Third National Communication- Biennial Update Report (TNC-BUR) – Republic of Yemen
Vulnerability and Adaptation Assessment of Climate Change on Yemen Health Sector
FINAL REPORT
Prepared by: Dr. Abdulsalam Al- Akel Senior Public Health Consultant
October 2016
Document Title Final Report Date October 2016 Project Name Third National Communication, Biennial Update Report (TNC-BUR-6-2016) Consultant Dr. Abdulsalam Al-Akel Project Manager Mr. Anwar A. Noaman Duration 03rd April 2016 and continuing through 31st October 2016
Objective of The Report
Iincorporating and consolidating all finding, results, products and outputs of the assignment including the review of existing studies, identification of vulnerable groups, levels of exposure, sensitivity and adaptive capacity, proposal of climate resilient options, assessment of the long term impact of climate change on human health using the recommended climate scenarios, assessment of the costs and benefits of sustainable health management practices, identification of climate resilient health management options, steps to be taken at central, provincial and local level to promote these options, and a plan for monitoring and reporting the effectiveness of measures.
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Table of Contents Objective of The Report ...... 1 Table of Contents ...... 2 List of Tables ...... 5 List of Figures ...... 6 Acronyms ...... 7 Acknowledgement ...... 9 Glossary Terms ...... 10 Map of Yemen ...... 12 Executive Summary ...... 13 1. Introduction ...... 18 2 Yemen General Background ...... 21 2.1 Yemen Socioeconomic and Political Context ...... 21 2.2 Yemen Health System Background ...... 26 2.2.1 Public Health Sector (MoPHP) ...... 26 2.2.2 Human Resources of Public Health Sector ...... 29 2.2.3 Public Health Care Financing ...... 31 2.2.4 Public Health Services Coverage ...... 33 2.2.5 Public Health Information System ...... 33 2.2.6 Governance, Leadership and Structural Arrangements ...... 34 2.2.7 Challenges of Public Health Sector...... 35 2.3 Private Health Sector ...... 36 3 Yemen Climate Change Background ...... 37 3.1 Precipitation Patterns ...... 38 3.2 Drought Pattern ...... 39 3.3 Temperatures Pattern ...... 39 3.4 Yemen National Response to Climate Change ...... 39 3.5 Climate Change’s Actions in the Health Sector ...... 40 4 Current Health Status and Health Indicators ...... 41 4.1 Life Expectancy ...... 41 4.2 Morbidity Status ...... 42 4.3 Mortality Status ...... 44 4.3.1 Infant and Under Five Mortality Rate Trends ...... 45 4.3.2 Maternal Mortality Rate ...... 46
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5 Objectives and Scope of Assessment ...... 47 5.1 Specific Objectives ...... 47 6 Vulnerability and Adaptation Assessment Methodology ...... 48 6.1 Assessment Framework ...... 48 6.2 Assessment Methodology ...... 49 7 Stages of Vulnerability Assessment ...... 50 7.1 First stage: identification of Vulnerable Population Groups ...... 50 7.1.1 Determinants of Sensitivity ...... 50 7.1.2 Determinants of Vulnerability ...... 50 7.1.3 Adaptive Capacity Assessment ...... 55 7.1.4 Vulnerability and Adaptation Assessment Questionnaire Findings ...... 55 7.2 Second Stage: Development of Two Socioeconomic Scenarios ...... 56 a. Population Growth and Size ...... 57 b. Economic Development ...... 57 c. GDP Growth Rate...... 58 d. Health Care Coverage...... 58 e. Basic Infrastructures Services (pure water supply and sanitation) ...... 59 f. Governance ...... 59 7.2.1 Characteristics of Socioeconomic Scenarios A ...... 59 7.2.2 Characteristics of Socioeconomic Scenario B ...... 60 7.2.3 Vulnerability Under Socioeconomic Scenarios ...... 60 7.3 Third Stage: Development of Climatic Change Scenario ...... 61 7.3.1 Precipitation Projection ...... 61 7.3.2 Temperature Projection ...... 62 7.3.3 Projected Hot and Cold Days ...... 62 7.4 Fourth Stage: Assessment of the impact of climate change on health ...... 63 7.4.1 Direct Impacts of Climate Related Hazards on Population Health ...... 64 7.4.2 Indirect Impacts of Climate Change on Health Outcomes ...... 68 7.4.3 Health Impacts Heavily Mediated through Human Institutions...... 77 8 Projections for Future Vulnerability ...... 78 8.1 Future Vulnerability to Flood ...... 79 8.2 Future Vulnerability to Drought ...... 79 8.3 Future Vulnerability to Malaria Disease ...... 80 8.4 Future Vulnerability to Diarrheal Diseases ...... 80 9 Adaptation Strategies (Options) to Impact of climate change on Health ...... 82 a. Primary adaptive measures ...... 83
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b. Secondary adaptive measures ...... 83 c. Tertiary adaptive measures ...... 83 9.1 WHO requirements for preparing health systems for climate change ...... 83 9.1.1 Leadership and Governance ...... 83 9.1.2 Allocate Financial Resources ...... 84 9.1.3 Human Resources and Capacity Building ...... 84 9.1.4 Service Delivery Mechanisms ...... 84 9.1.5 Technology and Pharmaceuticals Supplies ...... 84 9.1.6 Health Information System ...... 85 9.1.7 Health Partnerships and Community Engagement ...... 85 9.2 Levels of Needed Policies for Effective Adaptation Strategies ...... 85 9.2.1 Health Sectors ...... 85 9.2.2 Metrology Authority ...... 86 9.3 Principles of adaptation strategies of health impacts of climate change ...... 86 9.4 Necessities of Adaptation Strategies (Starting Now) ...... 87 9.5 Specific Adaption Strategies in the Health Sector ...... 88 9.6 Specific Adaptation Activities (Incremental)...... 89 9.7 Transitional Adaptation Actions ...... 90 9.7.1 Research and Surveillance ...... 91 9.7.2 Established environmental directorate/ program ...... 91 9.7.3 Establish climate change technical working group with clear TOR ...... 91 9.7.4 Formation of Task Group ...... 92 9.7.5 Health Systems Strengthening (HSS) ...... 92 9.7.6 Infrastructure Structure Development ...... 92 9.7.7 Human Capacity Development/Training ...... 93 9.7.8 Emergency Medical Services ...... 93 9.7.9 Strengthen and Utilize Climate-informed Early Warning and Response System ...... 94 9.7.10 Public health education and awareness ...... 94 10 References ...... 95 10.1 Studies ...... 95 10.2 Special Reports ...... 97 10.3 Arabic Reports and Documents related to the MoPHP ...... 98 10.4 English Reports and Documents related to the MoPHP ...... 98 10.5 Websites and Reports ...... 98 100 ...... الملخص التنفيذي 11
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List of Tables
Table (1): the proportion of population of access to drinking water and sanitation services in Yemen compared to other countries in the Arab’s region...... 24 Table (2) :number, type and sex of health manpower in the public sector in 2014 ...... 29 Table (3): percentage of doctors, nurses and midwifes to population in 2014...... 30 Table (4): number of GPs and Specialists in 4 governorates and population percentages in 2014 ...... 31 Table (5): number of Specialists and GPs to population percentages in 4 governorates in 2014 ...... 31 Table (6): the actual spending for 2012 and the estimated budget in thousands for 2013 – 2015...... 32 Table ( 7): percentage of primary health care coverage in 2010 ...... 33 Table (8): type and number of private HFs in Sana’a city, Hodeida, Aden and Taiz governorates...... 37 Table (10): Yemen’s observed precipitation pattern ...... 38 Table (11): Yemen’s drought pattern ...... 39 Table (9): Yemen’s temperature pattern ...... 39 Table (12): burden of different diseases at the national level for most common diseases in 2009...... 44 Table (13): Driving Force, Pressure, State, Exposure, Effect, Action (DPSEEA) Framework ...... 49 Table (14): different population’s groups vulnerable to the health impacts of climate change ...... 56 Table (15): vulnerability, sensitivity of population groups and adaptive capacity ...... 61 Table (16): the overall impact of climate change on vulnerable population groups in Yemen ...... 81
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List of Figures Figure (1): the distribution of population of Yemen in the different Governorates in 2016 ...... 21 Figure (2) :estimated population of Yemen by age groups in 2016 ...... 22 Figure ( 3): trends (in percentage) of adult literacy rate (15 years and older) 1990-2015 ...... 23 Figure (4): estimated population in million in need of any humanitarian aid in 2015 ...... 25 Figure (5): number and types of health facilities in 2014 ...... 27 Figure 6 :number, type and sex of health human resources with bachelor degree in 2014 ...... 29 Figure (7): number, type and sex of the qualified health manpower in the public sector in 2014 ...... 30 Figure (8): the different sources of funding and their contribution to the health sector ...... 32 Figure (9): numbers and type of private health facilities in 2014 ...... 36 Figure (10): Yemen map showing annual rainfall variation among region and seasons ...... 38 Figure (11): life expectancy in Yemen compare to some Arab states in 2014 ...... 41 Figure (12): changes of life expectancy from before 1980s – 2013 in Yemen ...... 41 Figure (13): the proportion of morbidity for the first top four diseases by months in 2015 ...... 43 Figure (14): the proportion of morbidity for the second top four diseases by months in 2015 ...... 43 Figure (16): trends of IMR and U5MR between 1980s – 2013 in Yemen...... 45 Figure (17): variation of U5MR in children between the different governorate in 2013 ...... 45 Figure (18): trends of IMR and U5MR in Yemen compared to selected Arab’s countries ...... 46 Figure (19): the trends of MMR between 2000 – 2013 in Yemen ...... 46 Figure (20): trends of MMR in Yemen compare to some selected Arab’s countries ...... 47 Figure (21): framework of vulnerability assessment of the impact of climate change on health ...... 48 Figure (22): percentages of population in the different geographical areas in 2016 ...... 51 Figure (23): projected population by age groups in 2050 ...... 52 Figure (24): projected proportion of population by age groups in 2100 ...... 53 Figure (25): the projected population growth between 2010 – 2100 ...... 57 Figure (26): GDP Annual Growth Rate in Yemen 2006 - 2015 ...... 58 Figure (27): percentages of the type of natural disaster incidence in Yemen 1900-2011 ...... 63 Figure (28): Pathways of climate change on health ...... 64 Figure (29): the movement of Chapala Cyclone towards Yemeni coast 2015 ...... 65 Figure (30): the distribution of malaria cases by governorate in 2015...... 71 Figure (31): the number of malaria cases per month in 2015...... 71 Figure (32): the number of dengue fever cases per governorate in 2015...... 72 Figure (33): the number of dengue fever cases per month in 2015...... 73 Figure (34): the distribution of acute diarrhea cases by month in 2015 ...... 74 Figure (35): the distribution of bloody diarrhea cases by month in 2015 ...... 74 Figure (36): the number of reported cases of typhoid and paratyphoid per month in 2015 ...... 75 Figure (37): the number of cases of typhoid and paratyphoid per governorate in 2015 ...... 75 Figure (38): the distribution of URTI cases in the different governorates in 2015 ...... 76 Figure (39): the distribution of LRTI cases in the different governorates in 2015 ...... 76
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Acronyms AR5 Fifth Assessment Report AREA Agriculture research and Extension Authority CAMA Civil Aviation and Meteorological Authority CBC Complete Blood Count CCMA Climate Change Mitigation and Adaptation CI Confidence Interval CHIK Chikungunya Fever DEN Dengue DG Director General DPSEEA Driving Force, Pressure, State, Exposure, Effect, Action DJF December, January, February EU European Union EWS Early Warning System AR4 Fourth Assessment Report FP Family Planning GCM Global Climate Model GDP Gross Domestic Product GFR General Fertility Rate GHOs Governorate Health Offices GP General Practitioner HC Health Centers HDI Human Development Index HMIS Health Management Information System HIR Health Information and Research HIS Health Information System IDP Internally Displaced People IMR Infant Mortality Rate INC Initial National Communication ITCZ Inter Tropical Convergence Zone IPCC Intergovernmental Panel on Climate Change LDCs least developed countries LRTI Lower Respiratory Tract Infection
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JJA June, July, August MAI Ministry of Agriculture and Irrigation MEWS Malaria Early Warning Systems MMR Maternal Mortality Rate MoPHP Ministry of Public Health and Population NAPA National Action Program NWRA National Water Resource Authority NHS National Health Strategy PDS Planning and Development Sector NGOs Non- Governmental Organizations NMCP National Malaria Control Program OCHA United Nations Office for the Coordination of Humanitarian Aid NWRA National Water Resource Authority PHC Primary Health Care RH Reproductive Health RSC Red Sea Convergence SEI Stockholm Environment Institute TB Tuberculosis TDA Tehama Development Authority U5NR U5 Mortality Rate UNDP United Nation Development Program U5MR Under Five Mortality Rate UNFCCC United Nations Framework Convention on Climate Change UNISDR The UN International Strategy for Disaster Reduction URTI Upper respiratory tract Infection VBDs Vector-borne diseases WB World Bank WG Working Group WGP World Gross Product WHO World Health Organization WHO/EMRO World Health Organization Eastern Mediterranean Regional Office WNV West Nile Virus YFCA Yemen Family Care association
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Acknowledgement
This report would not be finished without the full support and guidance of the National Project Manager (NPM) Mr. Anwar Noaman and all member staff in Third National Communication, Biennial Update Report Project. I would like to express my great thanks and appreciation for their technical help, support and easy communication.
I would like also to thank all deputies, director generals, program and different directorates directors in all sectors in the MoPHP for their contribution, insight and knowledge that have given an added value to this assessment report.
Dr. Abdulsalam Saeed Al-Akel
Public health senior Advisor and consultant
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Glossary Terms
Climate change: A change of climate which is attributed directly or indirectly to human activity that alters the composition of the global atmosphere and which is in addition to natural climate variability observed over comparable time periods." (UNFCCC) Climate variability: refers to variations in the mean state and other statistics (such as standard deviations, statistics of extremes, etc.) of the climate on all temporal and spatial scales beyond that of individual weather events.
Vulnerability: The Intergovernmental Panel on Climate Change (IPCC) defines vulnerability as the degree to which a system is susceptible to, or unable to cope with, adverse effects of climate change, including climate variability and extremes. It depends not only on a system’s sensitivity but also on its adaptive capacity. Vulnerability is a function of the character, magnitude, and rate of climate change and variation to which a system is exposed, its sensitivity and its adaptive capacity.
Risk: IPCC defines risk as a function of probability and consequences of an event, with several ways of combining these two factors being possible.
Risk assessment: UNISDR defines risk assessment as a methodology to determine the nature and extent of risk by analyzing potential hazards and evaluating existing conditions of vulnerability that could pose a potential threat or harm to people, property, livelihoods and the environment on which they depend.
Impact: An effect of climate change on the socio-bio-physical system
Climate impact assessment: IPCC defines climate impact assessment as the practice of identifying and evaluating the detrimental and beneficial consequences of climate change on natural and human systems.
Risk reduction: UNISDR defines disaster risk reduction as the conceptual framework of elements considered with the possibilities to minimize vulnerabilities and disaster risks throughout a society, to avoid (prevention) or to limit (mitigation and preparedness) the adverse impacts of hazards, within the broad context of sustainable development.
Risk management: IPCC defines risk management as the culture, processes and structures directed towards realizing potential opportunities, whilst managing adverse effects.
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Adaptation: Adjustment in natural or human systems in response to actual or expected climatic stimuli or their effects, which moderates harm or exploits beneficial opportunities.
Anticipatory adaptation: Adaptation that takes place before impacts of climate change is observed (Referred also to proactive adaptation).
Adaptive Capacity: The ability of a system to design or implement effective adaptation strategies to adjust to information about potential climate change (including climate variability and extremes), to moderate potential damages, to take advantage of opportunities, or to cope with the consequences (modified from the IPCC to support project focus on management of future risks) (Ballard, 2009). As such this does not include the adaptive capacity of biophysical systems.
Consequence: The end result or effect on society, the economy or environment caused by some event or action (e.g. economic losses, loss of life). Consequences may be beneficial or detrimental. This may be expressed descriptively and/or semi-quantitatively (high, medium, low) or quantitatively (monetary value, number of people affected etc.).
Response function: Defines how climate impacts or consequences vary with key climate variables. These can be based on observations, sensitivity analysis, and impacts modeling and/or expert elicitation.
Sensitivity: The degree to which a system is affected, either adversely or beneficially, by climate variability or change.
Uncertainty: A characteristic of a system or decision where the probabilities that certain states or outcomes have occurred or may occur is not precisely known.
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Map of Yemen
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Executive Summary
Yemen is one of the least developed countries (LDCs) in the world and is considered to be the driest and the poorest country in the Middle East. It is ranked 160 out of 188 countries in 2014. Though the annual GDP has averaged 3-4% since 2000 till 2010, reaching an all-time high of 7.70% in 2010, it recorded -28.10% in 2015. Yemen also has the lowest level of official development assistance (ODA) per capita at $12.70, or just 2.2% of GDP, compared to $33.40 per capita (18.7% of GDP) for the other LDCs in the World (UNDP/ Yemen HDR. 2015).
Poverty in Yemen is endemic and has been increased from 42% in 2009 to 54.5% in 2012 to more than 85 % in July 2016, particularly in rural, remote and less accessible areas where about two thirds of the population live including 80% of the poor. Hunger and undernutrition are widespread and one in three Yemenis are acutely hungry and with no sufficient resources to access to nutritious food necessary for their healthy and productive life (WB, Yemen 2016).
Yemen is also ranking the 11th most food insecure globally in 2015 with an estimated 14.4 million being food insecure of whom 7.6 million severely food insecure; and nearly 320,000 children are severely acutely undernourished (HNO, Yemen. 2016). 53% of children under five are stunted reaching to 63% among poor children (The Fourth 5-Year Health Development & Poverty Alleviation Plan 2011 -2015), and more than half of all children under 5 years is underweight making the country the third highest rates in the World after India and Bangladesh (WFP, Yemen 2015.).
Another challenging issue facing the country and not in pace with natural resources is the rapid and continuous population growth rate. According to medium variant projection, the population size is expected to increase from 27.534 million in July 2016 to 47.17 million in 2050 and to 51 million in 2100. The elderly people will increase from 2.7% in 2016 to 20% in 2100 (World Bank Data, Population density, 2015).
The already existed water scarcity in the country will be increased and the availability of water per capita is falling steadily, with only 31% of the population have access to pure drinking water. Illiteracy is very high with an overall rate of 45% and gender disparities are the highest in the world with Gender Inequality Index of 152 out of 187 countries (UNDP/ Yemen HDR. 2015).
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The current health status of the population is so poor as indicated by the very high rates of infant, under five and maternal morbidities and mortalities. Yemen still at the early stage of the third epidemiological transition and the most common and serious health conditions and causes of current morbidity and mortality are due to infectious and endemic diseases. Morbidities and mortalities from communicable diseases are predominating over non-communicable diseases. 96.7% of the total burden of disease are due to 10 infectious and endemic diseases with 86.2% of the total burden of disease caused by the top four and most common diseases which include acute diarrhoea, URTI, malaria, and LRTI, while 23 diseases account for only 3.3% of the burden of disease. Non-communicable diseases are also increasing but data are fragmented, distorted and lack uniformity over successive years (Surveillance report, 2015 ).
Climate change is among other emerging development challenges. In 2001,Yemen's Initial National Communication (INC) to the UNFCCC has reported the vulnerability of the social and biophysical environment from climate variability, the increased climatic variability will lead to the possibility of spread and growth of vector and water borne diseases (EPC, 2001 &NAPA, Yemen. 2009).
Yemen is a disaster-prone country and faces a number of natural hazards. Climate-related hazards such as extreme temperatures, floods, landslides, sea level rise and droughts, with floods being the most important and recurring form of disaster, are inevitably occurring (CRED, 2011). Exposure to these climate related hazards are expected to severely exacerbate health problems such as vectorborne and waterborne diseases which may extend their range into areas that are presently unaffected as well as chronic diseases such as cardiac, respiratory and renal disease. The largest risks will apply in populations that are currently most affected by climate related diseases and hence it is expected that health losses due to climate change-induced under-nutrition will occur mainly in areas that are already food-insecure (IPPC, 2013).
Health data and information are characterized by fragmentation and distortion and they lack a unique pattern of occurrence and changes when compared with the previous year’s neither for the same diseases nor for the same places and seasons of occurrences making them unreliable source for drawing causality relationship (Annual Health Statistical books, 2000 to 2015). Climate data also have the same defective characteristics as for the health data. Climate data for precipitation, temperatures and humidity records lack adequate spatial coverage, poor quality and
Page 14 long-term systematic records are very scarce. Climate data collection are fragmented between different institutions with little cooperation between these agencies (Wilby, R. 2009).
As a result of these difficulties and limitations which hinder the quantitative assessment of the direct and indirect health effect of climate change on the health of Yemeni population, a qualitative assessment of vulnerability and adaptation has been conducted through a structured interviews and questionnaire targeting leadership and decision makers in the MoPHP, in addition to literature review at local, regional and international levels in order to identify the vulnerable regions, the vulnerable population groups, the extent to which their health are sensitive to climate change and the subsequent adaptation actions taking into account the best practice of assessment of climate change impact, vulnerability and adaptation that are related to the frameworks and guidelines of WHO. The assessment process was composed of four stages:
1. First stage in which the vulnerable population groups have been identified based on IPCC Fifth Assessment Report definition of vulnerability. The potential vulnerable population groups included children under 5 years, women in the childbearing period especially pregnant, elderly people above 65 years, populations with infectious and chronic diseases and population with low socioeconomic standards living conditions and others. 2. The second stage involved the development of two baseline socioeconomic scenarios depending on the socioeconomic and demographic factors related to 2010 as a base year and the projected demographic status of the population in 2050 and 2100. Under Scenario A, the vulnerability of population health to climate change has been found to be higher than in Scenario B. 3. The third stage involved the development of a climate change scenario and the projected climate change from the available literature reviews. 4. The fourth stage, the impacts of climate change on the public health of Yemeni population were analyzed by combining both sensitivity and exposure analysis of the different population groups to the impact of climatic change. The impact of climate change on health was found to be more severe under scenario A than Scenario B which indicated the needs for higher adaptive capacity in the health care sector.
Minimizing the consequences of recent war and taking into account the 2010 health indicators as a base year, the degree to which current health programs and measures will need modification to
Page 15 address additional pressures from climate change will depend on the current burden of ill health; the effectiveness of current interventions; projections of where, when, and how the health burden could change with climate change; the feasibility of implementing additional programs; other stressors that could increase or decrease resilience; and the social, economic, and political context for intervention (Ebi et al., 2006).
Efforts to adapt to the health impacts of climate change can be categorized as incremental, transitional, and transformational actions. Incremental adaptation includes improving public health and health care services for climate-related health outcomes, without necessarily considering the possible impacts of climate change (IPCC, 2013). Rebuilding and maintaining of public health infrastructure are often viewed as the “most important, cost-effective and urgently needed” adaptation strategy to climate change in the human health sector (IPCC, 2001). These include public health training, effective surveillance and emergency response systems, and sustainable prevention and control programs (WHO & UNEP, 2003).
