 26.66 29.90 30.17 30.72 29.92 30.47 29.66 28.05 24.82 21.32

2013 19.71 22.41 26.74 29.99 30.26 30.81 30.01 30.56 29.75 28.14 24.90 21.39

2014 19.77 22.48 26.82 30.08 30.36 30.91 30.10 30.65 29.84 28.22 24.97 21.45

2015 19.83 22.55 26.90 30.17 30.45 31.00 30.19 30.74 29.93 28.31 25.05 21.51

2016 19.89 22.61 26.98 30.26 30.54 31.09 30.28 30.83 30.02 28.39 25.12 21.58

2017 19.94 22.68 27.06 30.35 30.63 31.19 30.37 30.93 30.11 28.48 25.20 21.64

2018 20.00 22.75 27.14 30.44 30.72 31.28 30.46 31.02 30.20 28.56 25.27 21.71

2019 20.06 22.82 27.22 30.53 30.81 31.37 30.55 31.11 30.29 28.65 25.35 21.77

2020 20.12 22.89 27.30 30.62 30.90 31.46 30.64 31.20 30.38 28.73 25.42 21.84

2021 20.18 22.95 27.38 30.71 31.00 31.56 30.73 31.30 30.47 28.82 25.50 21.90

2022 20.24 23.02 27.47 30.80 31.09 31.65 30.82 31.39 30.56 28.90 25.57 21.97

2023 20.30 23.09 27.55 30.89 31.18 31.74 30.92 31.48 30.65 28.99 25.65 22.03

2024 20.36 23.16 27.63 30.98 31.27 31.84 31.01 31.57 30.74 29.07 25.72 22.09

2025 20.42 23.22 27.71 31.07 31.36 31.93 31.10 31.66 30.83 29.16 25.80 22.16

2026 20.48 23.29 27.79 31.16 31.45 32.02 31.19 31.76 30.92 29.24 25.87 22.22

2027 20.54 23.36 27.87 31.26 31.54 32.12 31.28 31.85 31.01 29.33 25.95 22.29

2028 20.60 23.43 27.95 31.35 31.64 32.21 31.37 31.94 31.10 29.41 26.02 22.35

2029 20.66 23.50 28.03 31.44 31.73 32.30 31.46 32.03 31.19 29.50 26.10 22.42

2030 20.72 23.56 28.11 31.53 31.82 32.39 31.55 32.13 31.28 29.58 26.17 22.48

Figure 7 Time series decomposition plot for precipitation level

Ft = 188.26-0.0488t

0.00

300.00

600.00

900.00

Jan-7

1

Jan-7

3

Jan-7

5

Jan-7

7

Jan-7

9

Jan-8

1

Jan-8

3

Jan-8

5

Jan-8

7

Jan-8

9

Jan-9

1

Jan-9

3

Jan-9

5

Jan-9

7

Jan-9

9

Jan-0

1

Jan-0

3

Jan-0

5

Jan-0

7

Jan-0

9

54


Table 13 Projected precipitation level


2011 18.13 26.36 37.88 77.38 158.01 307.70 523.09 468.67 309.07 44.37 1.64 3.29

2012 18.06 26.26 37.74 77.11 157.45 306.60 521.23 467.00 307.97 44.22 1.64 3.27

2013 18.00 26.17 37.61 76.83 156.88 305.51 519.37 465.33 306.86 44.06 1.63 3.26

2014 17.93 26.08 37.47 76.56 156.32 304.41 517.51 463.66 305.76 43.90 1.63 3.25

2015 17.87 25.98 37.34 76.28 155.76 303.32 515.64 461.99 304.66 43.74 1.62 3.24

2016 17.80 25.89 37.21 76.01 155.20 302.22 513.78 460.33 303.56 43.58 1.61 3.23

2017 17.74 25.80 37.07 75.73 154.64 301.13 511.92 458.66 302.46 43.43 1.61 3.21

2018 17.68 25.70 36.94 75.45 154.07 300.03 510.06 456.99 301.36 43.27 1.60 3.20

2019 17.61 25.61 36.80 75.18 153.51 298.94 508.19 455.32 300.26 43.11 1.60 3.19

2020 17.55 25.51 36.67 74.90 152.95 297.84 506.33 453.65 299.16 42.95 1.59 3.18

2021 17.48 25.42 36.53 74.63 152.39 296.75 504.47 451.98 298.06 42.79 1.58 3.17

2022 17.42 25.33 36.40 74.35 151.82 295.65 502.61 450.31 296.96 42.63 1.58 3.16

2023 17.35 25.23 36.26 74.08 151.26 294.55 500.75 448.64 295.85 42.48 1.57 3.14

2024 17.29 25.14 36.13 73.80 150.70 293.46 498.88 446.97 294.75 42.32 1.57 3.13

2025 17.22 25.05 35.99 73.53 150.14 292.36 497.02 445.30 293.65 42.16 1.56 3.12

2026 17.16 24.95 35.86 73.25 149.58 291.27 495.16 443.64 292.55 42.00 1.56 3.11

2027 17.10 24.86 35.72 72.98 149.01 290.17 493.30 441.97 291.45 41.84 1.55 3.10

2028 17.03 24.77 35.59 72.70 148.45 289.08 491.43 440.30 290.35 41.69 1.54 3.09

2029 16.97 24.67 35.45 72.43 147.89 287.98 489.57 438.63 289.25 41.53 1.54 3.07

2030 16.90 24.58 35.32 72.15 147.33 286.89 487.71 436.96 288.15 41.37 1.53 3.06

55


Annex VIII

Table 14 List of Priority project scoring from Experts

Pro

ject

Str

ate

gic

va

lue

Ease

Peo

ple

's

part

icip

ation

Resourc

e

Cost

