Adapting Health Systems to Climate Challenges and Community Roles

She will also highlight some of the challenges that come from the high degree of decentralization in the country. Our second guest comes from Uganda and will share some reflections on the critical role of communities when it comes to making health systems more resilient to climate shocks. So, let's dive in. Hi and welcome back. I'm here with Dr Mujtaba. Let me first ask her to introduce herself. Dr. Mehreen Mujtaba: Thank you, Alex. I'm Dr Mehreen Mujtaba.

I'm Director Climate Change, Nutrition and Health at the Federal Ministry of Health in Pakistan. Would you mind telling us a little bit about the journey that you're going through for the development of the health climate adaptation plan in Pakistan? Dr. Mehreen Mujtaba: So actually climate and health nexus is something new that the Ministry of Health is exploring.

So, since COP 27 in Glasgow, where our minister was part of the negotiations for including health in the climate change negotiations and then in COP 28 when Minister Health from Pakistan was a signatory to the health declaration, the Ministry of Health has now a dedicated desk for climate change and health. We were supposed to submit our HNAP, which is Health National Adaptation Plan towards this COP.

But unfortunately, because conducting climate risk and vulnerability assessments in a country which is comprising of four provinces and two federating areas is a very big endeavor. So that took a lot of time, and unfortunately, we could not submit our HNAP this year, but next year hopefully we will be able to submit our adaptation plan to the rest of the world at UNFCCC forum. And where are you in that process right now?

Dr. Mehreen Mujtaba: So, the process started somewhere around last December with WHO supporting the ministry in conducting climate risk and vulnerability assessments in two of the big provinces, Punjab and Balochistan. And then FCDO also moved in, and they committed to conducting the same climate risk vulnerability assessments using the same methodologies and the tools developed by WHO to ensure uniformity in Khyber Pakhtunkhwa province.

We are left with one of the major provinces, which is Sindh, which was devastated during the floods in 2022 and has very high levels of malnutrition because of droughts and flooding and salination off the soil. UNICEF has committed to conducting the CRVAs for us in uh, province Sindh. So, the journey is still going on. You've already mentioned the challenge of working in a country that has strong authorities at provincial level. What other challenges do you face?

Dr. Mehreen Mujtaba: The biggest challenge is the fact that health is a decentralized subject. So, the implementation is with the provinces. The policies and the guidelines are made at the federal level, but the implementation is again at the provincial level. So there has to be a very robust cohesion between the national and the provincial governments. In some instances, it's very easy to work with the provincial governments.

Then there are certain authorities and provincial authorities where we find it a bit difficult for them to understand that the guidelines and the policies have to come from the federal side, and the benchmarking has to be federal because climate change is per se not a devolved subject. And the benchmarking and the reporting has to go from the federal level. It can't be from the provincial level. That is one of the challenges.

And then another challenge is when you have developmental partners who go directly to the provinces for conducting the CVRAs rather than coming to the federal ministry. That also becomes a bit of a challenge because then the province is doing some work which the national authority is not aware of. So that's another challenge. And how about coordination across different ministries and sectors? Is that an issue?

Dr. Mehreen Mujtaba: Just very recently, the Ministry of Health has constituted a steering committee, which is a multi-sectoral inter-ministerial body. It is going to have representatives from the Ministry of Climate Change, Ministry of Food Security, animal health, apart from that public works and all the ministries that are that the ministry does play a major role in climate change and health policies development. We have our technical working groups.

We have representatives from Pakistan Med Department in that as well. We have from the infectious disease control cell as well. So, the coordination mechanism is going very well. And a lot of good ideas and policies are coming out of that. And if I understand correctly, the similar coordination mechanisms need to then be replicated at the provincial level or not?

Dr. Mehreen Mujtaba: So, actually the technical working group and the steering committees that we have on climate change and health at the national level, they have representatives from the provincial level as well.

So there is a cohesion between the government counterparts, but the only challenge, which I mentioned earlier, is that the government is working at one level at the national and provincial side, but then you have developmental partners who are just going in silo to a province and then they are going to people that are not aware of or are not members of our technical working group or members of the steering committee.

So that kind of it makes it a little difficult to understand what's happening at the provincial level, but otherwise coordination mechanisms are very much in place, and we've been brainstorming and coming up with really good policies and initiatives for the future. That's great. Thank you for sharing that. Maybe a last question. This is the fourth day of the conference. What have been some of your impressions and some some things that you will take with you back to Pakistan?