The specific adaptation strategies (Incremental) in the health sector should include the following:
1. Establishing an epidemiological surveillance system for monitoring changes in vector population abundance in the main targeted high risk and expected transmission areas. 2. Strengthening surveillance for vectorborne, waterborne and foodborne diseases. 3. Establishing surveillance system for temperature-related mortality and morbidity and adverse health effects of air pollution exposure. 4. Improve access and utilization of health care services for all population taking into accounts equity and gender disparities. 5. Prepare effective and responsive preparedness system with full capabilities to deal with unexpectedly disasters. 6. Allocate financial and human resources for research on the field of climate change and its linkage to infectious disease and temperature related mortalities and morbidities. 7. Allocate adequate financial and human health resources and capacity building in the field of climate change impact which include training, surveillance and emergency response, and prevention and control programs. 8. Improve access to clean water and sanitation services for underserved and to vulnerable groups.
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9. Strengthening and expanding routine vaccination programs 10. Ensuring essential medical supplies for care of individuals with chronic conditions, including effective post-disaster distribution, would increase the ability of communities to manage large-scale floods and storms. 11. Ensuring the adequate supply of drugs against malaria and enteric infections for treatment of people promptly and effectively
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1. Introduction
Human influence on the climate system is clear, and recent anthropogenic emissions of green- house gases are the highest in history. Recent climate changes have had widespread impacts on human and natural systems. The atmosphere and ocean have warmed, the amounts of snow and ice have diminished, and sea level has risen (IPPC,2013).
The globally averaged combined land and ocean surface temperature data show a warming of 0.85°C [0.65 to 1.06] over the period 1880 to 2012, when multiple independently produced datasets exist (IPPC,2013). Due to the time lag between emissions and temperature rise, past emissions are expected to contribute to 0.2°C increase per decade in global temperatures for the next 2-3 decades, irrespective of mitigation efforts during that time period. IPCC projects a rise of 1.4 ºC to 5.8 ºC in the global temperature by the end of this century (IPCC, 2007b).
According to the WHO Regional Office of Eastern Mediterranean (WHO/EMRO, 2008a), the region is one of the most vulnerable regions to climate change because of its arid nature and reliance on rain-fed food production’ and because of the endemic nature of many diseases and health problems which are sensitive to poverty and climate change, making the impact of climate change on the region greater than that on the world as a whole (Fankhauser and Tol, 1997).
Yemen is chronically suffering from very weak economy, high levels of poverty rates, weak institutional capacities, lack of the necessary resources for adaptation, high and rapid population growth, poor management of available and scarce resources (NHS,2010 - 2025). These factors will make Yemen extremely vulnerable to the effects of climate related change such as drought, extreme flooding, pests, sudden disease outbreaks, changes of rainfall patterns, increased storm frequency/severity and sea level rise (Yemen Proposal for Phase 1, 2010).
The average annual temperature series for Yemen shows warming of 0.5°C throughout the entire 20th century and the mean annual temperature is projected to increase by 1.2 to 3.3°C by the 2060s, and 1.6 to 5.4 degrees by the 2090s. The projections of future rainfall disagree in most model with broad consistency between models project rainfalls increase in September, October, and November (SON). Increase heavy falls events are projected in autumn SON with an increased risk of floods and drought (UNDP, Climate Change Country Profile. Yemen, 2011).
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In regards to the impact of climate change on population health, the IPCC 5th Assessment Report stated that climate change is already having an impact on the global burden of morbidity and mortality and such effects are likely to increase all around the globe. The nature and magnitude of climate change will determine the extent and nature of future health impacts (IPCC, 2012).
In 2001,Yemen's Initial National Communication (INC) to the UNFCCC has reported the vulnerability of the social and biophysical environment from climate variability and the increased climatic variability will lead to the possibility of spread and growth of vector borne and water borne diseases (NAPA, Yemen. 2009), but there has been no action in the health sector in regards to the impact of climate change or on vulnerability and adaptation assessment.
The health of human population is sensitive to shifts in weather patterns and other aspects of climate change (very high confidence) and hence all population are vulnerable to health impact of climate change but the impact is expected to be more severe in children, the poor people, especially women and particularly pregnant women, elderly people and people with chronic medical conditions and disabilities. The impact of climate change on health can occur directly as a result of changes in temperature and precipitation and occurrence of heat waves, floods, droughts, and fires, and indirectly through ecological disruptions brought on by climate change on crop failures, shifting patterns of disease vectors, or on social responses to climate change such as displacement of populations following prolonged drought (Smith et al., 2014).
The main objective of this consultancy is to undertake an evaluation of climate change impact on human health and population vulnerabilities in order to determine the levels to which the Yemeni population is vulnerable to adverse climatic events and identify options for adaptation measures through a participatory mechanism with relevant stakeholders.
The assessment process of the impact of climate change on public health sector will be according to WHO framework that include vulnerability, impact and adaptation. The IPCC defines vulnerability as the propensity or predisposition to be adversely affected and is considered as a function of a) the exposure to the climate-related hazard, including the character, magnitude, and rate of climate variation; b) sensitivity, which includes the extent to which health, or the natural or social systems on which health outcomes depend, are sensitive to changes in weather and climate (the exposure–response relationship) and the characteristics of the population, such as its demographic structure, physical, environmental, social, cultural and economic situation; and c)
Page 19 the adaptation measures and actions in place to reduce the burden of a specific adverse health outcome (the adaptation baseline), the effectiveness of which may influence the exposure– response relationship (IPPC, 2007).
Because climate change is not the only factor affecting the geographical range and incidence of climate-sensitive health outcomes and because non-climatic factors, social determinants of health, can have a strong or even dominant effect, either independently or by modifying climate effects, it is important to understand the various causal pathways from climate change to health outcomes, in order to identify opportunities to address the environmental determinants of poor health outcomes. A modified Driving Force, Pressure, State, Exposure, Effect, Action (DPSEEA) Framework will be also used in the current assessment to describe the actions of various causes that act, more or less directly, on health outcomes from environmental or related behavioral conditions and the various levels of actions that can be taken to reduce health impacts (Corvalan et al., 2000).
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2 Yemen General Background
2.1 Yemen Socioeconomic and Political Context
Yemen population will continue growing even though fertility rate will be decreased markedly. According to the medium variant projection, the population size is expected to increase from 27.534 million in July 2016 to 47.17 million in 2050 and to 51million in 2100, an increase by nearly 23 million before it starts to a stabilize growth between 2050 – 2100, where the increase in the total size will not exceed 4.5 million (World Population Review, Yemen, 2016). The growth in size will come mainly from the already existed young population who form nearly 40% of the currently estimated population “a phenomena known as population momentum”. Yemen’s population are scattered over 130,000 localities and in 22 governorates, including the newly declared Socatra governorate, with a different population density that varies among governorates. About two third of the population (including 80 percent of the poor) live in rural areas and most of them depend on agriculture for their livelihoods and 43% of the population live in four governorates as shown in the below figure (UN Population Division, Yemen. 2016).
Figure (1): the distribution of population of Yemen in the different Governorates in 2016
Distribution of Population in the Different Governorates in 2016
11.95 11.0210.65 9.54 7.52 6.75
4.54 4.3 3.63 3.59 3.06 2.96 2.88 2.5 2.4 2.35 2.29 2.21 2.16 2.01 1.2 0.47
The age-population composition indicates that more than 40%of the population is below the age of 15 years, of whom 14.5% under the age of 5 years and 3.44% are infants, and the proportion of population in the age group 15- 64 years, for both male and female, accounts for 57.1% of whom 24.9% are women in the childbearing age group 15 - 49 years.
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Older population group aged 65 year and above form only 3.2% of the estimated total population of whom only1.2% are above 70 years. The figure below shows the distribution of population by age groups in 2016. Figure (2) :estimated population of Yemen by age groups in 2016
Estimated Population by Age Groups in 2016
14.5 13.6 12.1 11 10.7 9.1 7.3 5.6 3.9 2.9 2.5 2.2 1.9 1.3 0.8 0.4 0.2
0 - 4 5 - 9 10 -1415 - 1920 - 2425 - 2930 - 3435 - 3940 - 4445 - 4950 - 5455 - 5960 - 6465 - 6970 - 7475 - 7980 - 84 Economically, Yemen is one of the least developed country in the world and considered to be the driest and the poorest country in the Middle East. It ranks 160 out of 188 countries in 2014 on the UNDP Human Development Index (UNDP/ Yemen HDR. 2015). The annual GDP has averaged 3-4% between 2000 to 2010, and deteriorated after the 2010’s Arab Spring Upraising, which is only slightly above the population growth rate (3% around 2005), making the economic development so slow. Unemployment rate estimated as high as 40 percent. The country's poor natural resources base cannot meet the needs of a population that is growing and doubling every twenty years and so the economic growth must exceed 10% per year if the population growth rate and fertility trends remain as it is now 3% and 6.0% respectively (Sarah Clark, 2007).
Poverty in Yemen is endemic, particularly in more remote and less accessible areas increasing from 42% in 2009, to 54.5% in 2012 to more than 85 % in July 2016 (WB, 2016). An estimated 14.4 million are food insecure of whom 7.6 million severely food insecure in 2015; and nearly 320,000 children are severely acutely undernourished. A shrinking resource base, coupled with already low productivity and the shock of internal conflict, places enormous pressure on social and economic systems of Yemen’s and contributes further to increasing poverty (HNO, 2016).
Hunger and undernutrition are widespread ranking the country the 11th most food insecure globally with 32% of the population food insecure. One in three Yemenis are acutely hungry and with no sufficient resources to access nutritious food necessary for healthy and productive life. Half of the country's children are chronically undernourished and less than 1 in 10 children
Page 22 live to reach the age of 5 years. Such emergency levels of chronic undernutrition - or stunting - are second globally to Afghanistan. More than half of all children under 5 year in Yemen are underweight making the country the third highest in the World after India and Bangladesh (WFP, 2015). The percentage of stunted Yemeni children under five reached 53% and reaching to 63% among poor children (4th 5 Year Strategic Plan).
In addition, Yemen is ranked the 9th in the World Risk Report in 2012 that presented the top 15 list of countries with the greatest lack of coping capacities (World Risk Report, 2012). The conditions were exacerbated by deepening poverty, lack of gainful employment opportunities particularly for the youth, and loss of faith in a government that was increasingly seen as not being capable of meeting pressing social and economic needs (USAID, 2014).
Yemen also suffers from high illiteracy with an overall rate of 45%. The overall literacy rate in 1990 was 37.1% and reached in 2015 to 77.4% with high differentiation between male and female. The observed and projected literacy rates of adult women were 17% in 1990, 36% in 2000, 47% in 2010, and 55% in 2015 compared to male literacy rates of 56.7%, 74.3%, 81.2% and 85.5% for the same years (UNESCO, 2012). Gender disparities is the highest in the World with Gender Inequality Index of 152 out of 187 countries (UNDP, HDR. Yemen, 2015). The figure below shows the trends of literacy rate in Yemen between 1990 and 2015.
Figure ( 3): trends in percent of adult literacy rate (15 years and older) 1990-2015
Trends of Literacy Rates in Yemen Between 1990 - 2015 Total literacy Rate Male Literacy Rate Female Literacy Rate Female Illiteracy Rate
75.6 74 71.7 55.1 46.8 66.3 35.5 85.5 81.2 74.3 17.1 56.7 77.4 54.7 63.9 37.1
1990 2000 2010 2015 Source: UNESCO Institute for Statistics, May 2012. Another issue of great concerns is the Gender Inequality Index (GII) where Yemen is ranking 155 out of 155 countries in the 2014 index whereas Sudan is ranked at 135 on this index. Only
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0.7 percent of parliamentary seats are held by women, and 8.6 percent of adult women have reached at least a secondary level of education compared to 26.7 percent of their male counterparts. For every 100,000 live births, 270 women die from pregnancy related causes; and the adolescent birth rate is 47.0 births per 1,000 women of ages 15-19. Female participation in the labour market is 25.4 percent compared to 72.2 for men (UNDP, HDR Yemen, 2015).
Yemen also suffers from severe water scarcity and the current scarcity of water resources are becoming increasingly precious and the per capita availability is falling steadily with growing population. In 1955, Yemen’s per capita water availability was 1,098 cubic meters; fallen in 1990 to 460 m3, and is projected to drop to 150 m3 by 2025. Surface water is largely seasonal and unreliable and groundwater is being simultaneously polluted and extracted in excess of recharge (Nicole Glass, 2012). Only 31% of the population were having access to pure drinking water while sanitation services were available for only 23% (Annual Health Statistic Report, 2014). The table below shows the proportion of population of access to drinking water and sanitation services in Yemen compared to other countries in the Arab’s region.
Table (1): the proportion of population of access to drinking water and sanitation services in Yemen compared to other countries in the Arab’s region.
Indicator Year/ Yemen Egypt Iraq Jordan Oman Sudan Syria Indicator % of population Year 3002 3002 3002 3002 3002 3002 3002 with drinking water Indicator 21 44 11 41 27 72 11 % of population Year 3002 3002 3002 3002 3002 3002 3002 access to sanitation Indicator 32 44 14 20 14 21 42 Sources: WHO Report (Regional Office for Eastern Mediterranean – 2009)
Yemen political instability, civil insecurity, intensified war, and localized conflicts have plunged the country into a serious food security and humanitarian crisis, and put into further jeopardy an already precarious food security situation. The ongoing war has devastated Yemen, where the estimated number of people in needs of any kind of humanitarian assistance in 2015 exceeded 21.2 million (82% of the total population) compared to 15.9 million in 2014 and the severity of needs among vulnerable people has been intensified across all developmental sectors. These
Page 24 needs were aggravated by years of poverty, under-development, environmental decline, intermittent conflict, and weak rule of law – including widespread violations of human rights.
Nearly 19.3 million in 2015 (the figure is increasing) were lacking adequate access to clean water or sanitation and three out of four Yemeni are unable to meet their basic wash needs as a result of war and long-standing vulnerabilities. More over the war has caused 1.8 million children out of school since mid-March 2015. Low education levels have aggravated the high already illiteracy rates being at 66% for women and 27% for men (HNO, Yemen, 2016).
Figure (4): estimated population in million in need of any humanitarian aid in 2015
Estimated Population in Million of Any Humanitarian Needs in 2015 26.7 21.2 18.3 19.3 14.4 14.1 14.1 12.4 12.4 7.6 2.3 3 2.8
The total number of IDPs has raised to nearly three million, half of whom are in Aden, Taiz, Hajjah and Al Dhale’e governorates – and an additional 121,000 who have fled the country. About 2.7 million people now require support to secure shelter or essential household supplies, including IDPs and vulnerable host families. IDPs are currently sheltering in 260 schools, preventing access to education for 13,000 children (OCHA, Yemen. 2015).
In addition, 14.1 million people are lacking sufficient access to basic healthcare and 3 million children and pregnant or lactating women require malnutrition treatment or preventive services. Medical equipment and supplies for mass casualty management and medicine for most chronic diseases are increasingly in short supply. The difficult and chronic economic conditions superimposed by war have also forced the authorities of the Central Bank of Yemen to cut all operational expenses even the allocation of money for drugs and medication for chronic diseases (see health care financing). With nearly 600 health facilities being stopped functioning due to
Page 25 persistence war mainly in Taiz, conflict-related damage or lack of fuel, staff and supplies have led to the appearance of epidemics of dengue fever in AL Hodeida, Aden and Taiz with high fatality rates (OCHA, Yemen. 2015).
2.2 Yemen Health System Background
The healthcare system in Yemen is primarily managed by the following sectors: 1. Public health sector through the Ministry of Public Health and Population (MoPHP) 2. Few autonomous hospitals such as oil refinery hospital in Aden which specifically deliver health services for the oil refinery employees. 3. The private sector also play an important role in providing healthcare services of different quality either through well-structured hospitals with highly staffed and highly equipped facilities or through private clinics which are mainly allocated in the main cities. 4. Non-Governmental organizations which have health care facilities that provide health care in some specialties like RH and Obstetric and Gynecological health care and psychological care such as Yemen Family Care Association (YFCA) and the Charitable Society for Social Welfare (CSSW). 5. International donors and Organization which provide health services to internally displaced population and refugees so as to the local residents. 6. The Military and police health sector. 7. Ministry of higher education teaching hospitals such as AL Kuwait hospital. 2.2.1 Public Health Sector (MoPHP)
A standard pattern of four- levels health care facilities and health personnel staffing have been adopted by the MoPHP in order to achieve better health services coverage for the whole population in urban and rural areas. These include preventive, diagnostic and rehabilitative services, however, this model is facing so many challenges and constrains that impede the delivery of sufficient and quality health care. About 26% of health facilities are without drugs, 24% without equipment, 17% without operational budgets, and 7% without health staff all of which have been reflected directly on the utilization and accessibility of the health services including medical drugs (The NHS, 2010-2025).
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2.2.1.1 Public Health Facilities The public health sector is composed of a total of 4,209 health institutions and facilities which includes 2 referral hospitals, 56 general and provincial hospital, 187 district hospitals, 61 health centers with beds, 820 health centers without beds, 3,047 primary health care units and 36 health complex with a total of 16,851 beds (Annual Statistical Health Report, 2014).
Figure (5): number and types of health facilities in 2014
Type and Numbers of Public Health Facilities in 2014 3047 820 187 61 56 36
2
Referral General District HC with beds HC without Health Health Units Hospital Hospital beds Complexes
Despite this wide geographical spread of health units, centers and governorate’s and districts hospitals throughout the country in terms of numbers, they are poorly distributed, inadequately staffed, poorly financed and with a very primitive logistic system making coverage and quality of health services at the four levels of health delivery system of great concerns in terms of meeting the needs and satisfaction of beneficiaries. Variation in geographical distribution of health facilities, health personnel and budget allocations are neither dependent on population density, epidemiological situation nor on the number and type of population localities.
According to the NHS, 2010 – 2025 & 4th 5 years health plan for the MoPHP, the structure and service delivery model of public health facilities are classified into four levels: first level of primary health care (PHC), second level of secondary health care, third level of tertiary health care and fourth level of specialized health care services and these are explained as follows:
2.2.1.1.1 First Level: Primary Health Care (PHC)
This level includes health units, health centers and mother and child health care centers in addition to health complexes. These facilities are scattered at the level of sub-districts and villages and mainly located in rural areas except for health complexes which are mainly located
Page 27 in the Sana’a city that has 23 health complexes, Aden governorate with 12 health complexes and in Taiz governorate with only one health complex. The PHC health facilities are considered to be the first line of contact between targeted population and the preventive and therapeutic services before referring to higher levels of the national health system. The provided health care is based on the concept of “health for all” that is adopted by the MoPHP. The health care facilities are supposed to provide all immunization schedule for targeted population, the treatment of diarrheal disease, malnutrition, anemia, malaria, TB, family planning services, pregnancy test, antenatal and postnatal care, normal delivery and manual removal of placenta, causalities management, CBCs, blood grouping, X-Rays radiology and health education.
2.2.1.1.2 Second Level: Secondary Health Care
There are 243 district and provincial hospitals with 15,691 beds that provide health care which is not available at the first level. Most of these district hospitals provide services similar to those provided by health centers in addition to cesarean sections emergency management of abdominal pain, causalities management, genitourinary tract diseases, children emergency resuscitation, obstetrics and gynecology health services, cardio-pulmonary diseases, non-communicable diseases, chronic diseases and anesthesia.
2.2.1.1.3 Third Level: Tertiary Health Care
It includes two referral hospitals, Al-Thawra in Sana’a city and Al Jumhoria in Aden, which receive all cases ranging from simple cold cases to complicated hot cases due to absence of effective referral system in all layers of the health system. These hospitals are not capable of treating all cases with some patients resort to private centers or for abroad treatment. The proposed services provided at this level include caesarian section, abdominal emergency case management, causalities, genitourinary tract diseases, pediatric emergencies, cardio- pulmonary diseases, non-communicable diseases, chronic disease, anesthesia, blood transfusion, laboratory services, radiology and training of medical students, doctors and nurses.
2.2.1.1.4 Fourth Level: Specialized Health Care Services
These are specialized health centers such as cardiac, nephrology, rehabilitation, cancer and blood banks. These health institutions are mainly located in Sana’a city and in Aden governorate. The
Page 28 health care services provided by these facilities include rare specializations such as open heart surgery, organ transplantation, cancer therapy and so on. 2.2.2 Human Resources of Public Health Sector According to MoPHP’s Annual Statistic Health Report 2014, the total number of human health manpower forces in the public health sector reached (52,723) persons of whom 20.2% (10,635) are administrator staff. The health manpower forces with bachelor degree and above form only 21.5% (11,317) of the total health manpower of whom 41.7% (4,429) are general practitioners, 17.2% (1,826) medical and surgical specialists, 10.8% (1,153) laboratory specialist, 10.0% (1067) pharmacist, 6.0% (634) dentists and 9.9% (1,054) are nursing staff.
Figure 6 :number, type and sex of health human resources with bachelor degree in 2014
Male and Female Health Manpower with Bachelor Degree in 2014 Male Female Total 3066 4429 1826 1163 1363 1153 1067 1054 663 772 859 634 646 381 457 408 208 177
Specialist Physicians Laboratory Pharmacists Dentists Nurse
The remaining portion of the health manpower with bachelor degree collectively forms slightly less than 4% (424) and they are shown in the below table.
Table (2) :number, type and sex of health manpower in the public sector in 2014
Specialties Male Female Specialties Male Female Psychologist 22 26 Rehabilitation 0 0 Public Health 107 8 Physiotherapy 10 6 Radiology 50 39 Community medicine 24 3 Nutrition 20 4 Physics physician 2 0 Anesthesia 72 2 others 60 17 Total 271 79 Total 96 26
In addition, the number of qualified technicians and health manpower account for 56.4% (29,715) of the total health manpower of whom 22% (11,777) are nursing staff and 8.4% (4,432) are midwifes. The number, type and sex of technical health manpower in 2014 as shown below.
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Figure (7): number, type and sex of the qualified health manpower in the public sector in 2014
Male and Female Quaified Technical Health Manpower in 2014 Male Female 7545 3132 3982 1463 2429 1738 1443 1009 673 182 293 167 102
These facts indicate that the health sector still suffering from a significant staff shortage at the levels of speculations and sex (male and female) distribution where female form less than 34% for GPs, specialists and nurses.
According to WHO, Yemen is considered as one of the 57 countries that suffer critically from shortages of health human resources. WHO has approved a standards for health human resources of 2.3 per 1,000 people and in Yemen the figure is 0.86% per 1,000 people (WHO report, Yemen, 2006). The percentage of doctors, nurses and midwifes to population is shown below.
Table (3): percentage of doctors, nurses and midwifes to population in 2014.
Health Cadre Total Percentage to 1000 people Doctors 6,255 0.23 Nurses 12927 0.47 Midwifes 4432 0.16 Total 23,614 0.86
In addition there is a major differentiation in staffing between governorates and between rural and urban areas where 80% of staff are present in urban areas in terms of staff ratio per 10,000 of the population and this difference exists among governorates and districts.