effective

Susta

ina

bili

ty

Multip

le B

enefit

Accepta

bili

ty

Feasib

ility

Covera

ge

Tota

l

A: Managing safe drinking water with adequate quantity to the inhabitants of Kathmandu

4 3 4 4 4 4 5 5 3 4 40

B: Management of Air Pollution in Kathmandu valley for reducing respiratory disease in Kathmandu Valley

4 3 4 3 4 4 3 4 3 3 35

56


C: Maintaining environmental sanitation including proper solid waste management in Kathmandu for reducing nuisance and destroying the breeding places of diseases vectors

4 4 4 3 3 4 5 4 4 4 39

D: Organizing public awareness and advocacy program on climate change and urban health

4 4 4 3 3 4 4 4 4 4 38

E: Implementing Integrated Diseases Surveillance including diseases vector in Kathmandu valley

3 3 3 3 4 4 4 3 3 4 34

NB: Score for each criterion is 1 to 5(1= Very Poor, 2=poor, 3=Medium, 4= High, 5= Very High). The higher the score higher the project's priority

57


Annex IX

Steps in Conducting a Vulnerability, Impact, and Adaptation

Assessment

1. Identify stakeholders to be included in the assessment

The actual impacts experienced in a particular location over a particular time

period will depend not only on the actual climate change experienced, but also on the

vulnerability of that region and the actions taken within and outside the health sector to

address the risks and vulnerabilities. Examples include the effectiveness of vector-

borne disease surveillance and control programs, choices made by other sectors that

affect access to safe water, and that ability of infrastructure to withstand flooding events.

Therefore, it is critical that a vulnerability and adaptation assessment include a broad

range of stakeholders, including representatives of those who will implement identified

adaptation options and those who may be affected by climate change or the

intervention. Stakeholders contribute significantly to understanding current vulnerability

and to identifying necessary public health and health care interventions. At the same

time, their involvement in the assessment process will educate them about the risks of

climate change and motivate them to continue the adaptation process after the

assessment.

Ensuring effective stakeholder engagement requires identifying stakeholders for

inclusion in the assessment process; specifying their roles and responsibilities; and

ensuring their continued involvement. For national assessments, countries typically

hold at least one stakeholder meeting with representatives from all relevant ministries,

nongovernmental organizations (NGOs), universities, and others, where the

assessment goals are presented and discussed, with input sought on priority issues to

address (including geographic region or vulnerable populations). Ideally, stakeholders

should be included who represent the programs that deal with the health outcome,

organizations and institutions knowledgeable about climate change and development

plans, local, regional, and national policymakers, and the most vulnerable groups. If, for

example, waterborne diseases are a priority issue, then stakeholders could include

representatives from the department(s) in the ministry of health that deal with

waterborne diseases, the ministries of the environment (assuming they are the primary

58


ministry dealing with climate change) and finance (assuming they oversee development

infrastructure planning), water managers, university scientists involved in water-related

issues, and community leaders and others who understand patterns of water use and

misuse in their community.