Dr. Mehreen Mujtaba: One of the things which was most striking was that we are talking in terms of just countries, whereas climate change is more of a regional sort of a concept. Let's just, for instance, talk about air pollution. So, when you talk about Punjab, you're talking about Punjab in India and Punjab in Pakistan. Okay, so people in India and people in Pakistan are breathing the same toxic air and the AQI is above 1400 in both the areas.

So, climate change, you cannot just take it as a country-specific sort of a thing. It has to be more regional collaborations if we want to see differences. So we have to have regional benchmarks. We need to have regional knowledge sharing. We need to have regional synergies, and a regional hub. This was one of the ideas that I floated with our ADB and JICA partners also that we need to create a regional hub so that we can make regional policies. And you think that will happen?

Dr. Mehreen Mujtaba: I think so. Because by the end of the day, whatever affects the me across the border or the populations living in Pakistan across the border. The same thing happens in India. So, we cannot talk just about Pakistan and not do something about India or India cannot just talk about India and not talk about Pakistan? Because you're in Islamabad, the cloud, which is up there with high AQI is all over Punjab, whether it's India, Pakistan. That doesn't make a difference.

Yeah, very true. Thank you so much for joining us. Hi again, everyone. I'm now with Dr. Rawlance from Uganda, who's given a very interesting presentation that related to climate adaptation, climate resilience in his country. So, let me first start by asking could you please introduce yourself? Dr. Rawlance Ndejjo: Yes. Thank you. My name is Rawlance Ndejjo. I'm a lecturer and researcher at the School of Public Health, Macquarie University.

where I'm doing work on climate change and health and a few other health topics such as non-communicable diseases and also epidemics. During your session, there were quite a number of questions relating to the role of communities and also what they actually already do when climate crisis happens. Could you say a few words about those discussions? Dr. Rawlance Ndejjo: Yes. There were questions that were asked about the community, which I felt were actually very important questions.

Our presentations at the conference had focused more around issues to do with policymakers and the barriers that they face to actually build climate resilient health systems. But I think we had the opportunity to also discuss the community, which is really my passion. And I'm trying to think about the role that the communities play in climate change adaptation. So in a nutshell, I think communities is where everything starts and where all the action takes place.

So communities should have a very important role in all the discussions we have around climate change and climate change adaptation. So, that we work with the communities to empower them so that they can build adaptive capacity to move towards resilience. Many times, when I talk about communities, we also talk so much about them supporting the ideas and solutions that we have. But I'm always interested in us flipping this around and looking at communities as solutions.

We now experience a lot more extreme weather events in Uganda, but also in many parts of the world. But even before this communities have been dealing with these events for a very long time. They have slowly by slowly developed mechanisms through which they deal with these extreme weather events. They have ideas on how best to adapt to these events in a way that favors them, but also, in many of these communities you go and they also have information around early warning.

There's a lot of indigenous knowledge around how communities can actually predict these extreme weather events. And some of the inspiring case studies I have seen, actually those that integrate the scientific modelling and prediction together with indigenous knowledge which gives us more precision. And also, building more trust in terms of communities getting to learn and appreciate, um, the different predictions that are made, but also seeing their role and stake within all this.

So, in a nutshell, communities are here, they have been adapting we need to think about how do we work with them towards the solutions for climate change adaptation. There are several interventions that are usually implemented within the community. But sometimes you feel that the role of the community is not clear and communities are not brought at the center stage and these interventions cannot even be sustained because we can't implement things for others without giving them room.

To actually be part of the brainstorming, be part of the implementation of these interventions, be part of the evaluation of these interventions to tell us what is working and what's not working and how we can think through some solutions together to have more sustainability and through some of these mechanisms, we can actually be able to move towards resilience. So, in a nutshell, there's no way we're making any progress.

In dealing with climate change, there's no way we make progress in thinking about adaptation mechanism without bringing communities on board. Yes, absolutely. So, you really have this bottom-up approach, which is nice because very often when we hear about country's efforts it's, it starts very much top down. So, it's really nice to compliment that. Just a question, I believe that Uganda has already developed health national adaptation plan, which is now to be implemented.

How will what you just described be part of that? So basically, how will the community be involved in this implementation? Dr. Rawlance Ndejjo: Yes. That's important. I think with the many other stakeholders that Uganda now has. This is a health national adaptation plan, actually the second country among the low and middle-income countries to develop this plan after Nepal. So, it is a really good place to be to have this plan for 2025 to 2030.

First of all, I am impressed with the process of developing this plan because it involved the community and several other stakeholders. Different sectors were involved but the role of the community was also clear, and also views and ideas from the community were incorporated.