Geographically, 75% of the health manpower are concentrated only in four governorates with 82% of specialists and 52% of GPs. These governorates include Sana’a city, Aden, Taiz and Hadramout and they form 34% of the total population. Health manpower to population percentages vary greatly among these governorates. The distribution of specialist and general practitioner in four governorates in 2014 are shown in the following table.
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Table (4): number of GPs and Specialists in 4 governorates and population percentages in 2014
Governorate No. of SP No. of GPs Total Population Population % Taiz 37 563 600 329031300 13.0 Aden 569 404 973 84254040 3.06 Hadramout 221 472 693 144553500 5.25 Capital Sana'a 700 1081 1781 262674360 9.54 Total 1527 2520 4047 820513200 34 On the other hand 37% of the population who live in another four governances that include Hodeida, IBB, Dhamar and Hajja have only 14% of the health manpower. The distribution of specialist and general practitioner in 4 governorates in 2014 are shown in the below table.
Table (5): number of Specialists and GPs to population percentages in 4 governorates in 2014
Governorate No. of SP No. of GPs Total Population Population % Hodeidah 51 236 287 303424680 12.02 IBB 20 321 341 293237100 11.05 Hajja 18 98 116 207055680 7.52 Dhamar 18 167 185 185854500 6.75 Total 107 822 929 989571960 37.0
In General there are 2.58 doctors/10,000 of the population which means the availability of one doctor per 3,874 of the population. These ratio differ markedly between different governorates where the ratio in Aden is one doctor/834 of the population and one doctor/1,422 people in the capital Sana’a reaching to one doctor/2,250 people in Lahj. The ratio is much more higher in other governorates reaching one doctor/9,416 people in Hodeida, one doctor/13,04 in Dhamar and in Raimah the ratio is one doctor/ 22,008 people. At the same time there is only 0.2 dentists/ 10,000 people i.e. one dentist/38, 978 of the population and the ratio even higher in Taiz and Hodeida reaching one dentist per 55,799 and 72,105 respectively, comparing to one dentist per 462,176 in Raimah (that form the total population) governorate.
2.2.3 Public Health Care Financing
Reviewed literatures indicates that funding of the health sector is one of the most critical issues affecting the coverage and performance of the national health system. The governmental spending per capita on health in 2007 is estimated at $ 16.5 US/year. The allocated budget by the government for health for 2014 was 3.58% of the total government budget of 2.88 trillion Yemeni Rials which is equivalent to $13.4 billion. The actual spending on health from 2007 –
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2012 is in fact less than 50% of the already low allocated budget (General Government Budgets, 2014). The actual spending for 2012 & the estimated budget for 2013 – 2015 are shown below.
Table (6): the actual spending for 2012 and the estimated budget in thousands for 2013 – 2015.
Financial Year 2012 Financial Year 2013 Financial Year 2014 Financial Year 2015 Actual Expenditure Allocated Budget Estimated Budget Estimated Budget 89,976,921 117, 086,395 127, 117, 028 126,038,457
The main financial resources of the health sector in Yemen come from government budget and private payments from the patient’s own pockets. Yemen has a very high out-of-pocket health expenditure of 57.6% compared with other countries in the region (Yemen National Health Account , 2007). Moreover, it is evident that 29% of the health expenditure goes for treatment abroad and 95% of this expenditure is paid by the citizens themselves, and this make the estimated private expenditure on health as percent of total expenditure around 72%. The different sources of funding and their contribution to the health sector are shown below.
Figure (8): the different sources of funding and their contribution to the health sector
Source of Funding of Health Sector
Parastatal bodies Private Foreign 4% employers assistance 4% 11% Households Ministry 56% of Finance 25%
Though the main issue is the insufficient government allocations of financial resources for health sector, yet the effective public spending on health is very low. More than 50% of the total budget is consumed by salaries for the different health manpower and about 30% of the allocated (not effectively spend) money is for the investment program (30 to 40 billion allocated Yemeni Rials yearly) and is used for fixed costs such as buildings, energy and maintenance leaving only small fraction of the allocated money for direct health – related costs such as health promotion, disease prevention, and diagnosis and treatment of chronic diseases. In recent years, salaries and wages have been declined and resulted in low morale among staff. Because of the lack of the right and
Page 32 enough funds, health facilities became poorly equipped with no essential commodities and medicines (WHO Country Cooperation Strategy, Yemen. 2010) 2.2.4 Public Health Services Coverage The current percentage of average health care coverage has not been accurately calculated and it has been roughly estimated between 58% in 2005 to 66% in 2007 up to 67% in 2008 to 68% in 2010 and these percentages were dependent on selected primary health care services only (not including the secondary and tertiary health services) such as vaccinations coverage and RH services mainly FP, antenatal care, postnatal care and skilled birth attendance. The achieved primary health care coverage in 2010 is shown in the below table.
Table ( 7): percentage of primary health care coverage in 2010
Health institutions No. of beneficiaries/1000 Coverage/population Health units 4.141 39% Health Centers 2.124 29% Total 12.022 68%
2.2.5 Public Health Information System
This is the fifth axis of the National Health Strategy 2010 - 2050 which states “the work towards ensuring the availability of correct health information, with improved quantity and quality and increase their actual value to ensure accuracy and utilization in the right time through developing a simplified and unified system that aims at providing the flow of health information to assist in making and taking the right decisions and guarantee that the process is in line with the organizational development aiming at bringing investments in HIS”.
An interview with HIR director outlined the current status of HIMS and the challenges facing the department. Though the HIR department is well equipped and has the qualified personnel, it appears that there is no written standardized protocols defining roles, responsibilities and procedures related to the standardization, collection, management, analysis and dissemination of data. In addition, there is no written formal policy and legislations that outline the responsibilities of the other departments and health facilities on the way of reporting to HIR department.
The current HIR department is under the Planning and Development Sector (PDS) and it is considered to be the main body responsible for collecting, managing and disseminating health
Page 33 information. The major support of the departments comes from EU, WHO and the WB. The department faces so many challenges among which the creation of a unified health information system that is capable of providing continuous, comprehensive, correct, accurate, precise, based on facts and evidence and timely bound information that is necessary for sound decisions to be taken by decision makers. The manifestation of HMIS in the MoPHP as reported by HIR director can be listed as follows: 1. there is no established and respected mechanism of exchanging health information at governorate, district or health facility levels 2. the presence of separate unit for managing the health information system with different formats in the governorates, districts at the programs levels. 3. each vertical program maintains its own separate information system and data formats through its health information or M&E program coordinator and so reporting of some vertical programs does not always flow through the necessary steps. 4. there is no system for compiling data from all sources and producing comprehensive annual or periodic reports. 5. instead of the HMIS Department sending data to programs, various programs send their program specific report to the HIR department (Health Information Systems Assessment Report, 2009 & interview with HIR director, 2016). 2.2.6 Governance, Leadership and Structural Arrangements The role and functions of the MoPHP’s current structural system are not compatible or forming an integral part with the realistic developments with local authority and decentralization. There are no clear demarcation lines of tasks and responsibilities between the health system at the local level and the overlapping responsibilities at the central and local levels as well as the unclear responsibilities of the administrative entities between the Health Offices and the Local Authority Councils. The methods of running the districts health system and provision of integral services that are effectively sensitive to the community needs also haven't been improved.
At the central level of MoPHP, certain general directorates have more access and control of resources than others and that has made these directorate more influential in the health system and those with scarce financial resources are less efficient in their performance. This has led to power struggle that is manifested by continuous organizational restructuring changes and the
Page 34 movement of some directorates from their original positions in the organizational structure to be under another sector or under the direct authority of the minister of health.
This vertical management arrangement, based on subjective justification, has caused extreme centralization of authority which in turn has weakened control and monitoring of the functions of general directorates both at the central and at the GHOs levels which also connected directly to the minister office. The organizational setups of GHOs also don't have a general reference to guide health offices at the district levels.
All health programs are vertical and they are not linked by clear lines of authority to the MoPHP organogram. At the central level each program has its own management unit and most of them have their own financial and accounting department which is also linked to the central financial department in the MoPHP. At the governorates these programs are not integrated into the GHOs but each one has its own coordinator who is linked to the main program.
In regards to the legislation environment, there is a huge gaps and weaknesses either in the general frameworks of the health legislations or the way they address or guide the structure of the current health system. These facts and others have resulted in a weak monitoring and accountability system that is rather absent ,sometimes, leading in turn to a weaker health system.
2.2.7 Challenges of Public Health Sector The public health sector is facing multiple challenges and crisis hindering the processes of improving population health. Among the general challenges facing the health system are: 1. Persistence of high and steady population growth that is not in pace with available resources which are scares, limited and depleted. 2. The continuing heavy burden of communicable diseases and epidemic which form a double burden with chronic diseases. 3. Scarcity and low allocation of financial resources dedicated for the public health sector 4. Low level of wages and incentives of the health staff of different categories 5. Continuous increase in the dropout rate of the highly trained and qualified staff outside the national health system to the private and the Gulf States. 6. Weak institutional planning of the health services coupled with poor sector coordination in and outside the health system.
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7. Lack of a clear identification of roles, responsibilities and mandates at all the health system levels in light of absent effective system to supervise, measure, monitor and evaluate performance. 8. High costs of health services and the individual's bearing their financial burdens leading to increasing the likelihoods of falling in the poverty cycle. 9. Inadequacy of the financial policy that supports the improvement of the health system that is supposed to contribute to cost recovery. 10. Absence of any form of health insurance systems. 11. Great expectations among people of obtaining effective and quality health services. 12. Multiplicity of challenges facing the efforts to preserve a healthy environment such as the scarcity of clean water resources, limited piped water networks and limited and weak sanitation network system.
2.3 Private Health Sector
The private health sector has expanded largely in the last 20 years. At least there are more than four well established private hospitals which nearly provide all health care services even cardiac surgery and renal transplantation but radiotherapy is not provided. Other hospitals and health centers are small in capacity and in terms of procedures and their limited health services are of great concerns. The public - private relationships are not clear and not well established. The figure below shows the type and total number of private health facilities (HFs).
Figure (9): numbers and type of private health facilities in 2014
Type and Numbers of Private Health Facilities in 2014 13973 3340 3691 1453 731 687 1103 837 1296 323 181 153 104 74
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Most private HFs (profit) are concentrated in Sana’a city and in the capital cities of the different governorates (The NHS, 2010-2025). In 2014 there were (13,973) HFs distributed mainly in the capital cities of the main governorates where there were 3,354 HFs in Sana’a city which form 24% of the total private HFs most of which private pharmacies (1244), while there were only 62 hospitals. The table below shows that there were 57%.5 (8033) private HFs in three governorates in addition to Sana’a city (Statistics Health Report 2014).
Table (8): type and number of private HFs in Sana’a city, Hodeida, Aden and Taiz governorates.
Governorate Hospitals Polyclinic HCs G.P. clinic Spec. Dental. Dental Total clinic clinic lab Sana'a City 62 0 333 0 545 377 54 1371 Taiz 29 43 34 235 84 46 28 499 Aden 9 21 37 30 259 97 10 463 Hodeida 14 25 38 82 49 35 14 257 Total 114 89 442 347 937 555 106 2590 Labs Radiology PHC Midwifery Optics Pharmacies Drug Governorate Total Store Sana'a City 223 41 305 0 54 1244 116 1983 Taiz 103 13 180 0 17 421 578 1312 Aden 180 17 8 0 33 468 148 854 Hodeida 213 2 223 5 11 252 588 1294 Total 719 73 716 5 115 2385 1430 5443
Unfortunately, these private health facilities are in geographical competition with public health sector and they are present in the same governorates that the public health facilities are present and mainly in cities and hardly can be found in rural areas (NHS, 2010 – 2025).
3 Yemen Climate Change Background
Long-term systematic observations of precipitation and temperature data are very scarce in Yemen. There are recognized quality concerns associated with daily and monthly meteorological record. Meteorological data are not held by a central authority and they are collected by several authorities which include the Civil Aviation and Meteorological Authority (CAMA), Ministry of Agriculture and Irrigation (MAI), National Water Resource Authority (NWRA), Agriculture research and Extension Authority (AREA) and the Tehama Development Authority (TDA) and this will hamper any efforts in quantifying the long-term changes in climate. Without
Page 37 homogeneous rainfall and temperature records, it will be hard to benchmark future climate variability and change, or the associated impacts. (Rob Wilby, 2009).
3.1 Precipitation Patterns
Rainfall varies widely across the country, from less than 50 mm along the coast, rising with the topography to between 500 and 100mm in the Western Highlands, and dropping again to below 50 mm in the interior desert. Precipitation occurs primarily in spring and summer, and it is determined by two main mechanisms: the Red Sea Convergence (RSC) and the Inter Tropical Convergence Zone (UNDP, Climate Change Country Profile Yemen, 2011). Yemen’s observed precipitation pattern is shown in the below table Table (9): Yemen’s observed precipitation pattern Viable Value Precipitation December January February (DJF) Precipitation Mean Change (%) 14.6 (2030-2050, compared to 1980-1999, 11 GCMs; A1B scenario) Min across country (%) 8.26 Max across country (%) 35.41 Mean Model Concordance (% models that agree with sign of change) 64
Figure (10): Yemen map showing annual rainfall variation among region and seasons
https://chronicle.fanack.com/wp-content/uploads/sites/5/2014/10/geography-and- climate_Yemen_anualrain_map_02.jpg
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3.2 Drought Pattern
The occurrence of frequent prolonged hotter droughts during the last three decades has increased. These hotter droughts have been interrupted by occasional flooding. Dry climate with low rainfall and high temperatures is obvious during the seventies and eighties. The crucial question is whether emerging trends and effects of climate change are occurring already, and how these might evolve over in the near future and the next twenty to thirty years. Table (10): Yemen’s drought pattern Drought indicators* Change in (Max) Consecutive Dry Days (2030 - 2050, compared to - 4 1980 - 1999, 8 GCMs; A1B scenario) Mean Model Concordance (% models that agree with sign of change) 61 Change in r5d (max. rain over 5 day period) (%) (2030 - 2050, 23.86 compared to 1980 - 1999, 8 GCMs; A1B scenario) Mean Model Concordance (% models that agree with sign of change) 97
3.3 Temperatures Pattern
Temperature depends primarily on elevation, and in the coastal areas it is determined by distance from the sea. The mean temperature in the highlands ranges from below 150C in winter to 250C in summer, and in the costal lowlands from 22.50C in winter to up to 350 C in summer. (UNDP, 2015). Yemen’s observed temperature pattern is shown in the below table Table (11): Yemen’s temperature pattern Viable Value 1. Temperature* December January February (DJF) Temp Mean Change (degree C) (2030- 1.51 2050, compared to1980-1999) (8 GCMs, A1B scenario)
* Data from the World Climate Research Program’s Coupled Model Inter –comparison Project: Phase 3 (https://esg.llnl.gov:8443/ ) are extracted and reanalyzed by the World Bank.
3.4 Yemen National Response to Climate Change
In 2001,Yemen's Initial National Communication (INC) to the UNFCCC reported findings concerning the vulnerability of the social and biophysical environment from climate variability and climate change. The major impacts of climate change in Yemen as reported in the INC
Page 39 represent the starting point for the NAPA effort (NAPA, 2009). These major impacts include: (1) Increased water scarcity and reduced water quality – leading to increased hardship on rural livelihoods; (2) Increased drought frequency, increased temperatures, and changes in precipitation patterns – leading to degradation of agricultural lands, soils and terraces; (3) Deterioration of habitats and biodiversity – leading to expansion of desertification; (4) Reduced agricultural productivity – leading to increased food insecurity and reduced income generating activities; (5) Increased sea levels – leading to deterioration of wetlands, coastal mangrove migration, erosion, infrastructure damage, and seawater groundwater intrusion; (6) Increased climatic variability – leading to the possibility of spread and growth of vector borne and water borne diseases; and (7) Impacts on coastal zones – leading to a loss of tourism activity due to sea level rise including loss of beaches.
3.5 Climate Change’s Actions in the Health Sector
Interviews with MoPHP’s leadership and decision makers in 2016, found that only 30% of the health sector leaderships have a very good knowledge about climate change while 8% only have an excellent knowledge. Till now there has been no action taking in regard to climate change and its potential effect on health sector and there has been neither vulnerability nor adaptation studies or assessment, though more than 96% of those interviewed believe that climate change will have unexpected impacts on the health sector and will form an important emerging issue that would affect and face the public health sector. Regarding literature review, climate change and its health impacts in Yemen have not been dealt in a systematic forms in all departments of the MoPHP. There is only one statement in “The Fourth 5-Year Health Development & Poverty Alleviation Plan 2011 -2015” and in the “National Heath Strategy 2010 – 2025” in paragraph 12 under the “Strategic tendency of the healthcare services axis” stating (Linking the global climate change and its health effects to the Disease Surveillance System). Also, the malaria strategic successive plans from 2006 - 2014 stated that there is an association between climate change and future increase of malaria cases.
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4 Current Health Status and Health Indicators
4.1 Life Expectancy
The current average life expectancy at birth in 2014 reached 63.8 years with differentiations (slight) between males (62.03 year) and females (65.2 year), and varies also between urban and rural areas, but it is still below the average of all Arab countries where the average years of life expectancy in 2014 reached (70.8) year (UNDP, HDR. Yemen, 2015).
Figure (11): life expectancy in Yemen compare to some Arab states in 2014
Life expectancy in Yemen compare to some Arab State in 2014
70.6
63.8 63.5 62
Yemen Djibouti Sudan Arab States
The increased in life expectancy is partly due to improved standards of living that has begun to improve since early 1970s which has led to reduction of mortality rates especially among infants, U-5 children and newborns and also due to the relatively improved health services.
Figure (12): changes of life expectancy from before 1980s – 2013 in Yemen
Trends of Life Expectancy in Yemen 70 60 50 40 30 20 Age Years In 10 0 before 1992 1997 2003 2013 2014 1980 Life Expectancy 46 50 58 62 64.5 65.8
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4.2 Morbidity Status
While being in the midst of demographic transition, Yemen remains in the early stage of the third epidemiological transition, with morbidity and mortality from communicable diseases predominating over non-communicable diseases. The most common and serious health conditions and the most common causes of the current morbidity and mortality are due to infectious and endemic diseases mainly childhood diseases, malaria, bilharzias, TB, diarrhea, respiratory infections, malnutrition, mumps, viral hepatitis, anemia, intestinal parasites, accidents of all kinds and cardiovascular diseases. (Statistical Health Report, 2014). The current health situation has not been expected to deteriorate to the level of recording so many cases of acute flaccid paralysis, though no case of poliomyelitis was confirmed, and measles. Till the 30th week of 2016, there has been (222) of acute flaccid paralysis, reported from (99) districts out of the total (178) districts of the 10 governorates that have a well- established community surveillance program. In addition, and at the same week, there were (1,121) reported measles cases of which (477) cases reported by the community surveillance system and (644) reported by the health facilities. This fulminating issue is an indication of the future trend of the health situation of the whole society and it will reflect itself on health indicators such as life expectancy, morbidity and mortality trends especially for children under five years.
Having this health situation for the Yemeni population, the most populated governorates would become particularly vulnerable to malaria and a wide range of waterborne diseases and vectorborne diseases such as dengue (DEN), West Nile virus (WNV), chikungunya fever (CHIK), hemorrhagic fevers and diarrheal diseases. All of these diseases have shown rapid increase and unprecedented spread causing considerable burden of morbidity and mortality (Annual Statistic Health Report, 2014).
Poor socio-economic factors would also play an important role in shaping morbidity and mortality trends in Yemen. Among these factors are: (1) low income among individuals and households, (2) low education level, particularly among women, (3) poor health education techniques and means, (4) predominant harmful habits and behavior, (5) poor environment sanitation program and delayed community infrastructure concerning drinking water and sanitation services and other, (6) scarcity of financial resources for the health sector, (7) low quality health information system, and (8) lack of epidemiological mapping (NHS, 2010 - 2025)
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A close look at the national epidemiological surveillance list shows that there are 33 diseases that are subjected to community surveillance. The surveillance disease list indicates that 10 diseases account for 96.7% of the total burden of disease while 23 diseases accounts for only 3.3% of the burden of diseases. 86.2% of the total burden of disease is caused by the top four and most common watched epidemiological diseases which include acute diarrhea, lower respiratory tract infections, malaria and upper respiratory tract infections as shown in the below figure.
Figure (13): the proportion of morbidity for the first top four diseases by months in 2015
Proportion Morbidity for top 4 Diseases by Month 2015 Acute Diarrhea Lower R T I Malaria Upper R T I 150000
100000
50000
0 Jan Feb March April May June July Aug Sep Oct Nov Dec
On the other hand the second top four diseases which include bloody diarrhea. brucellosis, chicken pox and typhoid & paratyphoid fever form 9.2% of the total burden of disease. The figure below shows the second top 4 reported diseases. Dengue fever and schistosomiasis are also endemic in most governorates with (14509) and (5726) cases respectively.
Figure (14): the proportion of morbidity for the second top four diseases by months in 2015
Proportion Morbidity for top Second 4 Diseases by Month , 2015. Bloody Diarrhea Brucellosis Chicken Pox Typhoid&Paratyphoid 15000
10000
5000
0 Jan Feb March April May June July Aug Sep Oct Nov Dec
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Data for non- communicable diseases are patchy and they do not represent the actual burden of diseases. Most of the available data are recorded for each governorate separately and the validity of data cannot be tested (interview with HIR director & Health Development & Poverty Alleviation Plan 2011 -2015). The data for 2009 for the top causes of morbidity for communicable diseases and some non-communicable diseases are shown below
Table (12): burden of different diseases at the national level for most common diseases in 2009. Disease Pattern Annual Statistical Report 9002 Registered % 1 Respiratory system diseases 1014121 33.14 2 Epidemiological surveillance diseases 958491 30.43 3 Gastric system diseases 322002 2.02 4 Burns and wounds, accidents and causalities 254604 7.72 5 Urinary – genital diseases 235665 7.14 6 Intestinal parasites 314472 4.24 7 Skin and tissues diseases 114710 4.14 8 Anemia and Malnutrition 304241 4.71 9 Eye diseases 145977 2.14 10 Circulatory system diseases 128040 3.24 11 Diabetes 49973 1.04
1. Non-bloody diarrhea: one of the top five most watched diseases in 22 provinces and Socotra Island. It was number one in 19 governorates and came second in 4 others . 2. Malaria: one of the top five watched diseases in16 governorates and considered No. 1 in 3 provinces, No. 2 in 5 provinces, No. 4 in 5 provinces and No. 3 in 3 provinces . 3. Typhoid: one of the top five watched diseases in 20 governorates, and considered No. 1 in one province, No. 2 in 8 provinces, No. 3 in 9 provinces and No. 4 in two provinces . 4. Bloody diarrhea: one of the top five watched diseases in 19 governorates and No. 2 in 4 provinces, No. 3 in 8 provinces, No. 4 in 6 provinces, and disease No. 5 in one province . 5. Bilharzias: reported as one of the top five watched diseases in 9 governorates and came No. 2 in one province, No. 4 in two provinces and disease No. 5 in 6 others.