Possible Stakeholders to Include in Vulnerability and Impact Assessments

Stakeholders include policy- and decision-makers, scientists, program managers (from

ministries, departments, NGOs, in health, agriculture, water resources, urban planning,

transport, development and others), and those most likely to be affected by the health

risks of climate change. Including their expertise and experience during the

assessment will help ensure that key issues are identified.

The output from an initial stakeholder meeting will include further specification of

the content and process of the vulnerability and adaptation assessment, as well as

details of how to ensure active and sustained stakeholder dialogue throughout the

assessment. Note that the stakeholders included may change during an assessment as

different expertise and experience is needed to inform the process. For example,

stakeholders with information on vulnerability may differ from those with information on

the effectiveness of different public health and health care programs to address a

particular health outcome. A plan for identifying and engaging appropriate stakeholders

throughout the process should be developed at the beginning of the Adaptation Policy

Framework assessment. Consideration also should be given to using the assessment

to develop a network of partners engaged in or concerned about the health impacts of

climate change.

When identifying possible stakeholders, consideration should be given to

stakeholders who will be involved with the effective design, implementation, and

monitoring of public health and health care interventions. These stakeholders may differ

from those involved in the vulnerability and adaptation assessment. It would be

beneficial to include them early in the assessment cycle, to ensure their perspectives

are incorporated from the beginning.

59


A substantial literature exists on stakeholder engagement, including approaches,

the role of the facilitators, and principles of effective engagement. See, for example, the

Adaptation Policy Framework (Lim et al. 2004).

2. Describe vulnerability to current climate variability and change

2.1 Describe the current burden of climate-sensitive health outcomes, including

the populations and regions that are most vulnerable

This step involves describing, either qualitatively or quantitatively, the current

distribution and burden of climate-sensitive health outcomes by vulnerable populations

and regions. The health outcomes chosen should focus on those that are priorities for

the Ministry of Health and/or for the local community. Qualitatively, the burden can be

described relative to other health burdens (i.e. there is a high burden of endemic

malaria in a particular district, or there is a medium risk of epidemic malaria in another

region). Expert judgment can be used to estimate current health burdens.

National and sub-national data, when available, can be used to quantify the

burden. National data are available from WHO at

http://apps.who.int/whosis/data/Search.jsp. Information also may be available from

climate-health risk maps and surveys conducted by NGOs and other organizations. A

challenge is that data are preferably at sub-national scales and cover several decades.

Identifying gaps can inform the data needed for monitoring and surveillance programs.

This step also should identify the factors other than climate that increase or

decrease vulnerability to weather and climate. For example, adults with chronic

respiratory disease, people with asthma, children and outdoor workers are at increased

risk during episodes of poor air quality. Populations with greater proportions of these

groups may be at increased risk. In another example, land use change may be one of

the drivers of the distribution of a particular vector, so land use change may facilitate the

geographic spread of pathogens and vectors.

Although climate change will affect all populations and regions, some are more

likely to suffer harm, have greater vulnerability and less ability to respond to climate-

related stresses. For example, all persons living in a flood plain are at risk during a

flood, but those with lowered ability to escape floodwaters and their consequences

http://apps.who.int/whosis/data/Search.jsp

60


(such as children and the infirm, and those living in substandard housing along

riverbanks) are at higher risk.

The text box describes trends in climate change-related exposures of importance

to human health. Assessments should consider these trends scaled down to the area of

interest where possible.

Projected trends in climate change-related exposures of importance to human

health (IPCC 2007).

Heatwaves, floods, droughts and other extreme events: Heatwaves are

projected to increase, cold days to decrease over mid- to low-latitudes, and the

proportion of heavy precipitation events to increase, with differences in the spatial

distribution of the changes (although there will be a few areas with projected decreases

in absolute numbers of heavy events). Water availability will be affected by changes in

runoff due to alterations in the rainy and dry season. Changing temperature and

precipitation patterns also could affect the geographic distribution and abundance of

vectors and pathogens.