In terms of the implementation of this plan, which I think matters the most now that we have the plan, we really also need to think about the clear role of the community in terms of providing solutions to how we deal with the climate change. We're thinking about building climate resilient health systems across the globe within the country. But a lot of this cannot happen without the community.

So, the whole point is even as we think through the interventions, we need to think about having a community voice so that we continuously consult with the communities. We continuously co design the interventions we want to implement with the communities. We continuously think through and work with stakeholders to implement interventions that favor communities so that the communities can adopt some of these interventions.

Whether we are thinking about how do we reach communities that are hardly hit by extreme weather events? If we think about potential outreaches that we need to do at the health facility level, we need to think about the central role of how communities support this. The role of community health workers has also been key in a lot of the work that we have seen, including the work we have done in Uganda, in terms of bridging that gap between the communities and the health facility.

So, we need to get the community health workers on board, we need to support them, we need to facilitate them, and we need to ensure that they work very closely with the communities to bridge any gaps in healthcare access that may happen before, but also in the aftermath of extreme weather events.

There are also very good case studies around community health workers bridging the gap around access to commodities, family planning commodities that we have seen but also support in treatment of children, uh, for malaria and uh, diarrhoea and pneumonia within the community. And these are some potential mechanisms that we can expand to really work closely with the community health workers and build their capacity and also support bridging that gap so that we can ensure continuity of services.

The other aspects around the community that I could maybe mention is, we need to go back and rethink the role of health promotion in terms of disease prevention generally.

And still the community stakeholders, the leaders, the religious leaders, the other community workers and the community health workers are key in providing information to to, to these communities to help them prepare to prepare better but also to give them the information that they need to deal with potentialities maybe disease incidents that may happen.

Sometimes when we have these weather events, we actually also experience epidemics of infectious diseases and there's no way some of these can be clearly and appropriately be dealt with without proper information to the community, without a clear involvement of community stakeholders and community health workers and without adequate support from the health facility level.

We need to clearly continue to implement this plan, working with the communities, evaluate the interventions, get community feedback, and continue to work with them to improve the interventions and see how best we can tailor these to their needs for a climate resilient health system. Excellent. These are all important points, and it would be really nice to see how this unfolds in the years to come. Just maybe a last question, any big takeaway that that you got from this conference?

Dr. Rawlance Ndejjo: Yeah, of course there are several takeaways, but I was particularly interested in learning about adaptation mechanism at both community and health facility levels from other countries.

And by attending some presentations in some sessions, sharing some lessons from many low and middle-income countries, I was impressed to see that there are a lot more efforts in terms of thinking about climate smart health systems or climate smart health facilities in terms of thinking the whole infrastructure of how we construct health facilities, which I think is good, but also rethinking the whole building blocks of a health system to actually start to move towards a climate resilient health system.

One of the challenges that I think we have or we have been having in climate change discussions when we talk about health systems, has really been around a synopsis of what the issues are or the problems are, and and not getting towards real tangible solutions around how do we bridge the gaps that we see or that we experience in terms of infrastructure in terms of commodities in terms of the health workforce and preparing them much better.

And I feel that this this conference has provided a lot of discussions and solutions. That brings together a lot of these building blocks, whether it is thinking about better training for health workers and building their capacities and approaches that we can use and take whether it is thinking about how we work with the different sectors to develop solutions, the engineering solutions, and we will not provide those as health services.

Policy and system researchers, but we need to work with the other fields and sectors to actually start to move towards the solutions and some examples have been shared, whether it is about energy efficiencies and how we can reduce carbon emissions from facilities, but also how we can broadly Increase adoption of renewable energy at facility levels and some of these examples were broadly inspiring at the conference.

Aspects of data and how we can further interpret climate change and health and try to bridge the evidence gaps that we have. So, I leave this conference quite energized.

I'm also interested in furthering and digging much deeper into some of the solutions that have been suggested so that we start seeing what can we contextualize for some of our different settings and continue the learning so that by the time we meet the next time, we're actually sharing lessons from implementing some of these solutions, which I think are broadly inspiring and giving us hope for the future, but also for climate resilient health systems. Great.

Thank you so much for sharing these reflections and also for joining our podcasts and have a safe journey back to Uganda. Thank you to Dr. Mujtaba and to Dr. Rawlance for these great insights relating to the development of a health national adaptation plan and also to the importance of involving communities, including in the development and implementation of such plan, if we really want to build resilient health systems. Thank you everyone for tuning into Health Systems Pathways.

If you enjoyed this episode, please don't forget to subscribe or follow us wherever you get your podcasts. Until next time, I'm Alex Ergo. Let's keep working together to build stronger health systems that work for people.