4.3 Mortality Status
Infectious and endemic diseases and pregnancy and childbirth complications form number one cause of death but accurate figures and statistics are not available to identify morbidity and mortality rates of non-infectious diseases such as cancer, heart diseases, kidney failure and accidents (The Fourth 5-Year Health Development & Poverty Alleviation Plan 2011 -2015).
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4.3.1 Infant and Under Five Mortality Rate Trends Infant mortality rate has been declined so sharply starting in the late 19970s, where it was 130 per 1,000 live birth before 1980s to an estimated 48.6 per 1,000 in July 2016. IMR varies with sex and place of residence being higher in female and in rural areas. The data also shows a remarkable decline in childhood mortality rates over the past three decades. The under-5 mortality rate decreased from 150 deaths per 1,000 live births in 1985 to 53 deaths per 1,000 live births in about 2011(DHS, Yemen. 2013.)
Figure (15): trends of IMR and U5MR between 1980s – 2013 in Yemen.
Trends of Infant and Under five Mortality Rate
Infant Mortality Under Five Mortality
105 102 78 53 75 75 69 43
1997 2003 2006 2013
Great variation of U 5 MR exists between governorates, in particular the rate is more than double in the governorates of Dhamar, Amran, Sana’a and Almahweet than in the governorates of Al- Jawf (32), Hadramout (32) and Lahj (34). This might confirm that some governorates have greater vulnerability than others and children at younger age are at greater vulnerability than older age. The variation of U5MR between governorate is shown in the figure below.
Figure (16): variation of U5MR in children between the different governorate in 2013
Geographic Variation of U5MR Among Childrem 76 71 74 66 66 70 70 60 61 62 54 49 52 43 47 37 39 40 32 32 34
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Comparing both IMR and U5MR with Arabs countries have shown that Yemen still of greater vulnerability in all health indicators. The differences in rates may reach three to six folds in comparison to some Arabs countries (WHOEMRO, 2009) Figure (17): trends of IMR and U5MR in Yemen compared to selected Arab’s countries
IMR and U5MR in Yemen compare to selected Arab's countreis IMR U5MR
112 78.21
81 68.5 28 34 22 21 23.1 13 25 29 18.1 19 10.1 18.3 Yemen Syria 2006 Jordan Sudan Oman 2007 Palistaine Eygpt 2006 Iraq 2007 2006 2007 2006 2008
4.3.2 Maternal Mortality Rate Maternal mortality rate has shown wide variation in all sources of data but in general the trend is declining. MRR should be considered catastrophic irrespective of the rate of declining because no women should die as a consequence of pregnancy or delivery. In the 2nd 5-Year Health Development & Poverty Alleviation Plan 2001 – 2005, the MMR was stated as 1400 per 100,000 live births and in one decade the MMR figure has declined to 148 per 100,000 life birth with marked variation between the rural (164) and urban (97) areas (DHS, Yemen. 2013)
Figure (18): the trends of MMR between 2000 – 2013 in Yemen
Trends of Maternal Mortality Rate between 2000 -2013
800
351 365 280 148
3rd 5 years Plan DHS 1997 PAFFAM 2003 WHO 2010 DHS 2013
Maternal mortality contributes to 39% of deaths among women at reproductive age, more than any other single health problem. Most women dying from maternal causes are living in rural areas (80%), illiterate, with an age of marriage less than 20 years. Nearly 42% of maternal deaths
Page 46 occurred at home, 39% on health facilities, 17% on the way to HF and 2% on other places. In addition, 39% of maternal deaths in HF arrived in very critical and morbid conditions and in 18% of hospitals’ maternal deaths were dead upon arrival in the HF (DHS, Yemen. 2013).
Figure (19): trends of MMR in Yemen compare to some selected Arab’s countries
Trend of Maternal Mortality Rrate in Arab's countreis 2003 - 2007
1107
366
84 58 41 23 20 59 Yemen 2003 Syria 2006 Jordan 2006 Sudan 2006 Oman 2007 Palistaine Eygpt 2006 Iraq 2007 2008 5 Objectives and Scope of Assessment
The main objective of this consultancy is to undertake an evaluation of climate change impact on human health and population vulnerabilities in order to determine the levels to which the Yemeni population is vulnerable to adverse climatic events and identify options for adaptation measures through a participatory mechanism with relevant stakeholders.
5.1 Specific Objectives
1. Identifying the main communities and vulnerable groups. 2. Identifying and assessing the quality and quantity where applicable of available climate and health information. 3. Assessing the national exposure, sensitivity and adaptive capacity taking into account historic climate data and recommended climate change scenarios. 4. Assessing the potential short- and long-term impacts of climate change on human health including the spread of vector-borne diseases such as malaria, lung and respiratory diseases, as well as associated health problems caused by dust storms and heat waves. 5. Propose adaptive measures and options drawing on traditional knowledge, past experiences and good practices.
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6 Vulnerability and Adaptation Assessment Methodology
6.1 Assessment Framework
The assessment process of the impact of climate change on public health sector will be according to WHO framework that would include: impact, vulnerability, and adaptation. The IPCC defines vulnerability as the propensity or predisposition to be adversely affected and considered to be as a function of (a) the exposure to the climate-related hazard, including the character, magnitude, and rate of climate variation; (b) sensitivity, which includes the extent to which health, or the natural or social systems on which health outcomes depend, are sensitive to changes in weather and climate (the exposure–response relationship) and the characteristics of the population, such as its demographic structure, physical, environmental, social, cultural and economic situation; and (c) the adaptation measures and actions in place to reduce the burden of a specific adverse health outcome (the adaptation baseline), the effectiveness of which may influence the exposure– response relationship (IPPC, 2012. AR5). The framework of vulnerability assessment of the impact of climate change on human health. Figure (20): framework of vulnerability assessment of the impact of climate change on health
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Because climate change is not the only factor affecting the geographical range and incidence of climate-sensitive health outcomes, and because non-climatic factors, social determinants of health, can have a strong or even dominant effect, either independently or by modifying climate effects, it is important to understand the various causal pathways from climate change through health outcomes, in order to identify opportunities to address the environmental determinants of poor health outcomes.
A modified Driving Force, Pressure, State, Exposure, Effect, Action (DPSEEA) Framework will be used also in the current assessment to describe the actions of various causes that act, more or less directly, on health outcomes from environmental or related behavioral conditions and the various levels of actions that can be taken to reduce health impacts (Corvalan et al., 2000). Key driving forces such as agriculture, transport policies, land use change and urbanization process of DPSEEA framework will not be investigated. Table (13): Driving Force, Pressure, State, Exposure, Effect, Action (DPSEEA) Framework Actions Driving forces International agreements Energy, agriculture, transport policies; (e.g., Un Conventions: UNFCCC, Demographic change; land-use change; CBD, CCD) urbanization process Pressures National mitigation policies Greenhouse gas emissions State Adaptation policies and Climate change programs to manage risks Exposure Indicators; monitoring; Extreme weather events (droughts, floods, heat surveillance systems; public waves); ecosystem changes; water scarcity; food health policies; environmental availability; protection changes in vector distribution Effect Diagnosis and treatment Climate-sensitive diseases including cardiovascular; acute and chronic respiratory; acute diarrhoeal; mental; vector-borne; malnutrition; injuries Based on Kovats et al. (2005). 6.2 Assessment Methodology
Given the difficulties of quantifying the direct and indirect health impact of climate change on health of Yemeni population, a qualitative assessment of vulnerability and adaptation will be conducted. In this context, the analysis of both the climate change and socioeconomic situation
Page 49 of Yemeni population will result in identification of vulnerable population groups, vulnerable regions and the extent to which their health are sensitive to climate change, the magnitude and duration of the climate-related exposure such as temperature, changes in precipitation levels and the adaptive capacity that are in place to reduce the burden of a specific adverse health outcome.
7 Stages of Vulnerability Assessment
7.1 First stage: identification of Vulnerable Population Groups
In the first stage, the vulnerable population group will be identified through assessment of sensitivity and vulnerability determinants which would be based on IPCC Fifth Assessment Report definition of vulnerability mainly sensitivity and adaptive capacity to climate change. 7.1.1 Determinants of Sensitivity The vulnerability of a population group is the combination of its sensitivity to climate change and its ability to adapt to the projected climate change factors. The sensitivity of human communities and individuals to climate change stressors are determined, at least in part, by their biological traits which include the overall health status, age, and life stage in addition to other factors such as population density, level of economic development, food availability, income level and distribution, local environmental conditions, preexisting health status, the availability and quality of health care and services and the population’s accessibility to these services (WHO & UNEP, 2003). As mentioned in the climate scenario projection, Yemen average temperature is projected to increase so as the hot days and nights which may lead to extreme heat waves and extended dry periods during summer season. This may directly affect human health particularly with heart problems and asthma. Elderly, very young and the IDPs can be especially vulnerable to extreme heat. Floods can also be destructive to human health and well-being by increasing event-related deaths, injuries, infectious diseases, and stress-related disorders (EPA, 2009). 7.1.2 Determinants of Vulnerability 7.1.2.1 Geographical Vulnerability Yemen topography renders the different geographical regions susceptible to various natural disasters, and for the last twenty years Yemen had at least one natural disaster every year such as floods. The dispersed population over more than 130,000 localities make it so hard for the government to cover the whole population with the needed and essential services. Low – lying
Page 50 governorates are more sensitive to flooding events, contamination of freshwater reservoirs due to sea level rise, and salination of soil, all of which may have important effects on health. People living in rural and remote areas, which are characterized by very hard geographical terrains , lack of essential social services and with no system of social protection, are at increased risk of ill health because of limited access to all type of services including health services and because of the low levels of social and economic standards (UNDP, 2014). The figure below shows the percentages of population in the different geographical areas in 2016. Figure (21): percentages of population in the different geographical areas in 2016
Distribution Percentages of Population in the Different Geographical areas in 2016
6% Coastal area Sloppy Mountainous ( up to 200 m) 14% 25% Mountainous area (up to 1500m) The area1500-2000 m 20% 5% Above 2000 meters 30% Desert areas
Source: UN Population Division, 2015). In addition, population living in the western humid and temperate regions and in the high lands that are less than 1500 meter above sea level are highly susceptible to vector-borne diseases as a result of rising temperatures and altered patterns of rainfall, especially when disease control systems are weak (NMCP Annual Report, 2013). 7.1.2.2 Demographic Vulnerability In 2016 more than 40% of the population are below the age of 15 years, of whom 14.51% under the age of 5 year and 3.44% are infants, which means that 40% of the population are more vulnerable to climate sensitive related illnesses such as water and vectorborne diseases. Children are more vulnerable to the adverse health effects associated with climate change due to factors associated with their immature physiology and metabolism, their unique exposure pathways, their biological sensitivities and limits to their adaptive capacity. Though in 2050 and 2100 the proportions of children below 15 years will be decreased markedly to 25% and 16% respectively, yet the incidence of climate sensitive diseases might be increased because of weak health care system and due to the weak and poor socioeconomic living standards that are manifested by high poverty rates and undernutrition all of which would be exacerbated markedly by climate change.
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Perera (2008) highlighted that the fetus and young child are at increased risk of developmental impairment, asthma, and cancer from fossil fuel pollutants and from the predicted effects of climate disruption such as heat waves, flooding, infectious disease, malnutrition, and trauma. In addition, Kovats and Hajat (2008) indicated a substantial impacts from climate change on the incidence of diarrheal disease and the associated mean projected increases of relative risk of diarrhea in their six study regions were 8–11% by 2010–2039 and 22–29% by 2070–2100. Women in age group (15 - 49 years) are at increased vulnerability to a range of environmental hazards, including extreme heat. Strand, Barnett and Tong (2012) found a strong evidence of an association between increased temperature and increased risk of stillbirth and shorter gestation. The hazard ratio for stillbirth was 0.3 at 12°C relative to the reference temperature of 21°C. The projected population in 2050 is shown in the below figure. Figure (22): projected population by age groups in 2050
Projected Porportion of Population by Age Group in 2050 8.4 8.6 8.5 8.5 8.3 8.2 8.1 7.7 7 6.2 5.5 5.1 3.9 2.8 1.7 0.9 0.4 0.2
0 - 4 5 - 9 10 -14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 65 - 69 70 - 74 75 - 79 80 - 84 85 - 89
On the other hand the proportion of population in the age group (15- 64 years) for both male and female account for 57.1% in 2016 population estimates and they will form 69% and 64% of the projected population in 2050 and 2100 respectively. This age group is called the working force age group and it is a measure of dependency ratio. In Yemen, the dependency ratio is already very high in 2016 due to the high population in age groups below 15 years in 2016 added to the older age groups 65 years and above (http://worldpopulationreview.com/countries/yemen).
In 2050 and 2100 the dependency ratio will be decreased due to increase in the working force age group to 69% and 64% respectively. However, most members (male) of this working age group are outdoors workers and hence climate change may increase the prevalence and severity of known occupational hazards and exposures, as well as the emergence of new ones due to increase in the numbers of workers in one hand and the potential absence of coping strategies or
Page 52 work regulations laws on the other hand (https://health2016.globalchange.gov/populations- concern). Moreover, the economic and nutritional status are not expected to be improved on the near term and hence unemployment rate will be high leading to high poverty rate and its consequences mainly food insecurity and undernutrition among children.
Older population group aged 65 years and above form only 3.2% of the estimated population in 2016 (1.2% above 70 years), and they are projected to form 6% (2.83 million) of the population in 2050 with 3.2% above 70 years of age and in 2100 they will form 20% of the population.
Figure (23): projected proportion of population by age groups in 2100
Projected Porportion of Population by Age Group in 2099 6.9 7 6.9 6 6.5 6.7 6.6 5.7 6 6 6 5 5.3 5.5 5 4 2.7 1.3 0.4
0 - 4 5 - 9 10 -14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 65 - 69 70 - 74 75 - 79 80 - 84 85 - 89 90- 95 These older population age groups are generally suffering from non-communicable diseases and they will be at greater risk of death or injuries from storms, floods, heat waves, and other extreme events of climate change. Older population with chronic diseases such as diabetes and ischemic heart disease are at greater risk of death from elevated average ambient temperature.
Basu and Ostro (2008) found that each 10°F (∼4.7°C) increase in mean daily apparent temperature corresponded to a 2.6% (95% confidence interval) increase for cardiovascular mortality, with the most significant risk found for ischemic heart disease. The elevated risks were also found for persons at least 65 years of age (2.2%, 95% CI), infants one year of age or less (4.9%) and the Black racial/ethnic group (4.9%) and no differences were found in relation to gender or educational level. To prevent the mortality associated with ambient temperature, persons with cardiovascular disease, the elderly, infants, and Blacks among others should be targeted by preventive measures. Brunkard, Namulanda, and Ratard (2008) have identified that forty-nine percent of Katrina- related deaths in Louisiana were people 75 years old and older of whom fifty-three percent were men. The major causes of death among Louisiana victims were drowning (40%), injury and trauma (25%), and heart conditions (11%), and this is because older people tend to be less
Page 53 mobile than younger adults and so find it more difficult to avoid hazardous. In addition, older people are more likely to suffer from health conditions that limit the body’s ability to respond to stressors such as heat and air pollution (Gamble et al., 2013). It has been found that mortality due to natural disasters, including droughts, floods, and storms, is higher among women than men (WHO, 2011). The excess of flood deaths among males often related to rural farming (Abuaku et al., 2009). In Bangladesh, females are more affected than males by a range of climate hazards, due to differences in prevalence of poverty, undernutrition, and exposure to water-logged environments (Neelormi et al., 2009). 7.1.2.3 Nutritional vulnerability In Yemen, hunger and undernutrition are widespread and as they require urgent intervention, children especially girls are generally at greater risk of adverse health outcomes (DHS, Yemen, 2013). With restricted food supplies, with nearly five children per family, (more in rural areas), with lower households income and with high poverty rate and food insecurity, the adverse health outcomes related to climate change will be so severe and the effect of food insecurity on growth and development in childhood may be more damaging for girls than boys (Cook and Frank, 2008). 7.1.2.4 Socioeconomic Vulnerabilities
Due to the deteriorated economic status of the country, Yemen is highly susceptible to damages caused by climate extremes and climate variability. In Bangladesh, a study of the impacts of flooding found that household risk reduced with increases in both average income and number of income sources. Poorer households were not only more severely affected by flooding, but they also took preventive action less often and received assistance after flooding less frequently than did more affluent households ((Brouwer et al., 2007). 7.1.2.5 Water Scarcity and Sanitation Systems Vulnerability Because Yemen is suffering from severe water scarcity and current scarcity of water resources are becoming increasingly precious, the provision of water for drinking and washing, waste management, and sanitation will highly influence the health risks of the population. Yearly epidemics of dengue fever in Shabwa, Taiz and Hodeida governorates were due to poor supply of save drinking water and wrong storing of water in containers that become suitable breeding sites for the disease vector Aedes aegypti. The increased temperature in May – June 2016 above average and lack of electricity power supply in Hodeida have led to the appearance of different varieties of skin diseases and many human fatalities forcing people to use mosques that have air
Page 54 conditioning and electricity supply as shelters from excessive heat waves because there houses were without electricity. Certainly women would not be able or allowed to use such facilities due to cultural constraints and hence will be more affected by these extremes of heat waves together with their younger child’s (MoPHP report, 2015). 7.1.2.6 Internally Displaced Population With a total number of IDPs that raised to 3 million by July 2016, half of whom are in Aden, Taiz, Hajjah and Al Dhale’a governorates, their living conditions will be even so hard than the rest of the population. Living conditions are poor due to poor socioeconomic standards of living and poor building structures since they settle schools and health facilities in addition to the lack of proper public infrastructure that would be manifested by water shortages, contaminated water supplies and poor sanitation. These conditions will result in a higher risk for water-borne disease transmission. Climate change may worsen the situation by threatening livelihood, food and water security of refugees. 7.1.3 Adaptive Capacity Assessment The main determinants of a community’s adaptive capacity are economic wealth, technology, information, skills, infrastructure, institutions, and equity. Adaptive capacity is also a function of current population health status and pre-existing disease burdens (WHO & UNEP, 2003). These will be discussed in details in the last section of this report. 7.1.4 Vulnerability and Adaptation Assessment Questionnaire Findings Meetings and interviewing of leadership and decision makers in the MoPHP using vulnerability and adaptation assessment questionnaire have found that there is a strong belief among respondents that there will be certain risk on different population groups arising from climate change. 86% of respondents believe that children will be the most vulnerable and the most affected group by climate change, followed by the believe of 75% of respondents that elderly will be mostly vulnerable and affected, then pregnant women, displaced and refugees. Women and men were the least vulnerable and least affected by climate changes as reported by 44% and 14% of respondents Respectively. though 74% of respondents believe that the highest severity of climate change will be expected in coastal areas and Islands, only 33 percent believe that the cities will be affected by climate change, followed by desert and mountain regions (32% and 26% of respondents respectively).
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These findings, to some extents, are in line with the above sensitivity and vulnerability analysis and with the relevant literatures and the impact of each climate factors on each vulnerable group will be discussed under each climate factors. The vulnerable population groups to climate change could be summarized as in the below table. Table (14): different population’s groups vulnerable to the health impacts of climate change Vulnerability due to demographic Proportion of children under 5 years factors Proportion of women in the childbearing period Proportion of pregnant women Proportion of elderly population group 65 years and above Population density Vulnerability due to health status Populations with infectious disease Population living in high risk area of epidemics Populations with tuberculosis (TB) Undernourished populations Populations with chronic disease Mentally or physically disabled people Vulnerability due to culture or life Displaced populations condition Poor people Nomadic peoples Subsistence farmers (see agricultural lands owner) Low earning labourers Vulnerability due to limited access Poorly and Unplanned urban housing to adequate resources and services Drought risk areas Conflict areas Water-stressed areas Food-insecure population Urban areas Population living in rural and remote areas Vulnerability due to limited access Health care to adequate essential services Potable drinking water Sanitation Education Shelter (most live in poor housing conditions) Economic opportunities (low income and Indentured) Vulnerability due to sociopolitical Political stability conditions Existence of complex emergencies or conflict Freedom of speech and information Source: Joy Guillemot, WHO. (Modified) 7.2 Second Stage: Development of Two Socioeconomic Scenarios
The second stage involved the development of two baseline socioeconomic scenarios that have been linked to climate change scenarios projections taking into consideration changes in temperature and precipitation levels. The two socioeconomic scenarios depended on the socioeconomic and demographic factors related to 2010 as a base year and the projected
Page 56 demographic status of the population in 2050 and 2100. The current socioeconomic situation and related factors have not been used in the scenarios because the related indicators have changed dramatically between 2010 and 2015 and due to the existed war and its consequences. The two baseline socioeconomic scenarios constructed of the following factors: a. Population growth and size b. Gross domestic production growth c. Economic growth d. Health care coverage e. Basic infrastructures services (pure water supply and sanitation) f. Governance a. Population Growth and Size Population will continue to grow at steady speed even though the fertility rate decreased markedly. The growth in size will come mainly from the already existed youth population who form nearly 40% of the total population a phenomena known as population momentum. According to medium variant projection, population size will increase by nearly 23 million between 2010 – 2050 before it starts to a stabilize growth between 2050 – 2100 where the increase in the total size will not exceed 4.5 million. The projected population growth between 2010 – 2100 is shown below. Figure (24): the projected population growth between 2010 – 2100
Projected Population in Million Between 2010 - 2100 51.75 52.44 52.79 52.85 52.66 52.24 51.99 49.13 50.66 51.62 44.84 47.17 42.21 39.36 36.34 33.18 30.03 26.83 23.59
2010 2015 2020 2025 2030 2035 2040 2045 2050 2055 2060 2065 2070 2075 2080 2085 2090 2095 2100
b. Economic Development Yemen is one of the poorest countries in the World and its economy depends on foreign aid and remittances from workers in neighboring Gulf States. The economy is dominated by the oil sector, which accounts for 27 percent of the gross domestic product (GDP) and 70 percent of export revenues. Agriculture forms also a very important sector as it employs over 50 percent of the population. Before 2010, the government has engaged in efforts to diversify the economy
Page 57 from dependency on oil, and as a result, there was a surge of investment in the development of infrastructure for natural gas extraction. Yet, the political instability in 2011 has undermined development efforts, resulting in damage of infrastructure, rising unemployment, high inflation, depletion of oil reserves and ongoing disruptions at oil production facilities with decline in exporting oil and gas which stopped completely in 2015, all of which led to the marked recent decline in oil revenues causing severe fiscal difficulties. The budget deficit grew to about 10 percent of GDP in 2009, and is expected to increase much higher in the coming years with cut of all running cost from mid-2015 for all government institutes and organizations. Yemen also has the lowest level of official development assistance (ODA) per capita at $12.70, or just 2.2 percent of GDP, compared to $33.40 per capita (18.7 percent of GDP) for the other least developed countries in the World. c. GDP Growth Rate The Gross Domestic Product (GDP) in Yemen contracted 28.10% in 2015 from the previous year. GDP Annual Growth Rate in Yemen averaged 1.06% from 2001 until 2015, reaching an all-time high of 7.70% in 2010 and a record low of -28.10% in 2015 as seen below. Figure (25): GDP Annual Growth Rate in Yemen 2006 - 2015
GDP Trends Between 2006 - 2015 10 7.7 5 4.64 4.8 3.3 3.6 3.9 2.4 0 -0.2 -5 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 -10 -12.7 -15 -20 -25 -28.1 -30 Source: Central Statistics Office. http://www.tradingeconomics.com/yemen/gdp-growth-annual d. Health Care Coverage The current health care conditions will not be improved and heath indicators will be the same if not deteriorated as a consequence of population growth and low socioeconomic growth. Increase in population size implies low growth in the demand for health services and low growth in hospital admissions in cases of emergency and the low GDP growth entails higher reliance on public provision of health services.