Air quality: Climate change could affect tropospheric ozone by modifying

precursor emissions, chemistry and transport; each could cause positive or negative

feedbacks to climate change. Future climate change may cause significant air quality

degradation by changing the dispersion rate of pollutants, the chemical environment for

ozone and aerosol generation, and the strength of emissions from the biosphere, fires

and dust. The sign and magnitude of these effects are highly uncertain and will vary

regionally.

Crop yields: Crop productivity is projected to increase slightly at mid- to high

latitudes for local mean temperature increases of up to 1-3°C depending on the crop,

and then decrease beyond that in some regions. At lower latitudes, especially

seasonally dry and tropical regions, crop productivity is projected to decrease for even

small local temperature increases (1-2°C), which would increase risk of hunger, with

large negative effects on sub-Saharan Africa.

61


Table 1 lists some of the particularly vulnerable groups by climate-sensitive

health outcome. While there are baseline sensitivities that must be taken into account,

vulnerability among populations can differ dramatically between countries and even

communities.

Table 1: Climate-Sensitive Health Outcomes and Particularly Vulnerable Groups

Climate-Sensitive Health Outcome

Particularly Vulnerable Groups

Heat stress Elderly, chronic medical conditions, infants and children, pregnant women, urban and rural poor, outdoor workers

Air pollution Children, pre-existing heart or lung disease, diabetes, athletes, outdoor workers

Extreme weather events

Poor, pregnant women, chronic medical conditions, mobility and cognitive constraints

Water- and food-borne diseases

Immunocompromised, elderly, infants; specific risks for specific consequences (e.g., Campylobacter and Guillain-Barre syndrome, E. coli O157:H7)

Vector-borne and zoonotic diseases

Malaria Children, immunocompromised, pregnancy genetic (G6PD status), non-immune populations

Dengue Infants, elderly

Other Poor, children, outdoor workers, others

Balbus and Malina 2009

Particularly vulnerable populations and regions highlighted in the Human Health

chapter of the IPCC 4th Assessment Report include the following. Users can use this

information to help identify particularly vulnerable groups for their assessment.

Vulnerable urban populations: Urbanization and climate change may work

synergistically to increase disease burdens. Urbanization can positively influence

population health; for example, by making it easier to provide safe water and improved

sanitation. However, rapid and unplanned urbanization is often associated with adverse

health outcomes. Urban slums and squatter settlements are often located in areas

subject to landslides, floods and other natural hazards, as well as exposure to high-

polluting energy sources. Lack of water and sanitation in these settlements are not only

problems in themselves, but also increase the difficulty of controlling disease reservoirs

and vectors, facilitating the emergence and re-emergence of infectious diseases.

62


Populations in high density urban areas with poor housing will be at increased risk with

increases in the frequency and intensity of heatwaves, partly due to the interaction

between increasing temperatures and urban heat island effects.

Vulnerable rural populations: Climate change could have a range of adverse

effects on some rural populations and regions, including increased food insecurity due

to geographical shifts in optimum crop-growing conditions and yield changes in crops,

reduced water resources for agriculture and human consumption, flood and storm

damage, loss of cropping land through floods, droughts, a rise in sea level, and

increased rates of climate-sensitive health outcomes.

Food insecurity: Expert assessments of future food security are generally

pessimistic over the medium term. There are indications that it will take approximately

35 additional years to reach the World Food Summit 2002 target of reducing world

hunger by half by 2015 (Rosegrant and Cline 2003; UN Millennium Project 2005). Child

malnutrition is projected to persist in regions of low-income countries, although the total

global burden is expected to decline. However, this projection does not consider the

impact of climate change. Attribution of current and future climate change-related

malnutrition burdens is problematic because the determinants of malnutrition are

complex. Due to the very large number of people that may be affected, malnutrition

linked to extreme climatic events may be one of the most important consequences of

climate change. Overall, climate change is projected to increase the number of people

at risk of hunger (FAO 2005).

Populations in coastal and low-lying areas: Climate change could affect

coastal areas through an accelerated rise in sea level; further rise in sea surface

temperatures; an intensification of tropical cyclones; changes in wave and storm surge

characteristics; altered precipitation/run-off; and ocean acidification. These changes

could affect human health through coastal flooding and damaged coastal infrastructure;

saltwater intrusion into coastal freshwater resources; damage to coastal ecosystems,

coral reefs, and coastal fisheries; population displacement; changes in the range and

prevalence of climate-sensitive health outcomes, such as malaria, dengue, diarrheal

diseases; and others. (See http://www.who.int/globalchange/climate/en/oeh0402.pdf

and http://www.who.int/globalchange/publications/climvariab.pdf

http://www.who.int/globalchange/climate/en/oeh0402.pdf

http://www.who.int/globalchange/publications/climvariab.pdf

63


Populations in mountain regions: Changes in the depth of mountain snow

packs and glaciers, and changes in their seasonal melting, can have significant impacts

on the communities from mountains to plains that rely on freshwater runoff. Little

published information is available on the possible health consequences of climate

change in mountain regions. However, it is likely that vector-borne pathogens could take

advantage of new habitats in altitudes that were formerly unsuitable, and that diarrheal

diseases could become more prevalent with changes in freshwater quality and

availability (WHO Regional Office for South-East Asia 2006). More extreme rainfall

events are likely to increase the number of floods and landslides. Glacier lake outburst

floods are a risk unique to mountain regions; these are associated with high morbidity

and mortality and are projected to increase as the rate of glacier melting increases.

For example, a joint WHO/WMP/UNDP/UNDEP workshop was conducted in the

Hindu Kush-Himalaya region because of concerns about health vulnerabilities to climate

change (Ebi et al. 2007). Only crude estimates of the current burden of climate-sensitive

diseases in the Hindu Kush-Himalaya regions were available due to the lack of health

surveillance data at the local level. As a first step at generating this information, a

qualitative assessment was conducted (Table 2).

Table 2. Current climate-related health determinants and outcomes in the Hindu-Kush Himalaya regions

Country Afghanistan Bangladesh Bhutan China Nepal India

Heatwaves M-P P – P P P Flood deaths/morbidity

Glacial lake floods M-P – M-P M-P M-P M-P Flash M-P P M-P M-P M-P M-P

Riverine (plain) P P – P P P Vector-borne disease P P P P P P

Malaria P P P P M-P P Japanese encephalitis – P – P P P

Kala-azar P – – – P P Dengue – P P P – P

Waterborne diseases M-P P M-P M-P M-P M-P Water scarcity, quality M-P P P M-P M-P M-P Drought-related food insecurity

M-P P – M-P – M-P

An “M-P” indicates the health determinant or outcome occurs in the mountainous and non-mountainous (i.e. plains) areas; a “P” indicates the health determinant or outcome only occurs in the non-mountainous (i.e. plains) areas; a “–“indicates the health determinant or outcome is not present in the country (see http://www.searo.who.int/LinkFiles/Publications_and_Documents_healthImapcts.pdf)

http://www.searo.who.int/LinkFiles/Publications_and_Documents_healthImapcts.pdf

64


Other populations: There are other populations who also will be at increased risk, such as those living in fragile ecosystems (e.g. forests and deserts). Ecosystem services are indispensable to human health and well-being by providing food, safe water, clean air, shelter, and other services. Changes in their availability affect livelihoods, income, local migration and, on occasion, political conflict. The resultant impacts on economic and physical security, freedom, choice and social relations have wide-ranging impacts on well-being and health (see for example the Millennium Ecosystem Assessment Health Synthesis, http://www.maweb.org/documents/document.357.aspx.pdf).

2.2 Describe current programs and activities, planned changes to these

programs, and their effectiveness for addressing the additional health risks of

climate change

The health outcomes of concern with climate change are among the leading

causes of morbidity and mortality: every year there are millions of cases of malnutrition,

climate-sensitive infectious diseases, such as diarrheal diseases, malaria, and dengue,

and injuries and deaths due to extreme weather events. A wide range of programs and

activities exist to control these health burdens. It is important to understand the

strengths and weaknesses of these programs, as well as their flexibility for addressing

the additional health risks of climate change. The health ministry/department, NGOs,

and others may have responsibility individually or jointly for these programs. For

example, ministries/departments of health typically have responsibility for vector-borne

disease surveillance and control programs. Other programs, such as disaster risk

response activities, may be joint activities across ministries/departments (including

health, emergency management, and others) and NGOs, such as the International

Federation of Red Cross/Red Crescent Societies. Representatives from all relevant

organizations and institutions should be canvassed to understand what is working well,

what could be improved, and the capacity of the program to address possible increases

in incidence or changes in geographic range of the health outcome of concern.