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e. Basic Infrastructures Services (pure water supply and sanitation) Scarcity of water will be increasing with time as Yemen is a very scarce water country and the per capita availability is falling steadily with growing population. With the current socioeconomic situation, the current 31% of the population who have access to pure drinking water will not be increased so as with sanitation services. A part from households needs and usage, water is heavily needed for industry and agriculture which form the two main pillars for modern economy and economic growth. The equation is hard to be balanced between the rapid growth of the population and the increase demand on water in a scarce environment and this will be exacerbated if industrial or agricultural fields are planned to improve the economy. f. Governance Good governance aims at rationalization of political, economic power and decision-making. The future of governance in Yemen is so dull due to the very poor and weak governing institutions and values and the overwhelming current situation that will have its implications for so many decades and will be subjected and influenced to a great extent by developments in the current conditions. At times of political and security stability, health sector was never being of a priority concern for all previous governments and suffered from various challenges and crisis. In the coming years there might be the will to improve the population health but certainly the priorities will not be towards protecting the health of the population from the adverse effect of the climate change. Economic development and generation of financial resources and revenues will grow so slowly so the allocated resources for health will be decreased. 7.2.1 Characteristics of Socioeconomic Scenarios A Socioeconomic Scenario A will be built from the following building blocks: 1. Population growth will continue steadily at an increasing rate till 2050 but the growth will be declined between 2050 – 2100 2. Poor economic development 3. Low growth of GDP. 4. Low preparedness/ low prevention measures and adaptive capacity of the health care system and the population 5. Poor quality and scarcity of health care services. 6. Availability and accessibility to pure water resources will be of great challenge 7. Deterioration of living standards (sanitation, electricity, education and housing)
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7.2.2 Characteristics of Socioeconomic Scenario B Socioeconomic scenario B will be built from the following building blocks: 1. Population growth will continue at the low projection variant where fertility rate will be decreased to 3.3 per women by 2025 to 2 children per women by 2035 2. Improved economic development. Political and security situation will be improved and oil and gas extraction will be increased in the expected sites. Governance and autonomy to regions will be strengthened. 3. GDP growth will increase to 5% annually due to oil revenue and political stability. 4. Local governance will increase the preparedness and prevention measures and so the adaptive capacity of the health care system. 5. Improved quality and availability of health care services. 6. Availability and accessibility to pure water resources will be of great challenge 7. Living standards will be improved (sanitation, electricity, education and housing) 7.2.3 Vulnerability Under Socioeconomic Scenarios Under Scenario A, the vulnerability of human health to climate change will be higher than in Scenario B. The assumptions under Scenario A are based on high and rapid population growth which will have its consequences on population composition by age and sex which will be reflected on higher demands on already weak and poor public health services and essential infrastructure services such as education, water, sanitation, energy and housing. The increased numbers of those with food insecurity and undernourished people will exacerbate the population health and would lead to aggravation of poverty and people in needs. In addition the low GDP growth would entail an unequal access to health services causing marked disparities among all segments of the population regardless of gender, residential or economic status. Both, rapid population growth and low GDP growth, will undermine the opportunities for the adaptive capacities and coping options especially among vulnerable groups. On the other hand, the assumptions of Scenario B are characterized by the balanced population growth, the raised GDP growth, economic development, improvement of the environment of governance and the rules of laws and orders, peace and security all of which would improve the current health conditions along with the standards of living. Prevention and control measures, proper preparedness and emergency strategies in the health care system would lead to better health services leading to higher adaptive capacity of the population groups. The table below summarizes vulnerability assessment and vulnerable population groups
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Table (15): vulnerability, sensitivity of population groups and adaptive capacity Population Sensitivity to climate change Adaptive capacity Vulnerability group Children High sensitivity to thermal Scenario A: Very Very high stress and extreme weather low events Scenario B: Low High Women High sensitivity to thermal Scenario A: Very Very High stress and extreme weather Low events Scenario B: Low High Pregnant High sensitive to extreme Scenario A: Very Very High Women weather events, heat and Low floods Scenario B: Low High Elderly High sensitivity to thermal Scenario A: Very Very High people stress and extreme weather Low events Scenario B: Low High Population High sensitivity to chronic Scenario A: Very Very High with low diseases and heat stress Low SES Scenario B: Low High Outdoor High sensitivity of certain Scenario A: Very Very High working occupations to heat-related Low laborers outcomes Scenario B: Low High IDPs High sensitivity to food/ Scenario A: Very Very High waterborne diseases and Low extreme events (natural Scenario B: Low High disasters)
7.3 Third Stage: Development of Climatic Change Scenario
The third stage will involve the development of a climate change scenario and the projected climate change from the available literature reviews. The IPCC showed that climate change will have an impact on World weather patterns with particular effect more likely on some regions and sectors. The average temperature rises in the region is faster than the global average and is likely to persist in the future. 7.3.1 Precipitation Projection Projections of future rainfall disagree with all models, with some models projecting increases in rainfall while other models project decreases in some models. These large uncertainties in future rainfall patterns are in part a function of differences in model behavior of the Inter - Tropical Convergence Zone. There is, however, broad consistency between models in projecting increases in September, October, and November (SON) rainfalls, with the range of projections spanning small decreases and large increases (‐14mm to +49mm, or ‐21 to +265%). The proportion of
Page 61 rainfall that falls in ‘heavy’ events shows an increase for autumn (SON) in most model projections with an increased risk of floods and drought and is projected to change by ‐21% to +23% by the 2090s. The maximum 1‐ and 5‐day events in SON are projected to change by ‐6 to +19mm, and ‐13 to +37mm respectively by the 2090s. 7.3.2 Temperature Projection A country-average annual temperature series for Yemen shows warming of 0.5°C throughout the entire 20th century. However, over the period 1961-1990 local rates of warming have been greater, especially at higher elevation sites. The equivalent rates of 6.1°C, 5.4°C and 4.8°C per century were observed at Sana’a (2200 m), Seyoun (700 m) and Hodeida (10 m) respectively. The mean annual temperature is projected to increase by 1.2 to 3.3°C by the 2060s, and 1.6 to 5.4 0C by the 2090s. The range of projections by the 2090s under any one emissions scenario is around 1.5 to 2.0°C. The projected rate of warming is similar in all seasons, but it is more rapid in the interior regions than areas close to the coast. 7.3.3 Projected Hot and Cold Days All projections indicate substantial increases in the frequency of days and nights that are considered ‘hot’ in current climate. 1. Annually, projections indicate that ‘hot’ days will occur on 16‐30% of days by the 2060s, and 22‐47% of days by the 2090s. 2. Days considered ‘hot’ by current climate standards for their season are projected increase most rapidly in summer (JJA), occurring on 29‐94% of days of the season by the 2090s. 3. Nights that are considered ‘hot’ for the annual climate of 1970‐99 are projected to occur on 23‐38% of nights by the 2060s and 27‐56% of nights by the 2090s. 4. Nights that are considered hot for each season by 1970‐99 standards are projected to increase in frequency most rapidly in summer (JJA), occurring on 44‐96% of nights in every season by the 2090s. 5. All projections indicate decreases in the frequency of days and nights that are considered ‘cold’2 in current climate. These events are expected to become exceedingly rare, occurring on 0‐5% of days in the year by the 2090s.
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7.4 Fourth Stage: Assessment of the impact of climate change on health
In the fourth stage, the impacts of climate change on the public health of Yemeni population will be analyzed by combining both sensitivity and exposure of the population groups to the climatic change. Climate-related hazards include extreme temperatures, floods, landslides, sea level rise and droughts. While these hazards are natural occurrence in Yemen, they nevertheless pose serious constraints on development and food security. The extent and nature of climate change impacts on human health depend on their intensity, duration and frequency of the exposure and the ability to adapt to or cope with these changes.
As discussed, the future vulnerability to climate change is determined to a large extent by the socio-economic scenarios and the impact on health would be more severe under scenario A than Scenario B which indicates the needs for higher adaptive capacity in the health care sector. The table below shows the causes of these natural hazards across Yemen:
Figure (26): percentages of the type of natural disaster incidence in Yemen 1900-2011 Yemen Natural Disasters Incidenc by Type 1900 - 2011 77 100
10 7 7 3 3 3
1 Epidemics Earthquake Volcano Storm Landslides Floods Source: EM-DAT: The OFDA/CRED International Disaster Database, Université Catholique de Louvain, Brussels, Belgium Data version: v11.08 Moreover, these climate change hazards are expected to severely exacerbate the already existed development and socioeconomic issues and health problems such as vectorborne and waterborne diseases as well as chronic diseases such as cardiac, respiratory and renal disease. The impacts of climate change on health could arise through the following three basic pathways: 1. Direct impacts, which relate primarily to changes in the frequency, intensity, and duration of extreme weather events such as heat waves, floods, droughts, and windstorms that affect people, damage public health infrastructure and cause huge economic losses. 2. Effects mediated through natural systems that will increase the geographical range and incidence of vector borne, food- and waterborne diseases, and prevalence of diseases related to air pollutants and aeroallergens.
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3. Effects heavily mediated by human systems, for example, occupational impacts, under- nutrition, and mental stress. The above pathways are shown in the figure below: Figure (27): Pathways of climate change on health
Mediating Factors Environmental Social infrastructure Public health capability conditions Direct exposures and adaptation • Geography •Flood damage • Baseline weather •Strom vulnerability • Warning systems • socioeconomic status • Soil/dust •Heat stress • Health and nutrition • Vegetation status Indirect exposures • primary health care •Precipitation • Baseline air/water Mediated through • Under nutrition natural systems: • Heat. •Allergens. • Drowning • Floods disease • disease vectors. • Heat • Storms • Increased water /air • Malaria pollution
Via economic and social disruption - Food production /distribution - Mental stress
7.4.1 Direct Impacts of Climate Related Hazards on Population Health 7.4.1.1 Exposure to Floods Yemen is considered to be a disaster-prone country that faces a number of natural hazards every year with floods being the most important and recurring form of disaster. Rainfall in Yemen is characterized by seasonal intensity and short-lived heavy storms that often leads to flash floods. All governorates have been hit by floods for at least one time in the last 30 years. The June 1996 was the worst form of floods that hit the governorates of Shabwa, Mareb and Hadramout which resulted in (338) fatalities and around (238,210) people have being affected with 1.2 billion Dollars as economic damages. In October 2008, the heavy rains associated with a tropical storm brought 90 mm of rainfall over the course of 30 hours, as opposed to the usual 5-6 mm over the same period, has led to severe flooding in Hadramout and Al-Mahara governorates in eastern part of the country, resulting in over 70 deaths and the displacement of 25,000 people, and the destruction of over 2,800 houses with an overall economic damage of $1,638 million.
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On 3rd November of 2015, Cyclone Chapala is the first known hurricane-strength storm to make landfall in Yemen since modern records began in the 1940s, and just the third hurricane on record to make landfall across the entire Arabian Peninsula. Chapala Cyclone has hit Hadramout, Al-Mahara, Socotra Island and Shabwa governorates causing huge devastation of infrastructures, damaging and losses of public and private properties with many human and animal fatalities in addition to sweeping agricultural lands. The amount of rains that was associated with Chapala Cyclone was 20 times higher than the annual average rainfall ever experienced in Yemen and it is equivalent to the amount of ten years rainfall. Figure (28): the movement of Chapala Cyclone towards Yemeni coast 2015
http://pbs.twimg.com/media/CSrasCGXIAAzGZN.png According to the United Nations Office for the Coordination of Humanitarian Affairs (2015), more than 36,000 people have been displaced and at least 700 homes have been damaged or destroyed. The port city of Al-Mukalla experienced an outbreak of dengue fever by January 2016 due to floods, affecting 1,040 people where the earlier efforts to kill disease carrying mosquitoes were ineffective due to residual floods and unsanitary conditions. Seven people died due to the outbreak. A locust outbreak also began in December 2015 due to the floods. https://en.wikipedia.org/wiki/Cyclone_Chapala#Yemen
The V&A questionnaire and interviews with leadership and decision makers from the MoPHP, 57% of respondents believe that heavy and intense rain and floods hazards and incidences account for the second and third most important and most influential causes on public health sector. This was mainly judged to the recent floods events that hit Hadramout and Al-Mahara in 2008 and 2015 but the majority of respondents did not provide any information about other
Page 65 governorates or historical incidences of floods before the year 2008. Only few interviewees have pointed to the presence of some relationship between flood events and climate change but they do not know the mechanism of occurrences.
Nearly all interviewed directors have shown that eastern Yemen governorates are prone to flood disasters more than those of the west and highlands temperate governorates. The analysis of the questionnaire has shown also the lack of any sort of plans or the presence of a known teams at all levels of the health sector capable to meet such threat, in addition to the lack of any sort of communication or networking with relevant institutions such as meteorological institutes as well as the lack of early-warning system.
Though the direct effect of flash floods on people’s health is known and documented such as injuries, drowning, hypothermia and infectious diseases such as diarrheal disease and waterborne and vector-borne disease, yet there is no study on the long term effect of flash floods on Yemeni population. However, there are evidence that the long-term (months to years) effect of flood on health could have profound effects on peoples’ mental health (Neria, 2012). It was found that the prevalence of psychological distress, anxiety, and depression was two to five times higher among individuals who reported flood water in the home compared to non-flooded individuals (2007 flood in England and Wales; Paranjothy et al., 2011). In addition, the long- term (6 to 12 months) effect on mortality among the flooded population is uncertain (Milojevic et al., 2011).
7.4.1.2 Exposure to Drought
Although Yemen has identified drought as one of the major vulnerabilities that are related to climate change (NAPA, 2009), meeting with MoPHP leadership and decision makers and analysis of V&A questionnaire found that 78% of respondent do not believe that drought is an important issue of climate change which indicates clearly the knowledge gap and the importance of raising awareness about climate change and its impact on various sectors.
In fact Yemen is experiencing a meteorological drought cycle every 10 – 15 years with 2-3 years of duration for each episode, and the magnitude and impacts, due to different reasons, are rarely documented or drew public and government authorities’ attention compared to that given to floods. Drought directly hits the rain fed agriculture which constitutes around 60% of the total cultivable lands, reducing agricultural output by up to 40%, and affecting 65% of the population mainly living in the high rural lands and valleys where poverty and malnutrition are highly
Page 66 prevailed. In addition drought impact will affect the ranges of Yemen’s herders who possess 1.3 millions of livestock heads (Drought Conditions and Management Strategies in Yemen, 2014).
The health impact of drought has not been studied on Yemen but it is well documented in so many international literatures. Harsher weather conditions such as floods, droughts, and heat waves tend to increase the stress of all of those who are already mentally ill, and may create sufficient stress for some who are not yet ill to become so. Severe drought in Australia has been linked to psychological distress only for those living in rural and remote areas (Berry et al., 2010) and chronic psychological distress and increased incidence of suicide may occur in prolonged droughts events (Alston and Kent, 2008; Hanigan et al., 2012). Rural populations relying on subsistence farming in low rainfall areas are at high risk of undernutrition and water- related diseases (Acosta-Michlik et al., 2008) and mortality is higher among women than men (WHO, 2011). Dengue fever outbreak can also occur if households store water in containers that provide suitable mosquito breeding sites (Padmanabha et al., 2010). 7.4.1.3 Exposure to Increased Average Temperature Only 60% of all interviewed health leadership and decision makers in the MoPHP believe that the most occurring climate changes is elevation of temperature with some hot days and nights during summer season. In addition 84% do not believe that the number of cold days will be increased during winter season. On asking them about the effect of elevated temperature and extremes changes on population health they were hesitated to give answers due to lack of information on the association between morbidity/mortality events and the meteorological data related to the health events.
Searching all health statistical reports and meeting officials in Health and Information Research department in the MoPHP revealed that there has been neither data nor epidemiological studies that specifically linking elevated temperature, increased heat waves and cold spills with mortality and morbidity data collected from the different health facilities. Robust studies require not only extremely long-term data series on climate and disease rates, but also information on other established or potential causative factors, coupled with statistical analysis to apportion changes in health states to the various contributing factors (IPCC, AR5, 2012).
Numerous studies of temperature-related morbidity, based on hospital admissions or emergency presentations, have reported increases in events due to cardiovascular, respiratory, and kidney
Page 67 diseases (Hansen et al., 2008; Knowlton et al., 2009) and the impact has been related to the duration and intensity of heat (Nitschke et al.,2011). Admissions for renal diseases and acute renal failure were increased during heat waves compared with non-heat wave periods with an incidence rate ratio of 1.100 and 1.255 respectively but hospitalizations for dialysis showed no corresponding increase. The findings also suggest that as heat waves become more frequent, the burden of renal morbidity may increase in susceptible individuals as an indirect consequence of global warming (Hansen et al., 2008).
The excess mortality attributed to the heat wave (about 15,000 deaths in France alone (Fouillet et al., 2008) was caused by anthropogenic climate change, and in EMRO region which has experienced seven extreme temperatures events from 1990–2011, the number of death cases was more than 100 deaths. Mortality increases more during heat waves than would be anticipated solely on the basis of the short-term temperature mortality relationship.
Anderson and Bell (2011) have found that mortality due to heat waves has increased by 3.74% during heat waves compared with non-heat wave days, and has increased by 5.04% during the first heat wave of summer versus 2.65% during later heat waves compared with non-heat wave days. The largest effects of heat and heat waves earlier in the hot season may be testament to the importance of acclimatization and adaptive measures, or may result from a large group in the population that is more susceptible to heat early in the season.
7.4.2 Indirect Impacts of Climate Change on Health Outcomes 7.4.2.1 Vector-borne diseases (VBDs) These are infectious diseases transmitted by the bite of infected arthropod species, such as mosquitoes, ticks, bugs, sandflies, and blackflies. Arthropod vectors are cold-blooded (ectothermic) and thus especially sensitive to climatic factors. These diseases include malaria, dengue, schistosomiasis, human African trypanosomiasis, leishmaniasis, Chagas disease, Yellow fever, Japanese encephalitis and onchocerciasis. Vectorborne diseases account for more than 17% of all infectious diseases at the global level causing more than one billion cases and over one million deaths annually. The seasonality, distribution, and prevalence of vector-borne diseases are influenced significantly by climate factors, primarily high and low temperature extremes and precipitation patterns. Climate change can result in modified weather patterns and an increase in extreme
Page 68 events that can affect disease outbreaks by altering biological variables such as vector population size and density, vector survival rates, the relative abundance of disease-carrying animal (zoonotic) reservoir hosts, and pathogen reproduction rates. Collectively, these changes may contribute to an increase in the risk of the pathogen being carried to humans (Gage et al, 2008).
According to V&A questionnaire of leadership and decision makers of public health sector, 93% believe that climate change will have a profound effects on communicable diseases with major impact of climate change on infectious and chronic diseases. 92% of respondents believe that the expected impacts will be the heavily increased in the incidence and prevalence of malaria.
89%, 85% and 84% of respondents also believe that the expected impact of climate change would lead to an increase in cases of dengue fever, diarrhoea and respiratory diseases respectively, while the expected impact on skin and chronic diseases such as kidney and heart disease would be less (56%, 42% and 41% of respondents respectively).
7.4.2.1.1 Malaria Disease
Malaria is an extremely climate-sensitive tropical disease (Patz et al., 1998). The incidence of malaria varies seasonally in highly endemic areas, and malaria transmission has been associated with temperature anomalies (Zhou et al., 2008). A 2009 study by the Stockholm Environment Institute (SEI) estimated that the rural population at risk of malaria could increase by 150% by the 2050s. As a result, significant increase in disease burden and economic costs exceeding US$ 50 million annually are expected. In Botswana, the indices of El Nino - related climate variability can serve as the basis of malaria-risk prediction and early warning. (IPCC, 2007).
In regards to the epidemiology of malaria, nearly half of the world's population are at risk of malaria. In 2015, there were roughly 214 million malaria cases and an estimated 438, 000 malaria deaths most of them were children under 5 years of age. In Yemen, malaria remains at the top list of the most important ,complex and a serious endemic health problems for so many decades where nearly 60% of the population lives in areas at high risk of getting the disease. Pregnant women and children under-five are the most vulnerable groups victimized by malaria and its complications. In the late nineties, the estimated annual burden of malaria was 2-3 million cases per year. By 2006 the estimation dropped to 800,000- 900,000 malaria cases per year with an estimate of 1% related deaths (NMCP, 2006).
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Malaria disease in Yemen belongs to the Afro-tropical type with the Plasmodium falciparum being the predominant species (90-95%) and Anopheles arabiensis as the predominant vector but Socotra Island and the eastern governorates of Hadramout and Al-Maharah belong to the oriental type of malaria with Anopheles culicifacies being the predominant vector. Malaria is prevalent throughout the country with no governorate free of the disease. The endemic degree of malaria ranges from low to high endemicity depending on the geographical areas, climatic conditions and socio-economic development situation. According to the degree of endemicity, the country can be divide into: 1. The coastal area: this area represents 25% of the total population of the Yemen., and extends from sea level to 200 meter above sea level and is characterized with medium – high degree of endemicity. Malaria transmission season occurs during winter months that extends from October to April. 2. Sloppy Mountainous area to sea coast (mountain’s feet): this areas represent 5% of the total population which extends from 200-500 meters above sea level. The degree of endemicity is medium to high and malaria transmission occurs throughout the year. 3. Mountainous area (500-1500 meters above sea level): this region represents about 30% of the population and it is the most susceptible area for epidemics and outbreaks. The degree of malaria endemicity ranges from medium to high with less endemicity degree in the highlands and the transmission season occurs during summer from May-September. 4. The area1500-2000 meters above sea level: this area represents about 20% of the total population. Malaria transmission is rare and occurs only in areas where special environmental changes such as rains. Malaria cases might be imported from a malaria- endemic areas as a result of population movements. 5. 2000 meters altitude above sea level and desert areas: these are malaria-free areas and represents 20% of the total population. 6. Islands such as Socotra: it was a highly endemic area before establishing the national malaria control program for the eradication of malaria in the island in 2000. Malaria transmission stopped in 2005. In 2015 the surveillance department has reported that malaria is the third cause of morbidity in the country with 123,129 case, but the number of cases according to the NMCP for 2010 were 198,963 of which 106,697 cases were parasitologically confirmed and 92266 clinically
Page 70 diagnosed. The diagram below shows the distribution of cases by governorate in 2015 and it indicates that Al Hodeidah and Hajja governorates are highly affected by the disease and the least affected governorates are Mareb, Shabwa and Sayeon. Figure (29): the distribution of malaria cases by governorate in 2015.
Proportion of Morbidity for Malaria by Governorate , 2015. 123129 57562 28465 7015 3392 3515 4536 4948 1635 1674 2129 2185 2337 826 942 1506 224 101 39 65 14 18
1
On the other hand the monthly distribution of malaria shows great variations with most cases being recorded in the winter months that extends from October to early April. Figure (30): the number of malaria cases per month in 2015.
Malaria Cases by Month in 2015 23594
12012 11716 11314 9997 11394 8870 7726 8956 6114 5713 5723
7.4.2.1.2 Dengue Fever
Dengue is the most rapidly spreading mosquito-borne viral disease, showing a 30-fold increase in global incidence over the past 50 years (WHO, 2013). More than 2.5 billion people in over 100 countries are at risk of contracting dengue. http://www.who.int/features/factfiles/malaria/en/. Each year there are about 390 million dengue infections worldwide, of which roughly 96 million cases are manifested with symptoms (Bhatt et al., 2013). Three quarters of the people exposed to dengue are in the Asia-Pacific region, but many other regions are affected also (IPPC,
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AR5,2012).The principal vectors for dengue fever are Aedes aegypti and Ae. Albopictus both of which are climate sensitive.
Starting in 2000, Yemen faced repeated outbreaks of severe dengue fever but in 2015, an upsurge was reported after over one million people had been internally displaced and health systems had been disrupted. More than 3,000 suspected cases and three deaths were recorded between 27th of March and 4th June 2015 (WHO, June. 2015). In Hadramout the total confirmed dengue fever cases during the period from February to June 2010 were 982 with (890) in urban areas and 92 cases in rural areas with 12 cases fatalities, giving case fatality rate of 1.9%.
In the age group 14 -25 the number of cases were (370) which form38% of the total cases (Ghouth et al, 2012). In Taiz governorate, despite incomplete levels of reporting, an extreme spike in DF cases of from 145 at the start of August 2015 to 1243 by the end of August 2015. The total suspected DF cases that were recorded were 6320 by 31st August 2015 (WHO, 2015). In December, DF cases continued to be reported with 972 suspected DF cases were reported in 10 governorates; out of these 264 cases reported from Abyan, 120 cases from Shabwah, 88 cases from Al-Hodidah, 14 cases from A-Mahra and one case with hemorrhagic manifestations was reported in Aden governorate (WHO, 2015). Also in 2015 the surveillance department has reported that DF has raised markedly in the country with 14,509 cases. The diagram below shows the distribution of cases by governorate in 2015 and it indicates that Al Hodeidah and Abyan governorates were highly affected by the disease and the least affected governorates were Dhamar and Sana’a. Figure (31): the number of dengue fever cases per governorate in 2015.
Poroportion of Morbidity for Suspected Dengue Fever by Governorate 2015 100000 14509 5318 10000 16902103 2309 655 735 1137 1000 145 173 65 76 27 28 100 12 14 15 6 10 1 1
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On the other hand the monthly distribution of DF shows great variations with most cases being recorded through September, October to December.
Figure (32): the number of dengue fever cases per month in 2015.
The distribution of Dengue Fever by Month in 2015 14509 2797 1124 1455 977 1211 1779 1287 2124 443 387 621 304
7.4.2.2 Food and Waterborne Infections Yemen is highly vulnerable to floods, droughts, heavy storms, changes in rain pattern, increase of temperature and sea level (NAPA, 2009), all of which will affect the biological, physical and chemical components of water through different paths and thus enhancing the risk of waterborne diseases. As Yemen is highly prone to floods events and this can be associated or followed by elevated disease burden from waterborne diseases, it will pose a greater threat for the human health. Outbreaks of waterborne diseases often occur after a severe precipitation event. Climate may act directly by influencing growth, survival, persistence, transmission, or virulence of pathogens; indirect influences include climate-related perturbations in local ecosystems or the habitat of species that act as zoonotic reservoirs (IPPC,2013).
7.4.2.2.1 Diarrheal Disease
Climate change is likely to increase diarrheal disease incidence, and extreme weather conditions may also complicate already-inadequate prevention efforts. Diarrheal diseases are so common in Yemen and it is one of the top five causes of morbidity and mortality (Statistical Annual Book, 2014). The impact of climate change on the prevalence/ incidence of climate change sensitive diseases in Yemen has not yet been studied or quantified.
Though certain studies associating an increase of relative risk of diarrhea with temperature increase between 8–11% by 2010–2039 and 22–29% by 2070–2100, yet it is associated with large uncertainties that can be attributed mainly to the scarcity of empirical climate–health data (Kolstad and Johansson, 2011).
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However, neither the specific causes of the diarrheal illness are known, nor the mechanism for the association with temperature. Exceptions include Salmonella and Campylobacter, among the most common zoonotic food- and water-borne bacterial pathogens worldwide, which both show distinct seasonality in infection and higher disease rates at warmer temperatures. The association between climate and non-outbreak (“sporadic”) cases of salmonellosis may, in part, explain seasonal and latitudinal trends in diarrhea (Lake, 2009). In 2015 the surveillance department has reported that acute diarrhea is the first cause of morbidity in the country with 398,583 cases. The diagram below shows the distribution of cases by month in 2015, which indicates the highest recorded number of cases in the winter months.
Figure (33): the distribution of acute diarrhea cases by month in 2015
The Distribution of Acute Diarrhea Cases by Month in 2015 398583 58808 34759 31869 30799 23690 18664 21992 28438 28342 35833 42084 43305
In 2015 the surveillance department reported that bloody diarrhea is the fifth cause of morbidity in the country with 34238 cases. The diagram below shows the distribution of cases by month in 2015 and it indicates that the highest number of cases are recorded in the winter months.
Figure (34): the distribution of bloody diarrhea cases by month in 2015
The Distribution of Bloody Diarrhea Cases by Month in 2015 34238 3384 3165 3621 4897 2618 2456 1382 2066 2459 2443 2789 2958
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7.4.2.2.2 Typhoid
Typhoid and paratyphoid fevers are the eighth cause of morbidity in Yemen in 2015. These are infectious diseases caused by the bacteria Salmonella typhoid and Salmonella paratyphi respectively which are transmitted through feces and into food and water sources and they are associated with poor hygiene, unsafe drinking water, inadequate sewage disposal and flooding (WHO, 2010e). As Yemen is suffering from chronic water scarcity of water, prone to flooding and variation in precipitations patterns and changing in temperature, the incidence of typhoid and paratyphoid fever will be increased. The number of cases per month in 2015 is shown below.
Figure (35): the number of reported cases of typhoid and paratyphoid per month in 2015
Number of cases of typhoid and paratyphoid fever per month in 2015 13950 11023 11277 9716 8487 9537 7624 6599 6783 7672 5588 5336
In regards to the distribution of typhoid and paratyphoid cases in the different governorates, the data shows that Hajja, Sana’a city and IBB governorates were having the highest number of cases compare to the lowest number of cases in the governorate of Abyan, Mareb and Almahara.
Figure (36): the number of cases of typhoid and paratyphoid per governorate in 2015
Number of Cases of Typhoid and Paratyphoid by Governorate in 2015
103592 20284 7453 8151 9740 9784 1240312557 3186 5383 1549 1918 2278 2630 796 915 1110 1366 408 519 662 233 267
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7.4.2.3 Respiratory Diseases
While upper respiratory tract infection diseases account for the first cause of morbidity in Yemen in 2015, the lower respiratory tract infection account for the third cause for the same year. According to surveillance department, the reported cases in 2015 reached 655,459 cases for URTI, and the number of cases of LRTI reached 290,053 in the different governorates in 2015 as shown in the figures below.
Figure (37): the distribution of URTI cases in the different governorates in 2015
Cases of Upper Respiratory Tract Infections in by governorate 2015 655459
56870 57937 73725 87479 28442 29199 33844 37185 43144 16898 17413 18429 24258 24816 25799 26265 26438 9699 10488 2422 3303 1406
Figure (38): the distribution of LRTI cases in the different governorates in 2015
Reported Cases of Lower Respiratory Tract Infections in 2015 290053
37231 22938 30947 36499 13628 16321 16451 19752 7763 8774 9771 9822 10511 11249 11426 11657 2329 2789 2854 3060 3596 685
Climate change also affects natural or biogenic sources of particulate matter (PM) such as wildfires and dust from dry soils which is a complex mixture of extremely small particles and liquid droplets (EPA, 2009). Exposure to these PM and breath them in will go to the deepest areas in the lungs causing a variety of health problems in cities including visibility impairment.
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7.4.3 Health Impacts Heavily Mediated through Human Institutions 7.4.3.1 Nutrition Undernutrition can be chronic, leading to stunting (low height for age), or acute, leading to wasting (low weight for height) and underweight (low weight for age) which is a combination of chronic and acute undernutrition. Worldwide, millions of deaths are caused by undernutrition per year from both the lack of sufficient nutrients to sustain life and as a result from vulnerability to infectious diseases such as malaria, diarrhea, and respiratory illnesses. The processes through which climate change can affect human nutrition are complex but higher temperatures and changes in precipitation may reduce both the quantity and quality of food harvested (Battisti and Naylor, 2009). For each degree above 30 0C, yields of African maize decreased by 1% under optimal rainfall conditions and by 1.7 % under drought conditions (Lobell et al., 2011b). Climate change is a threat to crop productivity in areas that are already food insecure (Knox et al. 2012). Increasing temperatures on the planet and more variable rainfalls are expected to reduce crop yields in many tropical developing regions, where food security is already a problem (WHO, 2010b). In Yemen with an estimated 14.4 million food insecure, the projected hunger and undernutrition will be widespread and the number of chronically undernourished children will be increased. 7.4.3.2 Occupational hazards
Outdoor workers are often among the first to be exposed to the effects of climate change and it is expected to affect the health of outdoor workers through increases in ambient temperature, degraded air quality, extreme weather, vector-borne diseases, industrial exposures, and changes in the built environment. Workers affected by climate change include farmers, ranchers, and other agricultural workers; commercial fishermen; construction workers; paramedics, firefighters and other first responders; and transportation workers.
As Yemen is highly prone to climate change, disasters and extreme weather events such as floods and heat waves and as 60% of the population is working in the fields of agricultur and construction and most of whom are outdoor laborers, more cases of heat-related illnesses such as heat stroke and heat exhaustion and fatigue among workers would be seen especially among more physically demanding occupations. Heat stress and fatigue can also result in reduced vigilance, safety lapses, reduced work capacity, and increased risk of injury. Rescue and recovery workers will be exposed to physical and psychological hazards of flood.
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In addition, outdoor workers are especially at risk of vector-borne disease and, as the global climate changes, they may be exposed to vector-borne diseases in areas and at times where transmission was previously not possible. Changes in daily work activities due to increased heat, such as longer rest periods in the middle of the day and increased work at dawn and dusk, may coincide with the times when insect vectors are most active thus increasing the likelihood of disease transmission (Global Health Action. 2010).
Also Yemen is an endemic country for malaria and dengue fever diseases, and people working out door in fields without effective protection may experience a higher incidence of these diseases when climatic conditions favor mosquito breeding and biting.
8 Projections for Future Vulnerability
It is of a certain that the rate of global warming is higher over East Africa and the Arabian Peninsula than the global average (high confidence) and extreme rainfalls is expected to increase (medium confidence). Human health is highly sensitive to shifts in weather patterns and other aspects of climate change (very high confidence), climate risks will magnify the harmful impacts on the population and will act mainly by exacerbating health problems that already exist (very high confidence). New conditions may emerge under climate change (low confidence), and existing diseases (e.g., food-borne infections) may extend their range into areas that are presently unaffected (high confidence) but the largest risks of health losses will be mainly among food- insecure population (IPPC, 2013).
In Yemen both population growth and climate change are inevitably occurring and these two factors are the main determinants of vulnerability. Other factors that will determine future health vulnerability include; the current public health status, the age - sex structure of the population, socioeconomic development status and the political and security stability of government.
The projected proportion of population 65 years and above in 2080 will form 14.2% of the total population of which 6.4% will be men and 7.8% will be women, whereas the projected proportion in 2100 will form 19.9% of which 8.8% will be men and 11.1% will be women. This will bring an increase in the prevalence of chronic diseases such as cardiovascular, renal and respiratory diseases all of which are sensitive to climate change and hence the patterns of mortality and morbidity and health expenditure will be changed.
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Because population growth is linked to climate change vulnerability, even if nothing else has been changed, and because Yemen is characterized by a very low HDI, a widespread hunger, high percentage of under-nutrition, weak, poor and low coverage of health care, poor physical infrastructures, lack of safe water supply, poor sanitation, poor waste management will all form the main entrance of the future vulnerability of all population and all of which would need policies and structural arrangements in all government sectors which should be aimed to improve health, education, balanced population growth and economic development.
8.1 Future Vulnerability to Flood
According to the Emergency Events database (EM-DAT) approximately 100,000 people are affected annually by disasters triggered by natural hazards in Yemen. In terms of exposure hazards, floods are the most important and recurring disaster in Yemen and it is expected that more people will be exposed to floods and it is very likely that health losses caused by storms and floods will increase this century if no adaptation measures are taken, but it is not clear by how much the projected increase can be attributed to climate change (IPPC, 2013). Flash floods is ranked as the top four natural disasters in Yemen since 1990 in regard to economic damages, eight of the top 10 in regard to killed persons, and nine of the top 10 in regard to the affected people (CRED, http://www.emdat.be/).
8.2 Future Vulnerability to Drought
Climate change may increase the length of the dry periods that result in widespread drought, land degradation and desertification. Water stress is observed to be increasing and the groundwater reserves are most likely to be depleted in two to three decades regardless of climate change leading to reduction of agricultural output by up to 40 %. High aridity, fast-depleting reserved groundwater and projected increases in temperature indicate more stress on agricultural production. Greater rainfall variability could result in prolonged drought periods (WB, 2010).
Moreover, the future effect of drought will indirectly affect the health of the society specially women and children mainly in the rural areas. The distance travelled to collect water during the drought terms will be doubled or four folded. Children in general, but specifically girls, will be forced to leave school and help their mothers for bringing water for house consumption and this will have its implication on socioeconomic development of the society leading to more poverty, illiteracy and ill health .
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8.3 Future Vulnerability to Malaria Disease
Models for predicting the effects of climate change on vector-borne diseases are subject to a high degree of uncertainty due to 1) vector-borne diseases are maintained in nature in complex transmission cycles that involve vectors, intermediate hosts, and humans; and 2) there are a number of other significant social and environmental drivers of transmission of vector-borne disease in addition to climate change. For example, while climate variability and climate change both alter the transmission of vector-borne diseases, they will likely interact with many other factors, including how pathogens adapt and change, the availability of hosts, ecosystems changing and land use, demographics, human behavior, and adaptive capacity (IOM, 2003, Allan et al, 2005), and these complex interactions make it difficult to predict the effects of climate change on vector-borne diseases.
The influence of temperature on malaria development appears to be nonlinear, and is vector specific (Alonso et al., 2011). Increased temperature variations, when the maximum is close to the upper limit for vector and pathogen, tend to reduce transmission, while increased variations of mean daily temperature near the minimum boundary increase transmission (Paaijmans et al., 2010). The strongly nonlinear response to temperature means that even modest warming may drive large increases in transmission of malaria, if conditions are otherwise suitable (Pascual et al., 2006; Alonso et al., 2011). On the other hand, at relatively high temperatures, modest warming may reduce the potential of malaria transmission (Lunde et al., 2013).
Using the A1B climate change scenario, Beguin et al. (2011) projected the population at risk of malaria to 2030 and 2050. With GDP per capita held constant at 2010 values, the model projected 5.2 billion people at risk in 2050, out of a predicted global population of 8.5 billion. Keeping climate constant, and assuming strong economic growth allied with social development (“best case”), the model projected 1.74 billion people at risk (approximately half the present number at risk) in 2050.
8.4 Future Vulnerability to Diarrheal Diseases
Kolstad and Johansson (2011) projected an increase of 8 to 11% in the risk of diarrhea in the tropics and subtropics in 2039 due to climate change. In Botswana, if hot, dry conditions begin earlier in the year, and are prolonged, as projected by down-scaled climate scenarios, the present dry season peak in diarrheal disease may be amplified (Alexander et al., 2013). However, the
Page 80 same analysis projected that incidence of diarrheal disease in the wet season would decline. Mangal et al. (2008) constructed a mechanistic model of the transmission cycle of another species, S. mansoni, and reported a peak in the worm burden in humans at an ambient temperature of 300C, falling sharply as temperature rises to 350C. The authors attribute this to the increasing mortality of both the snails and the water-borne intermediate forms of the parasite, and noted that worm burden is not directly linked to the prevalence of schistosomiasis. The overall impact of climate change on the different vulnerable population group is shown below.
Table (16): the overall impact of climate change on vulnerable population groups in Yemen Climatic Climate Vulnerable Climate Socioeconomic Change change Overall impact groups effect Scenarios factors scenario Under 5 Scenario Scenario Scenario Scenario Increase in High years A* B* A B Children temperature increase malnutrition High Moderate High Moderate
increase Increase increase increase Scenario Scenario Scenario Scenario Heat stress Increase in High Women A* B* A B related temperature increase High Moderate High Moderate diseases increase Increase increase increase Scenario Scenario Scenario Scenario Heat stress Increase in High Pregnant A* B* A B related temperature increase Women High Moderate High Moderate diseases increase Increase increase increase Scenario Scenario Scenario Scenario Elderly Heat related Increase in High A* B* A B People deaths and temperature increase High Moderate High High injuries increase Increase increase increase Scenario Scenario Scenario Scenario Increase in High Heat A* B* A B Outdoor temperature increase stroke Moderate Moderate Moderate Stable increase Increase increase Population Scenario Scenario Scenario Scenario Chronic Increase in Moderate with low A* B* A B diseases temperature increase SES High Moderate High High and flood risk increase increase increase increase Scenario Scenario Scenario Scenario Increase in IDPs Vectorborne A* B* High A B temperature diseases High Moderate increase High High
increase increase increase increase *Scenario A: it depends on the assumption of persistence of the same current health care system and the same existing standards of living but the population growth is very high and the economic growth is slow or moderately growing. *Scenario B: it depends on the assumption that the current health care system and the existing standards of living will improve and both the population growth and the economic growth will grow moderately
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9 Adaptation Strategies (Options) to Impact of climate change on Health
Climate change may threaten the progress that has been made in reducing the burden of climate- sensitive disease and injury. Not only this, the health indicators that have been improved through decades could be deteriorated by the consequences of climate change and the recent massive war that hit badly all developmental sectors in the whole country that were indeed very fragile and weak. This two synergistic factors will shape the future vulnerabilities of the population health and could be reduced through adaptation measures bearing in mind that reduction in mortality or morbidity should not necessarily attributed with confidence to climate change itself.
Neutralizing the consequences of the recent war and taking into account the 2010 health indicators as the base year, the degree to which programs and measures will need modification to address additional pressures from climate change will depend on the current burden of ill health; the effectiveness of current interventions; projections of where, when, and how the health burden could change with climate change; the feasibility of implementing additional programs; other stressors that could increase or decrease resilience; and the social, economic, and political context for intervention (Ebi et al., 2006).
Efforts to adapt to the health impacts of climate change can be categorized as incremental, transitional, and transformational actions. Incremental adaptation strategies include improving public health and health care services for climate-related health outcomes without necessarily considering the possible impacts of climate change. Transitional adaptation means shifts in attitudes and perceptions leading to initiatives such as vulnerability mapping and improved surveillance systems that specifically integrate environmental factors. Transformational adaptation which requires fundamental changes in systems has yet to be implemented in the health sector (IPPC, 2012).
The rebuilding and maintaining of public health infrastructures are often viewed as the “most important, cost-effective and urgently needed” adaptation strategy (IPCC, 2001) to climate change in the human health sector. This includes training in the public health sector, effective surveillance and emergency response systems and sustainable prevention and control programs. Adaptive actions to reduce health impacts can be considered in terms of the conventional public health categories of primary, secondary and tertiary prevention (WHO & UNEPA, 2003).
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a. Primary adaptive measures Primary prevention largely corresponds to anticipatory adaptation and these are measures that reduce or prevent the risk of developing a disease which include actions taken to prevent the onset of disease arising from environmental disturbances in an otherwise unaffected population This may involve protection from an infectious or harmful agent such as immunization or the use of bed nets, or the removal of the harmful agent or exposure from the environment such as indoor residual spray for eradication of disease vectors. b. Secondary adaptive measures Secondary prevention is analogous to reactive adaptation and these are preventive actions taken in response to early evidence of health impacts. It involves the detection and treatment of a disease at a stage early enough to prevent serious clinical illness. Examples include screening for malnutrition, enhancing monitoring and surveillance, improving disaster response and recovery, and strengthening the public health system’s ability to respond quickly to disease outbreaks. c. Tertiary adaptive measures These are health care actions taken to lessen the morbidity or mortality caused by the disease (McMichael and Kovats, cited in WHO, 2000). It involves limiting long-term deterioration of health from disease (e.g. treatment of infectious diseases and rehydration therapy for diarrhea), better treatment of heat stroke and improved diagnosis of vector-borne diseases. As the adverse health outcome is not prevented, tertiary prevention is inherently reactive.
9.1 WHO requirements for preparing health systems for climate change
9.1.1 Leadership and Governance The health sector has a challenge – and an opportunity – to demonstrate its leadership and responsibility in dealing with climate change through its own actions, through leadership in developing national health adaptation plans that consider how climate change-related actions in other sectors could affect current and future population health, and through promoting equity and good governance in national and regional policies. This includes, but not limited to,: 1. developing strategic policy frameworks. 2. preparing and implementing adaptation plans. 3. ensuring effective monitoring and management.
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4. building coalitions between relevant sectors and partners, including national and international climate policy mechanisms. 5. public advocacy and risk communication to ensure public understanding and support. 9.1.2 Allocate Financial Resources 1. Adequate funds are needed to maintain core health system functions. 2. Providing funds for core health and public health services mainly for water, sanitation, environmental hygiene, and disaster and health emergency preparedness. 3. Preparing and implementing effective plan for insurance or cost recovery/ replacement costs for health facilities and equipment lost or damaged due to extreme weather events. 9.1.3 Human Resources and Capacity Building Ensuring adequate human and financial resources to protect individuals and communities from the health impacts of climate change. A well-performing health workforce is needed to achieve the best health outcomes possible and this includes: 1. sufficient numbers, equitable distribution and mix of qualified health workforce. 2. competent and productive staff to deliver health promotion and protection taking account of location and seasonal demands for staff. 3. providing training and capacity building for professionals and public to support efforts to reduce health risks and providing effective service delivery during disasters. 9.1.4 Service Delivery Mechanisms 1. Health service delivery should combine inputs to provide effective, safe, good-quality health interventions in an efficient and equitable manner. 2. Prepare health services for shifts or additional burdens, which require revisions of organizational and management processes and the timing and location of service delivery. 9.1.5 Technology and Pharmaceuticals Supplies A range of medical products and technologies are needed to protect populations from climate- sensitive health conditions and these include: 1. medical equipment and supplies for emergency response. 2. permanent and emergency health facility services. 3. technologies in health-supporting sectors such as water and sanitation and environmental hygiene.