It will also be important to know of any planned changes to these programs and

activities. Ministries/departments of health often have 5- and 10-year plans. These will

detail proposed changes that could affect the reach and effectiveness of programs.

Understanding these changes is necessary when developing modifications to address

climate change health risks.

http://www.maweb.org/documents/document.357.aspx.pdf

65


It could be helpful to create a series of questions to answer for each program,

including:

What is the management structure for the program? This information will

be necessary to identify constraints and opportunities for modifying the

program.

What human and financial resources are available for the program?

Cataloguing these assets is important when planning additional activities.

How effective is the program in controlling the current health burden?

Less than optimal effectiveness may be the result of limited human and

financial resources, limited laboratory and material supplies, etc. This

should include not only an overall assessment, but also evaluation of

effectiveness in particularly vulnerable populations and regions.

Are any changes to the program planned in the next 5- to 10-years?

What changes are needed to effectively handle the additional health

burden (i.e. more cases in more regions) due to climate change?

3 Project the health impacts of climate change

This step includes (1) describing how the current burden of climate-sensitive health

outcomes is likely to change over coming decades irrespective of climate change; and

(2) estimating the possible additional burden of adverse health outcomes due to climate

change; this can be done qualitatively or quantitatively

3.1 Describe how the current burden of climate-sensitive health outcomes is

likely to change over coming decades irrespective of climate change

This step involves combining the evaluation of current and planned surveillance

and control programs with demographic trends and trends in other risk factors to

estimate the likely burden of climate-sensitive health outcomes in 2030. Information on

the current burden of climate-sensitive health outcomes (by region and vulnerable

groups whenever possible) will be available from a previous step in the assessment.

66


The 5- or 10-year plan should be evaluated to identify planned modifications to reduce

current burdens. For example, there are currently n cases of malaria in a particular

region, with a new program planned to reduce the burden by 20%, taking population

growth into account, through distribution of insecticide-treated bednets and integrated

vector management programs. Therefore, the burden of malaria in 2030 would

reasonably be expected to be between the current burden and 80% of the current

burden. In another region, control programs are not expected to change but

demographic growth is expected to increase the number of cases by 10%. It is also

important to note where climate-sensitive health outcomes are currently absent or

where the burden is not expected to change; for example, there may be regions where

certain vector-borne diseases do not exist or where there is limited vector-borne

disease control. This description is the baseline against which the possible additional

health burdens of climate change will be assessed.

3.2 Estimate the possible additional burden of adverse health outcomes due to

climate change

The possible additional burden of climate-sensitive health outcomes can be

estimated qualitatively or quantitatively.

Qualitative estimates can be based on simple scenarios of climate change, such

as a 1C increase in average temperature within 20 years, with a 10% increase in

precipitation variability. Climate projections used in the National Communication1 or

other assessment should inform the scenario used. Based on the results of previous

steps, possible future health burdens can be estimated by those with experience with

the health outcome. For example, in rural areas in tropical countries with limited access

to safe water and improved sanitation, increasing average temperatures and

precipitation variability will likely increase the burden of diarrheal diseases. The

implications of this increase for diarrheal disease control depend on the effectiveness

and geographic coverage of current programs. When possible, future health burdens

should be estimated at the scale at which interventions are implemented, such as

community, city, or region.

1 All countries that are signatories to the United Nations Framework Convention on Climate Change are required to produce regular

National Communications that cover emission inventories; vulnerability, impacts, and adaptation; and mitigation (www.unfccc.int).

http://www.unfccc.int/

67


For example, qualitative storylines were used during the assessment of health

risks and responses in the first Portuguese national assessment (Climate Change in

Portugal: Scenarios, Impacts and Adaptation Measure). The assessment included

consideration of the possible impacts of climate change on vector-borne diseases,

including Malaria, West Nile virus, Schistosomiasis, Mediterranean Spotted Fever, and

Leishmaniasis; the latter two are endemic to Portugal. Although human cases of vector-

borne diseases have generally decreased in Portugal over recent decades, many

competent vectors are still present. Disease transmission risk was categorized

qualitatively based on vector distribution and abundance, and pathogen prevalence.

Four brief storylines were constructed that differed according to key climate variables,

including current climate and projected climate change, and assumed either the current

distribution and prevalence of vectors and parasites, or the introduction of focal

populations of parasite infected vectors (Tables 3 and 4). These storylines were

discussed with experts to estimate transmission risk levels. For Mediterranean Spotted

Fever, the risk of transmission was high under all storylines, suggesting that climate

change is likely to have a limited impact. For the other diseases, the risk level varied

across the storylines. For example, the risk of leishmaniasis varied from medium under

current climate to high under both climate change storylines. The risk of

schistosomiasis varied from very low (current climate and current vector distributions) to

medium (climate change and focal introduction).

Table 3: Scenarios Used in Portuguese Vector-borne Disease Risk Assessment

Climate Model Scenario

Assuming Current Knowledge of Vector and Parasite

Prevalence

Assuming the Introduction of Focal Populations of Parasite-Infected

Vectors

Current climate

Scenario 1 Scenario 2

Climate change


68


Table 4: Vector-borne Disease Transmission Risks for Portugal

Transmission Risk Levels

Disease Scenario 1

Scenario 2


Malaria

P. vivax Very low Low Very low Low-medium

P. falciparum Negligible Low Negligible Low-medium

West Nile Low Low Low-medium

Low

Leishmaniasis Medium Medium High High

Lyme Medium Medium Medium high

Medium high

Mediterranean Spotted Fever

High High High High

Schistosomiasis Very low Low Very low Medium

4 Identify and prioritize implement adaptation options to address current and

projected health risks

Based on expert judgment and stakeholder input, a list can be created of all

possible (reasonable) adaptation options that could improve the effectiveness of current

programs and activities, as well as new programs that are needed. These additional

options can range from additional personal and equipment to increase the coverage of

current programs, to vaccine development, to a department specifically focused on

climate change and health). This list of options should address distal and proximal

drivers of the disease, and should consider factors such as inequities that result in

differential disease burdens within and between different populations.

The approaches used by public health authorities to manage health risks depend

on the nature of the risk, the health outcome, and the enabling conditions. Policy

responses to the health risks associated with climate variability and change range from

implementing successful measures used by other countries/regions to developing new

policies for addressing emerging health threats. In most cases, the primary response

will be to enhance current health risk management. The degree to which programs and

measures will need to be augmented to address the additional pressures due to climate

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change will depend on factors other than climate change, such as the social, economic,

and political context. The critical factors should be identified during the assessment, as

well as possible approaches to overcome any barriers. Adaptation will be a process of

continual adjustment to increases in the degree and rate of climate change.

Given the broad range of climate-sensitive health outcomes that communities

face, priorities will need to be set for which issues to tackle first. There are multiple

criteria that can be used when setting priorities; those commonly considered include

significance, benefits ad effectiveness, costs, and feasibility. There may be other

criteria of importance to stakeholders, including maintaining cultural and social

institutions. Significance is used to assess the relative importance of the anticipated

impact, such as the possible burden of additional adverse health outcomes. Benefits

and effectiveness is used to assess the degree to which the option would likely reduce

vulnerability to the anticipated health or culture impact. The benefits of the interventions

should exceed their cost, however stakeholders agreed on the metrics for measuring

benefit. This criterion also considers the flexibility of the option to be modified in a

changing climate. The cost of the option includes operation and maintenance,

administration and staffing, required equipment, etc. Feasibility is used to evaluate

whether the option can realistically be implemented in the context of current and

planned programs and activities. Stakeholders may want to include additional criteria,

such as whether the proposed adaptation will reduce social inequities. The costs of

these interventions should be estimated.

For each priority option, it is helpful to write a brief (i.e. up to several page)

description of the option, including benefits and effectiveness for reducing vulnerability;

the human and financial resources required; feasibility; and constraints to

implementation. There should be a discussion of the current programs and measures

designed to address the health outcome, and where and when modifications are

needed to increase their effectiveness. This discussion should consider how to ensure

active and continued stakeholder engagement, how to address changes in climate and

vulnerability over times, how uncertainties in climate projections and development

pathways can be incorporated, and social justice concerns.

The options should explicitly identify objective indicators for monitoring and

evaluation of policies and measures to ensure the necessary information is collected to

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determine whether the changes made are effective in reducing climate-related disease

burdens. The option should note if the necessary information is currently being

collected or if new programs will be needed.