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9.1.6 Health Information System Establish health information systems that ensure the production and application of reliable and timely information on health determinants, health systems performance, health status, and the incidence and geographical range of climate-sensitive health outcomes and these include: 1. data collection, analysis, communication and reporting. 2. collaborations with national meteorological and hydrological services to ensure that appropriate environmental data are collected on the same scale as health data, and that policies and programs are effective in addressing climate-sensitive health outcomes. 3. hazard and vulnerability assessments. 4. early warning systems. 5. information on infrastructure such as hardware and networks. 6. coordination mechanisms to link relevant information from meteorological or hydrological services to inform health decisions. 9.1.7 Health Partnerships and Community Engagement The delivery of public health depends upon individual and community use of public health services and acquisition of public health education. Partnerships across stakeholder groups and levels are necessary to engage members of society as actors in their own health protection.
9.2 Levels of Needed Policies for Effective Adaptation Strategies
9.2.1 Health Sectors 1. Political well and government commitments towards the impact of climate change on health sector. 2. Establishing highly credible and validated scientific approaches to implement climate change surveillance and documentation. 3. Creating an environment of open, free and easy access channels of exchanging, feedback, transition and dissemination of information. 4. Full cooperation with neighboring and bordering countries in issues of health impact of climate changes which are not restricted to one country but can be extended to far distances, for example extreme events of heat waves, sand storms and floods. 5. Reinforcement of technical cooperation with international organizations such as IPCC, UNDP, IEA, ISDR, WB and WHO.
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6. Selecting and agreeing among concerned stakeholders on the most sensible and valid indices to evaluate surveillance systems and networks, and choosing indices of early warning and other technical and health indicators 7. Seeking and initiating concepts of sustainable environment taking into account friendly development projects that consider public health and respect human dignity as a priority. 9.2.2 Metrology Authority 1. Develop the capacity of national meteorological services to monitor and detect meteorological and climatological conditions that could pose a health risk. 2. Strengthening available weather stations and establishing new stations as needed. 3. Establishing effective early warning system (EWS). 4. Creating healthy environment for exchange of information and climate data among the concerned authorities.
9.3 Principles of adaptation strategies of health impacts of climate change
1. Evidence based planning Assessment of diseases’ current situation focusing on environmental and climatic factors through scientific field studies and researches. Availability of accurate, valid and free access database that should act as a baseline for further studies through analysis and evaluation of available data sources and information of health sector and other relevant sectors for a period of time as long as possible aiming at finding relation and association to establish projection models.. 2. Strengthening inter-related sector cooperation involving private sector, governmental, and non-governmental organization and creating unified understanding among all parties and activities implementers of health outcomes that result from such activities whether directly or indirectly. 3. Strengthen cooperation with metrological authorities and related authority to start establish sufficient and effective metrological stations for daily temperatures, precipitation, humidity, storms and etc. and the proper and standards of data required. 4. Strengthening relation with UNDP, WHO, WB, EPA, and other international research and funding organizations on climate changes
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9.4 Necessities of Adaptation Strategies (Starting Now)
The adaptive strategies developed in anticipation of future climate conditions may have substantial utility for the present situation. Many of the suggested adaptation strategies are not specific to climate change and, in fact, should not be viewed in isolation from the more generalized health problems. Yemen health system has been suffering from long lasting and substantial crises and the application of WHO full set of requirements (above) for preparing such health systems for climate change in a country such as Yemen would require not only huge investments in terms of financing and human resources but rather fundamental structural adjustments in many related sectors that would be beyond the capabilities and abilities of the government as a whole, especially with the consequences current war.
The application of simple cost effective measures in scientific manner such as reliable seasonal forecasts can help in predicting impending climate-related health crises, and allow more time for interventions to limit impacts. Public health education and awareness programs and campaigns can be highly effective in reducing the risk of diarrhoeal and vector-borne diseases. Another example that is simple and cost effective measure would be the development of Malaria Early Warning Systems (MEWS) in the malaria control program, and building its capacity to use simple transmission risk indicators such as excess rainfall and changes in temperature.
The economic consequences of inaction are immense. While it is estimated that for every 1°C rise in average global temperature, the economic growth would drop by between 2-3%. The World Economic and Social Survey released by the UN in 2009 estimated the costs of mitigation and adaptation at 1% of World Gross Product (WGP), which is small compared to the costs and risks of the impacts of climate change. A review by the World Health Organization in 2012 estimated that commitments to health adaptation internationally amount to less than 1% of the annual health costs attributable to climate change in 2030 (WHO Regional Office for Europe, 2013). If action is not taken, or is delayed “by continuing in the present business-as-usual scenario, or making only marginal change, the permanent loss of projected WGP could be as high as 20%. If these facts are applied for the case of Yemen and its current situation, the cost of inaction would be unbearable which leaves no room for the decision makers other than to start implementation of adaptive strategies right now.
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9.5 Specific Adaption Strategies in the Health Sector
Though the vulnerability assessment has shown that all sectors and people are potentially vulnerable to health impact of climate change, the resilience of the health systems including infrastructure, policies and programs to climate risks will depend on the extent to which they incorporate flexibility and adaptive management (WHO, 2010). The ability to respond adequately, quickly and effectively to potential climate-related hazards is of critical importance to program success, as failure to adapt will result in huge costs. The main top urgent issues to start with are: 1. Health impact of climate changes should be integrated and stated clearly and efficiently enough in all national health polices and plans and long term visions such as 2025. 2. Climate-related adaptation strategies should not be considered in isolation of broader public health concerns such as population growth and demographic change, poverty, public health infrastructure, sanitation, availability and accessibility of health care, nutrition, risky behaviors, misuse of antibiotics, pesticide resistance, and environmental degradation. All of these factors (and others) will influence the vulnerability of populations and the health impacts they experience, as well as possible adaptation strategies. 3. The MoPHP should generalize concepts of precise, accurate and valid routine data collection through well established and monitored health information systems. Organized and systematic valid morbidity and mortality data collection formats should be one of the main criteria of appraising performance of health directors and the allocation of resources. Writing the correct diagnosis clearly in clean and clear records with date and time, keeping records for as many years as possible, keeping electronic version of records and pack up, and easy access to these records any time needed are mandatory and should be considered for judging on the work of health facilities that include hospitals, health centers, and health units. 4. Death records and certificate, if available, should be valid if it stated the direct and indirect causes of death. 5. Training physicians and promote them to describe the real cause of death should be started as soon as possible.
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6. Promoting and supporting health services and training health workers on how to deal with the health impact of climate change. 7. University hospitals, military health providers, private sector and non-governmental health services providers’ involvement in cooperative program with the MoPHP in the area of health impact of climate changes would strengthen the monitoring of the potential health impact of climate changes. 8. Adopting WHO indicators and standards on national level because there is no national matches that has been built on national policy basis. 9. Strengthen ongoing prevention and control programs such as malaria, diarrhea, nutrition and schistosomiasis and surveillance directorate. 10. Providing additional budgets to set a network to monitor and evaluate diseases related to climate change.
9.6 Specific Adaptation Activities (Incremental)
According to findings of V&A questionnaire analysis, 68% of respondents believe that the priority interventions to reduce the impact of climate change and reduce its effects is health education and raising awareness about the scale and the importance of climate change and its effect on health. This is followed by the believe of 66% and 62% of respondents of the need to build an early warning system and providing safe drinking water respectively. Other adaptation strategies such as building water network, providing health care services and provision of sanitation system were believed by nearly 54% of respondents.
Regarding the adaptive capacities of the health sector to address the impact of climate change and reduce its effects, 74% of respondents believe that the health sector is very weak and unable to cope with climate changes comparing to 26% who believe of the availability of somehow (acceptable) capacities of health sector to address the impact of climate change on health .
55%, 52% and 42% of respondents believe that the health sector has some sort of adaptive capacity in terms of technical skills, infrastructure and financial resources respectively whereas only 40% and 37% of respondents believe that the health sector has institutional networking with other related agencies and the required legal frameworks. The following activities are the priority interventions needed from the perspectives of the MoPHP leadership and decision makers:
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1. Health education and raising awareness on the scale and importance of climate change and its impact on health 2. Establishing an epidemiological surveillance system for monitoring changes in vector population abundance in the main targeted high risk areas and expected transmission areas. 3. Strengthening surveillance for vectorborne, waterborne and foodborne diseases. 4. Establishing surveillance system for temperature-related mortality and morbidity and adverse health effects of air pollution exposure. 5. Improve access and utilization of health care services for all population taking into accounts equity and gender disparities. 6. Prepare effective and responsive preparedness system with full capabilities to deal with unexpectedly disasters. 7. Allocate budget and human resources for research on the field of climate change and its linkage to infectious disease, temperature related mortalities and morbidities. 8. Allocate adequate financial and human health resources and capacity building in the field of climate change impact which include training, surveillance and emergency response, and prevention and control programs. 9. Improve access to clean water and sanitation for underserved and to those most vulnerable population groups. 10. Strengthening and expanding routine vaccination programs 11. Ensuring essential medical supplies for care of individuals with chronic conditions, including effective post-disaster distribution, would increase the ability of communities to manage large-scale floods and storms. 12. Ensuring the adequate supply of drugs against malaria and enteric infections for treatment of people promptly and effectively
9.7 Transitional Adaptation Actions
As stated above, transitional adaptation means shifts in attitudes and perceptions, leading to initiatives such as vulnerability mapping and improved surveillance systems that specifically integrate environmental factors. Most of these actions are beyond the capacity and capability of
Page 90 the health system and they are mentioned here to give an idea on the broad spectrum of actions that can be taken. These actions include: 9.7.1 Research and Surveillance 1. Generating baseline data and tracking the changes over time through repeated surveys. 2. Develop modeling and forecasting/ predicting climate change related health effects 3. Mainstreaming climate change into health policies and strategies. 4. Establish comprehensive early warning system 5. Prepare preparedness and response plan 9.7.2 Established environmental directorate/ program 1. coordination and partnership with related sectors 2. technical support to the relevant directorate in the MoPHP 3. generate information on climate change and heath data 4. integration, harmonization and alignment of climate change health impacts and adaptation options into health sector at different levels 9.7.3 Establish climate change technical working group with clear TOR Memberships should include, but not limited to,: 1. Ministry of Public Health and Population (MOPHP) 2. Environmental Protection Agency (EPA) 3. Ministry of Agriculture (MoA) 4. Ministry of Education (MoE) 5. Ministry of Higher Education (MoHE) 6. United Nation Development Program (UNDP) 7. World Bank (WB) 8. United Nation children’s Fund (UNICEF) 9. World Health Organization (WHO) 10. Teaching Hospitals 11. Supreme for Drug and pharmaceuticals 12. Private Health Sectors 13. Military Health Sectors
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14. Non-Governmental Organization 9.7.4 Formation of Task Group 1. establishment of climate change adaptation technical working groups at governorate levels that include health offices, health institutions, Universities, Professional Associations, NGOs, and others 2. develop clear TOR. 3. develop climate change adaptation program to health 4. undertake and exercise inter- and intra-collaboration, coordination and partnership building for climate change adaptation options to health at all levels 5. develop and implement health protection and response strategies ,manuals, guidelines, standards operation procedures, integrated work plans for adaptation to climate change at all levels 6. dissemination/training on the above documents 7. develop climate change adaptation program to health strategies, guidelines, integrated work plans for adaptation to climate change and measures relating to climate change and their effectiveness, including cost-effectiveness as appropriates. 8. implementation manuals and guidelines with regards to each climate sensitive diseases and extreme climate events at different levels 9. training and dissemination of manuals and guideline 9.7.5 Health Systems Strengthening (HSS) It is of paramount important to enable the health system to deal with direct and indirect health impacts of climate change. Health system strengthening includes the following: 9.7.6 Infrastructure Structure Development 1. Design, strengthen and enforce building codes and standards, roofs, roads, use of UV resistant materials such as glasses/windows/ shades etc. to be more climate change resistant for existing and new facilities 2. Provide air conditioned for all health facilities 3. Provide continuous electric power for health facilities 4. Provide air conditioned for all health facilities 5. Provide equipment for health facilities 6. Strengthening Emergency Ward (ER) for health facilities
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7. Provision of mobile clinics 8. provision of adequate emergency and ambulances vehicles. 9. Water network supply for the main vulnerable areas 10. Sewerage and sanitation 9.7.7 Human Capacity Development/Training 1. promote health workforce as well as relevant others development to respond to the health threats of c climate change 2. in-service training targeting all health workers 3. short term trainings for school teachers and students and scouts, fire brigade works, police, community leaders, NGOs and relevant sectors 4. pre- service training on climate change and its impact on human health 5. Provide short term trainings for human health personnel 6. Provide post graduate trainings for health staff in public health and environmental health, GIS, meteorology health related to climate change. 9.7.8 Emergency Medical Services 1. Prepare effective and flexible emergency health plan 2. Improve and upgrade available emergency mobile and stationary medical center, equipment, medicine, feedings, water and sanitation facilities 3. Provide medical equipment and supplies including vaccines and therapeutic feedings. 4. Mainstreaming and prioritizing climate sensitive diseases management in routine health service delivery system 5. Procure and distribute Long Lasting Insecticide Nets (LLINs) to prevent and control malaria in more vulnerable areas and population segments 6. Rehabilitating existing facility structure that take into consideration the extreme effect of climate change and on new building structure, building materials, roof water harvesting and storage 7. Procure and distribute Rapid Diagnostic Tests (RDTs) and Arthemesinin Based Combination Therapy (ACTs) to diagnose and treat malaria cases in more vulnerable population segments
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9.7.9 Strengthen and Utilize Climate-informed Early Warning and Response System Many infections and chronic diseases are either directly or indirectly sensitive to the climate changes. Managing this climate sensitivity more effectively requires new working relationships between the health sector and the providers of climate data and information to facilitate networking and to increase the return from the investment. 1. Build strong link between the Ministry of Health and the National Metrological Agency to avail and utilize climate information for health interventions for climate-sensitive diseases such as malaria 2. Create an enabling mechanism on the existing 9.7.10 Public health education and awareness 1. First Yemen conference on climate change impact on health (participants from international community, donors, experts, regional and local governmental and NGOs bodies 2. Develop communication strategy on climate change and adaption option to increase awareness of links between climate change and health on Climate Change (IEC/ BCC). 3. Mass media campaign Produce TV and radio materials and broadcast through national TV channels and local radio stations 4. Design awareness campaign and material and usage of short SMS messages through mobile phones, electronic media, printing brochures of different sizes and designs, street banners and other possible media of mass communication towards creating awareness and publicity for climate change behaviour change 5. Education programs targeted specifically for vulnerable groups mainly children, women, IDP and refugees. 6. Advocacy meeting and workshops for shaping policy and programming for results using different media at different levels 7. Improved community engagement processes with a partnership approach among communities, government and NGOs and private sectors. 8. Organize workshop to advocate and reach on consensus in incorporating climate change adaptation and mitigation issues in school curricula
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10 References
10.1 Studies
1. Abuaku, B.K., J. Zhou, X. Li, S. Li, A. Liu, T. Yang, and H. Tan, 2009: Morbidity and mortality among populations suffering floods in Hunan, China: the role of socioeconomic status. Journal of Flood Risk Management, 2(3), 222-228. 2. Acosta-Michlik, L., U. Kelkar, and U. Sharma, 2008: A critical overview: local evidence on vulnerabilities and adaptations to global environmental change in developing countries. Global Environmental Change, 18(4), 539-542. 3. Alexander, K.A., M. Carzolio, D. Goodin, and E. Vance, 2013: Climate change is likely to worsen the public health threat of diarrheal disease in Botswana. International Journal of Environmental Research and Public Health, 10(4),1202-1230. 4. Allan, B. F., F. Keesing, and R. S. Ostfeld, 2003: Effect of forest fragmentation on Lyme disease risk. Conservation Biology, 17, 267-272. 5. Alonso, D., M.J. Bouma, and M. Pascual, 2011: Epidemic malaria and warmer temperatures in recent decades in an East African highland. Proceedings of the Royal Society B, 278(1712), 1661-1669. 6. Alston, M. and J. Kent, 2008: The Big Dry: the link between rural masculinities and poor health outcomes for farming men. Journal of Sociology, 44(2), 133-147. 7. Anderson, G.B. and M.L. Bell, 2011: Heat waves in the United States: mortality risk during heat waves and effect modification by heat wave characteristics in 43 U.S. communities. Environmental Health Perspectives, 119 (2), 210-218. 8. Basu, R. and B.D. Ostro, 2008: A multicounty analysis identifying the populations vulnerable to mortality associated with high ambient temperature in California. American Journal of Epidemiology, 168(6), 632-637. 9. Battisti, D.S. and R.L. Naylor, 2009: Historical warnings of future food insecurity with unprecedented seasonal heat. Science, 323(5911), 240-244. 10. Berry, H.L., K. Bowen, and T. Kjellstrom, 2010: Climate change and mental health: a causal pathways framework. International Journal of Public Health, 55(2), 123-132. 11. Brouwer, R., S. Akter, L. Brander, and E. Haque, 2007: Socioeconomic vulnerability and adaptation to environmental risk: a case study of climate change and flooding in Bangladesh. Risk Analysis, 27(2), 313-326. 12. Brunkard, J., G. Namulanda, and R. Ratard, 2008: Hurricane Katrina deaths, Louisiana, 2005. Disaster Medicine and Public Health Preparedness, 2(4), 215-223. 13. Clark, Sarah C. Mission Report. Yemen 25 May – 03 June 2007. 14. Cook, J.T. and D.A. Frank, 2008: Food security, poverty, and human development in the United States. Annals of the New York Academy of Sciences, 1136(1), 193- 209. 15. Corvalan, C et al. (2000). Decision Making in Environmental Health: From Evidence to Action. E & FN Spon, London 16. Ebi, K.L., J. Smith, I. Burton, and J. Scheraga, 2006: Some lessons learned from public health on the process of adaptation. Mitigation Adaptation Strategies Global Change, 11, 607-620. 17. EPA (2009). National Adaptation Program of Action on Climate Change (UNFCCC), 2009. Environmental Protection Authority, Sana’ a, Yemen. 18. EPC (2001). Initial Communication of Yemen to the United Nations Framework on Climate Change (UNFCCC), April 2001. Environmental Protection Council, Sana’ a, Yemen. 19. Fankhauser, S. and R.S.J. Tol (1997). ‘The social costs of climate change: the IPCC Second Assessment Report and beyond’. Mitigation and Adaptation Strategies for Global Change.1:385- 403.
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20. Fouillet, A., G. Rey, V. Wagner, K. Laaidi, P. Empereur-Bissonnet, A. Le Tertre, P. Frayssinet, P. Bessemoulin, F. Laurent, P. De Crouy-Chanel, E. Jougla, and D. Hemon, 2008: Has the impact of heat waves on mortality changed in France since the European heat wave of summer 2003? A study of the 2006 heat wave. International Journal of Epidemiology, 37(2), 309-317. 21. Gage, K. L., T. R. Burkot, R. J. Eisen, and E. B. Hayes, 2008: Climate and vectorborne diseases. American Journal of Preventive Medicine, 35, 436-450. 22. Gamble, J.L., B.J. Hurley, P.A. Schultz, W.S. Jaglom, N. Krishnan, and M. Harris, 2013: Climate change and older Americans: state of the science. Environmental Health Perspectives, 121(1), 15-22. 23. Ghouth, A. S. B., Amarasinghe, A., & Letson, G. W. (2012). Dengue Outbreak in Hadramout, Yemen, 2010: An Epidemiological Perspective. The American Journal of Tropical Medicine and Hygiene, 86(6), 1072–1076 24. Hanigan, I.C., C.D. Butler, P.N. Kokic, and M.F. Hutchinson, 2012: Suicide and drought in New South Wales, Australia, 1970-2007. Proceedings of the National Academy of Sciences of the United States of America, 109(35), 13950-13955. 25. Hansen, A.L., P. Bi, P. Ryan, M. Nitschke, D. Pisaniello, and G. Tucker, 2008: The effect of heat waves on hospital admissions for renal disease in a temperate city of Australia. International Journal of Epidemiology, 37(6), 1359-1365. 26. IOM, 2003: Microbial Threats to Health: Emergence, Detection, and Response. M.S. Smolinski, Hamburg, M.A., and Lederberg, J., Eds., Institute of Medicine. The National Academies Press, 398 pp. 27. Knowlton, K., B. Lynn, R.A. Goldberg, C. Rosenzweig, C. Hogrefe, J.K. Rosenthal, and P.L. Kinney, 2007: Projecting heat-related mortality impacts under a changing climate in the New York City region. American Journal of Public Health, 97(11), 2028-2034. 28. Knox, J., T. Hess, A. Daccache, and T. Wheeler, 2012: Climate change impacts on crop productivity in Africa and South Asia. Environmental Research Letters, 7(3). 29. Kolstad, E. and K.A. Johansson, 2011: Uncertainties associated with quantifying climate change impacts on human health: a case study for diarrhea. Environmental Health Perspectives, 119(3), 299-305. 30. Kovats, R.S. and S. Hajat, 2008: Heat stress and public health: a critical review. Annual Review of Public Health, 29, 41-55. 31. Lake, I.R., 2009: A re-evaluation of the impact of temperature and climate change on foodborne illness. Epidemiology and Infection, 137(11), 1538-1547. 32. Lobell, D.B., M. Banziger, C. Magorokosho, and B. Vivek, 2011b: Nonlinear heat effects on African maize as evidenced by historical yield trials. Nature Climate Change, 1(1),42-45. 33. Lunde, T.M., M.N. Bayoh, and B. Lindtjorn, 2013: How malaria models relate temperature to malaria transmission. Parasites & Vectors, 6, 20 34. Mangal, T.D., S. Paterson, and A. Fenton, 2008: Predicting the impact of long-term temperature changes on the epidemiology and control of schistosomiasis: a mechanistic model. PLoS One, 3(1), e1438, doi:10.1371/journal.pone.0001438. 35. Milojevic, A., B. Armstrong, S. Kovats, B. Butler, E. Hayes, G. Leonardi, V. Murray, and P. Wilkinson, 2011: Long-term effects of flooding on mortality in England and Wales, 1994-2005: controlled interrupted time-series analysis. Environmental Health, 10, 11. 36. Neelormi, S., N. Adri, and A. Ahmed, 2009: Gender dimensions of differential health effects of climate change induced water-logging: a case study from coastal Bangladesh. Proceedings of IOP Conference Series: Earth 37. Neria, Y., 2012: Mental health effects of Hurricane Sandy characteristics, potential aftermath, and response. JAMA: The Journal of the American Medical Association, 308(24), 2571- 2572. 38. Nicole Glass, (2012). The Water Crisis in Yemen: Causes, Consequences and Solutions, Global Majority E-Journal, Vol. 1, No. 1 (June 2010), pp. 17-30
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39. Nitschke, M., G. Tucker, A. Hansen, S. Williams, Y. Zhang, and B. Peng, 2011: Impact of two recent extreme heat episodes on morbidity and mortality in Adelaide, South Australia: a case- series analysis. Environmental Health, 10(1), 42-51. 40. Paaijmans, K.P., S. Blanford, A.S. Bell, J.I. Blanford, A.F. Read, and M.B. Thomas, 2010: Influence of climate on malaria transmission depends on daily temperature variation. Proceedings of the National 41. Padmanabha, H., E. Soto, M. Mosquera, C.C. Lord, and L.P. Lounibos, 2010: Ecological links between water storage behaviors and Aedes aegypti production: implications for dengue vector control in variable climates. Ecohealth, 7(1), 78-90. 42. Paranjothy, S., J. Gallacher, R. Amlot, G.J. Rubin, L. Page, T. Baxter, J. Wight, D. Kirrage, R. McNaught, and P. SR, 2011: Psychosocial impact of the summer 2007 floods in England. BMC Public Health, 11(1), 145. 43. Pascual, M., J.A. Ahumada, L.F. Chaves, X. Rodo, and M. Bouma, 2006: Malaria resurgence in the East African highlands: temperature trends revisited. Proceedings of the National Academy of Sciences of the United States of America, 103(15), 5829-5834. 44. Patz J.A., Strzepek K., Lele S., Hedden M., Greene S., Noden B., Hay S.I., Kalkstein L., Beier J.C. (1998), “Predicting key malaria transmission factors, biting and entomological inoculation rates, using modeled soil moisture in Kenya”, Tropical Medicine and International Health, 3, 818-827. 45. Perera, F.P., 2008: Children are likely to suffer most from our fossil fuel addiction. Environmental Health Perspectives, 116(8), 987-990. 46. Smith, K.R., A. Woodward, D. Campbell-Lendrum, D.D. Chadee, Y. Honda, Q. Liu, J.M. Olwoch, B. Revich, and R. Sauerborn, 2014: Human health: impacts, adaptation, and co-benefits. In: Climate Change 2014: Impacts,Adaptation, and Vulnerability. Part A: Global and Sectoral Aspects. Contribution of Working Group II to theFifth Assessment Report of the Intergovernmental Panel on Climate Change [Field, C.B., V.R. Barros, D.J. Dokken, K.J. Mach, M.D. Mastrandrea, T.E. Bilir, M. Chatterjee, K.L. Ebi, Y.O. Estrada, R.C. Genova, B. Girma, E.S. Kissel, A.N. Levy, S. MacCracken, P.R. Mastrandrea, and L.L. White (eds.)]. Cambridge University Press, Cambridge, United Kingdom and New York, NY, USA, pp. 709-754. 47. Strand, L.B., A.G. Barnett, and S. Tong, 2012: Maternal exposure to ambient temperature and the risks of preterm birth and stillbirth in Brisbane, Australia. American Journal of Epidemiology, 175(2), 99-107. 48. Wilby, R. (2009). An evaluation of climate data and downscaling options for Yemen 49. World Bank Yemen study (2010): Assessing the Impact of Climate Change and variability on the Water and Agriculture Sectors, and the Policy Implications, 2010. 50. Zhou, X., G. Yang, K. Yang, X. Wang, Q. Hong, L. Sun, J.B. Malone, T.K. Kristensen, N.R. Bergquist, and J. Utzinger, 2008: Potential impact of climate change on schistosomiasis transmission in China. American Journal of Tropical Medicine and Hygiene, 78(2), 188-194. 10.2 Special Reports
1. World Health Organization (2013). Protecting health from climate change: vulnerability and adaptation assessment 2. Intergovernmental Panel on Climate Change (2013). Fifth Assessment Report, Working Group II 3. Intergovernmental Panel on Climate Change (2007). Fourth Assessment Report, Working Group II 4. UNDP (2015). Climate Change Country Profile: Yemen. 5. United Nations Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2015 Revision. (Medium variant) 6. USAID /Yemen CDCS, (2014-2016). Yemen Country Development Cooperation Strategy.
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10.3 Arabic Reports and Documents related to the MoPHP
1. وزارة المالية. خالصة تقديرات الموازنة العامة )3014 ( 3. وزارة الصحة العامة والسكان. التقرير اإلحصائي السنوي )3014(
10.4 English Reports and Documents related to the MoPHP
1. Ministry of Public Health and Population Malaria control Program Reports 2003 - 2013 2. Ministry of Public Health and Population Yemen Demographic health surveys, 2013. 3. Ministry of Public Health and Population. Malaria Country Profiles Yemen 2005 - 2014 4. Ministry of Public health and population. National Health Strategy 2010 -2025 5. Ministry of Public Health and Population. National Health Strategy, 2010-2025. 6. Ministry of Public health and population. The Fourth 5-Year Health Development & Poverty Alleviation Plan 2011 -2015 7. Ministry of Public health and population. The Third 5-Year Health Development & Poverty Alleviation Plan 2011 -2015 8. Ministry of Public Health and Population. Yemen Family health survey 2003 9. Yemen census 1994 and 2004 10.5 Websites and Reports
1. Drought Conditions and Management Strategies in Yemen, 2014 http://www.ais.unwater.org/ais/pluginfile.php/605/mod_page/content/23/Yemen.pdf 2. European Commission (2015): Yemen ECHO Factsheet: http://ec.europa.eu/echo/files/aid/countries/factsheets/yemen_en.pdf 3. Republic of Yemen and Health Metrics Network. Health Information Systems Assessment Report. The Ministry of Public Health and Population, Sana’a, Yemen, 2009. http://www.who.int/healthmetrics/library/countries/HMN_YEM_Assess_Final_2009_07_en.pdf) 4. Transparency International (2014) http://www.transparency.org/cpi2014/results 5. UNDESA (2012): World Population Prospects: The 2012 Revision: http://esa.un.org/wpp/unpp/panel_population.htm 6. UNDP (2015) http://hdr.undp.org/en/content/table-1-human-development-index-and-its- components 7. UNDP (2015). http://hdr.undp.org/en/content/table-4-gender-inequality-index 8. United Nations University (2012): World Risk Report 2012: https://www.ehs.unu.edu/file/get/10487.pdf 9. Vulnerability, Risk Reduction, and Adaptation to Climate Change (2011): http://sdwebx.worldbank.org/climateportalb/doc/GFDRRCountryProfiles/wb_gfdrr_climate_chan ge_country_profile_for_YEM.pdf 10. WFP (2015). Yemen Situation Report. https://www.wfp.org/countries/yemen/overview 11. WHO & UNEP. (2003). Climate change and human health - risks and responses. Summary (Adobe Digital Editions version), Retrieved from ttp:// www.who.int/globalchange/publications/cchhbook/en/ 12. WHO (2015),http://reliefweb.int/report/yemen/yemen-conflict-situation-report-14-31-august-13- september-2015 13. WHO, June 2015. http://reliefweb.int/report/yemen/dengue-yemen-palais-briefing-notes-12-june-2015 14. World Bank Data (2015) – GDP per capita. , http://data.worldbank.org/indicator/NY.GDP.PCAP.PP.CD 15. World Bank Data (2015) – Population density, http://data.worldbank.org/indicator/EN.POP.DNST
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16. World Food Program. http://reliefweb.int/report/yemen/wfp-yemen-situation-report-december-2015 17. World Health Organization (2008 – 2013). Country Cooperation Strategy for the Republic of Yemen. http://www.who.int/countryfocus/cooperation_strategy/ccs_yem_en.pdf 18. World Population Review – Yemen, http://worldpopulationreview.com/countries/yemen- population/ 19. Yemen humanitarian needs overview, 2016. www.unocha.org/yemen 20. Ministry of Public Health and Population, National Health Account, 2007. http://apps.who.int/nha/country/yem/Yemen_NHA_2000.pdf 21. National Health Accounts Team, Republic of Yemen, and Partners for Health Reform plus. June 2006. Yemen National Health Accounts: Estimate for 2003. Bethesda, MD: The Partners for Health Reform plus Project, Abt Associates Inc. http://www.phrplus.org/Pubs/Tech103_fin.pdf 22. http://www.ais.unwater.org/ais/pluginfile.php/605/mod_page/content/23/Yemen.pdf 23. https://health2016.globalchange.gov/populations-concern
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11 الملخص التنفيذي
تُعد اليمن واحدة من أقل بلدان العالم نمواً )LDCs(، كما تعتبر من أشد بلدان الشرق األوسط جفافا وفقرا، وقد احتلت المرتبة 120 من بين 111 بلدا في عام 3014 )برنامج األمم المتحدة اإلنمائي، تقرير التنمية البشرية، اليمن،3017(. وعلى الرغم من أن الناتج المحلي اإلجمالي السنوي كان يتراوح في المتوسط بين 2 إلى 4 في المائة خالل الفترة ما بين عام 3000 وحتى عام 3010، وصوال إلى أعلى ارتفاع 2.20 في المائة في العام 3010، إال أنه قد سجل - 31.10 في المائة في العام 3017. وباإلضافة إلى ذلك فإن اليمن تتميز بأن لديها أدنى مستوى من المساعدة اإلنمائية الرسمية )ODA( وفي حدود 13.20 دوالر للفرد الواحد أو 3.3 في المائة فقط من الناتج المحلي اإلجمالي، مقارنة بحوالي 22.40 دوالرا للفرد الواحد )11.2 في المائة من الناتج المحلي اإلجمالي( في البلدان األقل نمواً في العالم.
ويتفشى الفقر في اليمن بصورة مفجعة وقد زادت معدالته من 43 في المائة عام 3004 إلى 74.7 في المائة عام 3013 إلى أكثر من 17% في تموز/يوليو عام 3012 )البنك الدولي، عام 3012(، وال سيما في المناطق الريفية والنائية والمناطق الي يصعب الوصول إليها والتي يعيش فيها حوالي ثلثي السكان بما في ذلك 10 في المائة من الفقراء. كما ينتشر الجوع ونقص التغذية على نطاق واسع، حيث يعاني واحد من كل ثالثة يمنيين من شدة الجوع في الوقت الذي ال توجد ألي منهم أي موارد كافية للوصول إلى األغذية المفيدة والالزمة لحياة صحية ومنتجة )OCHA, 2015(.
كما احتلت اليمن أيضا في العام 3017 المرتبة 11 بين أكثر بلدان العالم التي تعاني من انعدام األمن الغذائي، حيث يقدر عدد السكان الذين يعانون من انعدام األمن الغذائي بحوالي 14.4 مليون منهم 2.2 مليون يفتقرون و بشدة لألمن الغذائي، وحوالي 230,000 من األطفال يعانون من سوء التغذية الوخيم الحدة )HNO, 2016(. أما األطفال دون الخامسة من العمر فإن %72 يعانون من التقزم لتصل النسبة إلى 22 في المائة بين األطفال الفقراء )الخطة الخمسية الرابعة للتنمية الصحية والتخفيف من الفقر 3011- 2015(، كما أن أكثر من نصف جميع األطفال دون سن الخامسة من العمر يعانون من نقص الوزن مما يجعل اليمن ثالث بلد على مستوى العالم بعد الهند وبنغالديش )برنامج األغذية العالمي، 3017(.
وباإلضافة إلى ذلك تواجه اليمن تحديا آخر ال يتوافق مع الموارد الطبيعية يتمثل بالنمو السكاني السريع والمستمر. فوفقا لإلسقاطات القائمة على البديل المتوسط للخصوبة فإنه من المتوقع أن يزداد حجم السكان من 32.724 مليون في يوليو عام 3012 إلى 42.12 مليون في العام 3070 وإلى 71 مليون في العام 3100، وبالتالي سترتفع نسبة كبار السن الذين تزيد أعمارهم عن 27 عاما من 3.2 في المائة عام 3012 إلى 30% في العام 3100 مما سيلقي بظالله على الحالة الصحية لهذه الفئة العمرية مع تغير ملحوظ في نمط اإلنفاق الصحي. كما أن ندرة المياه سوف تزداد فعليا ، وسينخفض نصيب الفرد من المياه المتوفرة انخفاضا مطردا حيث يمثل السكان الذين يحصلون على مياه الشرب النقية حوالي 21 في المائة فقط . أما األمية بين السكان فهي مرتفعة جداً وبنسبة 47 في المائة، والفوارق بين الجنسين هي األعلى في العالم حيث تحتل اليمن المرتبة 173 من بين 112 بلدا في مؤشر عدم المساواة بين الجنسين )برنامج األمم المتحدة اإلنمائي، تقرير التنمية البشرية، اليمن 3017(.
أما الحالة الصحية الحالية للسكان فهي متدنية جداً كما هو واضح من المعدالت العالية جداً لمراضة ووفيات الرضع واألطفال دون سن الخامسة ومراضة ووفيات األمهات ألسباب متعلقة بالحمل والوالدة والنفاس. وحيث أن اليمن ال تزال في مرحلة
Page 100 مبكرة من المرحلة الثالثة من التحول الوبائي، فإن األوضاع الصحية األكثر شيوعاً وخطورة وأكثر أسباب الوفيات والمراضة الحالية شيوعا وأشدها خطورة هي تلك المتعلقة باألمراض المعدية والمتوطنة أكثر من األمراض غير المعدية.
إن حوالي 42.2 في المائة من العبء الكلي للمرض هو بسبب 10 أنواع من األمراض المعدية والمتوطنة في قائمة الترصد الوبائي لوزارة الصحة العامة والسكان تمثل أربعة منها حوالي 12.3 في المائة من العبء المرضي الكلي وهي أمراض االسهاالت الحادة، وعدوى الجهاز التنفسي العلوي، والمالريا، وعدوى الجهاز التنفسي السفلي. ، بينما يسبب 32 نوعا من قائمة األمراض فقط 2.2 في المائة من العبء المرضي. وعالوة على ذلك فاألمراض غير المعدية تتزايد بشكل مستمر ولكن البيانات عنها مجزأة ومشوهة وتفتقر إلى االتساق عند مقارنتها بالسنوات السابقة.
وعالوة على ذلك يعتبر التغير المناخي من بين التحديات الناشئة األخرى التي تواجه التنمية في اليمن. ففي عام 3001، أقر االتصال الوطني اليمني األول )INC( وفقا لالتفاقية اإلطارية لألمم المتحدة بشأن التغيرات المناخية )UNFCCC( هشاشة البيئة االجتماعية والطبيعية الحيوية الناشئ من التقلب والتغير المناخي، كما أفاد التقرير أن زيادة التقلبات المناخية ستؤدي إلى إمكانية انتشار وزيادة األمراض المنقولة بالنواقل واألمراض المنقولة بالمياه )EPC, 2001 & NAPA, 2009(.
وكون اليمن بلدا معرضا للكوارث فإنه يواجه عددا من اإلخطار الطبيعية، فالمخاطر المتصلة بالمناخ كدرجات الحرارة العالية، واالنهيارات األرضية، وارتفاع مستوى سطح البحر والجفاف مع الفيضانات التي تشكل أهم الكوارث المتكررة الحدوث، ال شك من أنها ستحدث. ومن المتوقع أن التعرض لهذه المخاطر ذات الصلة بالمناخ ستؤدي إلى تفاقم المشاكل الصحية الحالية بشدة مثل األمراض المحمولة بالنواقل واألمراض المحمولة بالمياه كما سيمتد نطاقها إلى المناطق غير المتأثرة حاليا عالوة على زيادة األمراض المزمنة مثل أمراض القلب والجهاز التنفسي والكلى. إن المخاطر الكبرى ستنطبق على السكان األكثر تأثرا حاليا باألمراض ذات الصلة بالمناخ، ومن ثم فإنه من المتوقع حدوث الخسائر الصحية بسبب سوء التغذية الناجمة عن تغير المناخ والتي سوف تحدث بشكل أساس في المناطق التي بالفعل تعاني من انعدام األمن الغذائي )IPPC, 2013(.
غير أن البيانات والمعلومات الصحية تتسم بالتبعثر، ويسودها التشوه، وتفتقر إلى وجود نمط موحد للحدوث أو للتغيرات التي جرى مقارنتها مع األعوام السابقة سواء لنفس األمراض واألماكن أو لنفس مواسم الحدوث لهذه االمراض مما يجعلها مصدرا غير موثوق بها لرسم العالقة السببية بين التغيرات المناخية وزيادة معدل حدوث األمراض )الكتب اإلحصائية الصحية السنوية، 3000 إلى 3017(، وذلك ينطبق على بيانات المناخ أيضا والتي لها نفس خصائص وعيوب للبيانات والمعلومات الصحية. فالبيانات المناخية لهطول األمطار ودرجات الحرارة وسجالت الرطوبة تفتقر إلى التغطية المكانية الكافية، كما أنها رديئة النوعية والسجالت المنتظمة طويلة األجل شحيحة جداً، وعملية جمع البيانات المناخية مجزأة بين العديد من الجهات الرسمية المختلفة مع وجود القليل من التعاون بين هذه المؤسسات )البنك الدولي، 3010(. ونتيجة لهذه الصعوبات والقيود التي تعيق التقييم الكمي للتأثيرات الصحية المباشرة وغير المباشرة الناجمة عن التغير المناخي على صحة السكان، فقد تم إجراء التقييم النوعي للهشاشة والتكيف ولتأثير التغيرات المناخية عل صحة السكان من خالل استبانة ومقابالت استهدفت قيادة وصانعي القرار في وزارة الصحة العامة والسكان، باإلضافة إلى استعراض األدبيات على المستويات المحلية واإلقليمية والدولية بغية تحديد المناطق والفئات الهشة من السكان، ومدى الحساسية لتغير المناخ وإجراءات التكيف
Page 101 الالحقة مع مراعاة اتباع أفضل الممارسات لتقييم تأثير التغير المناخي، والهشاشة والتكيف وفقا لألطر العملية واألدلة الصادرة عن منظمة الصحة العالمية، حيث تكونت مراحل التقييم من أربع مراحل: 1. المرحلة األولى: وفيها تم تحديد الفئات الضعيفة من السكان استناداً إلى تعريف "تقرير تقييم الفريق الحكومي الدولي الخامس للهشاشة" )IPPC,2012(، حيث تم تحديد الفئات السكانية الضعيفة المحتملة باألطفال دون سن 7 من العمر، والنساء في فترة اإلنجاب وخصوصا النساء الحوامل، وكبار السن فوق 27 عاما، والمصابون باألمراض المعدية والمزمنة والسكان الذين يعيشون في ظروف اجتماعية واقتصادية متدنية وغيرها. 3. المرحلة الثانية: وشملت تطوير نوعين من السيناريوهات )A&B( االجتماعية واالقتصادية باالعتماد على العوامل االجتماعية واالقتصادية والديموغرافية ذات الصلة بالعام 3010 كسنة أساس، باإلضافة إلى االسقاطات السكانية المتوقعة للسكان للعام 3070 و 3100. وقد وجد أن صحة السكان الناجمة عن تغير المناخ ستكون أكثر هشاشة في إطار سيناريو )A( من سيناريو )B(. 2. المرحلة الثالثة: شملت وضع سيناريو للتغير المناخي وتغير المناخ المتوقع من خالل مراجعة األدبيات المتاحة. 4. المرحلة الرابعة: وتم فيها تحليل آثار التغير المناخي على الصحة العامة للسكان عن طريق الجمع بين تحليل كل من الحساسية والتعرض لتغير المناخ للفئات السكانية الهشة. لقد وجد أن آثار تغير المناخ على الصحة ستزداد سوء في إطار سيناريو )A( من سيناريو )B( وهو ما يشير إلى حاجة القطاع الصحي لزيادة قدراته التكيفية.
إن التقليل من عواقب الحرب الحالية واألخذ بعين االعتبار المؤشرات الصحية في 3010 كسنة أساس، سوف يتطلب قدرا من التعديالت على البرامج واالجراءات الصحية لمواجهة الضغوط اإلضافية الناجمة عن تغير المناخ والتي سوف تعتمد على العبء الحالي من اعتالل الصحة، وفعالية التدخالت الحالية، واإلسقاطات أين، ومتى، وكيف يمكن للعبء الصحي أن يتغير مع تغير المناخ؛ والجدوى من تنفيذ البرامج اإلضافية، وعوامل اإلجهاد األخرى التي يمكن أن تزيد أو تقلل من المرونة، والسياق االجتماعي واالقتصادي والسياسي للتدخل )Ebi et al., 2006(.
وفقا لذلك يمكن تصنيف الجهود الرامية إلى التكيف مع اآلثار الصحية المترتبة على تغير المناخ كإجراءات تدريجية وانتقالية، وتحولية بحيث يشمل التكيف التدريجي تحسين خدمات الصحة العامة والرعاية الصحية لمواجهة التأثيرات الصحية المتعلقة بالمناخ، وليس بالضرورة النظر إلى اآلثار المحتملة لتغير المناخ )IPCC, 2013(. وغالباً ما يعتبر إعادة البناء والمحافظة على البنية التحتية للصحة العامة االستراتيجية التكيفية األكثر أهمية وفعالية من حيث التكلفة والحاجة الماسة إليها والناتجة عن تأثير تغير المناخ على قطاع الصحة )IPCC, 2001(، حيث تشمل هذه االستراتيجية التدريب في مجال الصحة العامة والترصد الفعال ونظم االستجابة لحاالت الطوارئ، والوقاية المستدامة وبرامج السيطرة )WHO & UNEPA, 2003(. وبوجه عام فإنه ينبغي أن يتضمن القطاع الصحي على استراتيجيات تكيفية )متدرجة( محددة وكما يلي: 1. إنشاء نظام للترصد الوبائي لرصد التغيرات في زيادة تكاثر النواقل في المناطق الرئيسية المستهدفة عالية المخاطر وفي مناطق االنتقال المتوقعة. 3. تعزيز الترصد لألمراض المحمولة بالنواقل والمياه واألغذية. 2. إنشاء نظام لترصد الوفيات والمراضة المرتبطة بالحرارة ولآلثار السلبية على الصحة من التعرض لتلوث الهواء. 4. تحسين إمكانية الوصول واالستفادة من خدمات الرعاية الصحية للسكان مع مراعاة الفوارق بين الجنسين واإلنصاف.
Page 102 7. إعداد نظام التأهب الفعال والمستجيب بالقدرات الكاملة للتعامل مع الكوارث غير المتوقعة. 2. تخصيص الموارد المالية والبشرية للبحوث في مجال تغير المناخ، وربطها باألمراض المعدية، و بالوفيات والمراضة المتعلقة بدرجة الحرارة. 2. تخصيص الموارد الصحية البشرية والمالية الكافية وبناء القدرات في مجال تأثير التغير المناخي والتي تشمل التدريب والترصد واالستجابة لحاالت الطوارئ، وبرامج الوقاية والمكافحة. 1. تحسين إمكانية الوصول إلى المياه النظيفة وخدمات الصرف الصحي للفئات المحرومة والضعيفة. 4. تعزيز وتوسيع برامج التطعيم الروتيني 10. ضمان اإلمدادات الطبية األساسية لرعاية المصابين باألمراض المزمنة، بما في ذلك التوزيع الفعال في مرحلة ما بعد الكارثة والتي ستزيد من قدرة المجتمعات المحلية على إدارة العواصف والفيضانات على نطاق واسع. 11. ضمان اإلمداد الكافي بالعقاقير المضادة للمالريا وااللتهابات المعوية لمعالجة األشخاص على وجه السرعة وبفعالية.
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