It is often helpful for decision-makers to have a summary of the costs and

benefits of each option, including how the option is planned to reduce the burden of

climate-sensitive health outcomes and other benefits, the possible consequences for

population health if the option is not implemented (i.e. increased likelihood of disease

epidemic), and estimates of the costs over time of implementing and continuing support

for the option.

Finally, it would be helpful to provide a summary of the process, stakeholders

included, priority adaptation options, including the more detailed descriptions, to

decision-makers for their action.

5 Determine the potential health risks of adaptation and mitigation measures

implemented in other sectors, such as water resources, land use, and transport,

and identify possible interventions to reduce any identified risks

Climate change mitigation and adaptation decisions taken in other sectors can

have important implications for public health. For example, the IPCC stated that the

"there is general agreement that health co-benefits from reduced air pollution as a result

of actions to reduce greenhouse gas emissions can be substantial and may offset a

substantial fraction of mitigation costs" (IPCC 2007). Co-benefits, or ancillary benefits,

of greenhouse gas mitigation policies have been defined as health improvements other

than those caused by changes in greenhouse gas emissions, arising as a consequence

of mitigation policies (Bell et al. 2008). Potential health effects are not limited to air

quality impacts - for example, development and promotion of active modes of transport

would likely have an impact on the 1.9 million annual deaths associated with physical

inactivity, and the 1.2 million deaths occurring in road traffic accidents. Decisions on

promotion of biofuels can affect food availability and prices, in turn impacting on the 3.5

million annual deaths from undernutrition (Black et al. 2008). With respect to

adaptation, decisions taken by, for example, the water sector, have the capacity to

increase or decrease risks from vector-borne diseases and other health risks associated

with water resources management.

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Co-benefits, or ancillary benefits, of greenhouse gas mitigation policies have

been defined as health improvements other than those caused by changes in

greenhouse gas emissions, arising as a consequence of mitigation policies. While

WHO and other agencies are beginning to provide qualitative descriptions of the range

of links between energy policies and health, this has not yet been carried out in a

systematic manner. Decisions taken by water and agriculture ministries and agencies,

for example, have the capacity to increase or decrease risks from a range of infectious

diseases, undernutrition, and other health risks.

Energy production and use are associated with greater environmentally mediated

premature morbidity and mortality than any other sector, primarily through exposure to

harmful indoor and outdoor air pollutants. In addition to harm from exposure to air

pollution, patterns of energy use and transportation may also contribute to human

morbidity and mortality through accidents (both occupational and non-occupational) and

unhealthy changes in physical activity.

Climate change (including impacts on sea level rise, temperature, rainfall, run-off

from snowfall, and storm intensity) is one of multiple stresses on the quantity and quality

of freshwater sources; other factors include economic growth, land use, and

urbanization. Considerable attention has been paid to the implications of climate

change for water quantity, with less paid to the extent to which water quality also may

be affected. Adaptation steps implemented for the water sector, including infrastructure

development, irrigation, and use of treated wastewater, may have implications for

human health and well-being.

The four dimensions of food security (food availability, stability of food supplies,

access to food, and food utilization) will be affected by climate change. Climate change

impacts on food availability will be mixed, and will vary regionally. Limited research has

been conducted on the health impacts of options designed to address the global food

challenge for example, biotechnologies.

Conducting health impact assessments in collaboration with stakeholders from

other sectors can identify where and when adaptation and mitigation choices could

affect population health. Some cities and countries have established inter-ministerial

climate change committees to coordinate these assessments.

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6 Implement, monitor, and evaluate the burden of climate-sensitive health

outcomes and interventions to address these burdens, to ensure continued

effectiveness in a changing climate

Once the adaptation options are chosen, they need to be implemented in a

manner that allows for monitoring and evaluation to ensure continued effectiveness in a

changing climate. The only difference in implementing, monitoring, and evaluating

interventions to address the health risks of climate change from other public health

programs is that these activities should be designed with greater flexibility so that they

can be adjusted as climate and other factors change. It is important to identify good

indicators to allow the follow-up and to observe the effects of the interventions chosen.

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World Health Organization Centre for Health Development (WHO Kobe Centre – WKC)

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