Incorporating Climate Change Considerations in Health Policy of Punjab (Pakistan)

Incorporating Climate Change Considerations in Health Policy of Punjab
Rafay Alam & Arshad Rafiq
About The Authors

Mr. Ahmad Rafay Alam is a lawyer and environmental activist. He has a decade's experience in civil and corporate litigation throughout Pakistan and is currently the Chairman of the Board of Directors of the Lahore Electric Supply Company. Although he continues his private practice, his current focus is to improve the efficiency of Pakistan's largest electricity distribution company. He also teaches a course on environmental law and regulation and property law at the Law & Policy Department of the Lahore University of Management Sciences (LUMS). At LUMS, he is also the coordinator of the Environment and Natural Resource Cluster of the Development Policy Research Center (DPRC), which is about to begin a Canadian $500,000 three-year project in partnership with WFF-Pakistan to study the effects of climate change on food security in 10 districts of Pakistan. He is also the coordinator of the LUMS Water Program, which was established in 2009 to act as a platform for Track-II diplomacy on water issues between India and Pakistan. Mr. Arshed Rafiq is working as the communication specialist at The Urban Unit (P&D department, Govt of Punjab). Prior to that, he worked with Cleaner Production Institute Lahore (www.cpi.org.pk) in the capacity of Communication Coordinator for the Dutch funded Programme for Industrial Sustainable Development where he was responsible for the preparation and implementation of Communication plans and instruments, networking and institutional support activities with stakeholders. He also supervises the CSR team which facilitate leading industries in Pakistan to generate CSR reports. Earlier he worked in the projects of Cleaner Technology Program for Textile Industry and the EU funded project of Promoting Better Environmental Practices in Textile Processing Industry of Pakistan in 2005-06 as communication coordinator at NEC Consultants Lahore. Mr. Arshed has also served as Cambridge English language teacher at DPS Lahore for seven years. He has master degrees in English Literature and Public Administration, a diploma in French from Punjab University Lahore and a post graduate diploma from Maastricht School of Management Netherlands.
Abbreviations and Acronyms

ADPs AMIS ART BOD CBR CDC CDGs CO2 CIW CSR DDMA DEWS DRM DPOs ERC ERGMS FEWSNET FFC FFD GDP GIS GSK HIPC IMMPACT LDA MDA NADRA NASA NDMA NFC NDMC NGOs NOAA PDMA PIDA RIDMAS SUN TEPA VBDs VRIP WAPDA WMO WHO Annual Development Plans Agricultural Market Information System Alternative Risk Transfer Burden of Disease Community Based Rehabilitation Center for Disease Control City District Governments Carbon Dioxide Commissioner for Indus Water Corporate Social Responsibility District Disaster Management Authorities Disease Early Warning System Disaster Risk Management District Program Officers Emergency Relief Cell Emergency Response Geo-Meeting System Famine and Early Warning System Network Federal Flood Commission Flood Forecasting Division Gross Domestic Product Geographic Information System GlaxoSmithKline Highly Indebted Poor Countries Initiative for Maternal Mortality Program Assessment Lahore Development Authority Multan Development Authority National Database Registration Authority National Aeronautics and Space Administration National Disaster Management Authority National Finance Commission National Disaster Management Commission Non Governmental Organizations National Oceanic and Atmospheric Administration Provincial Disaster Management Authority Provincial Irrigation and Drainage Authority Real Time Integrated Disaster Management System Scaling Up Nutrition Transport Engineering and Transport Planning Agency Vector Borne Diseases Vulnerability-Resilience Indicator Prototype Water and Power Development Authority World Meteorological Organization World Health Organization
Table of Contents
Foreward Executive Summary 1.0 Introduction 2.0 Strengthening of Healthcare System 2.1 Service Delivery 2.2 Governance and Accountability 2.3 Health Workforce 2.4 Health Information Systems 2.5 Drugs and Essential Medicines 2.6 Healthcare Financing 3.0 Disaster Management 3.1 Sustainable Institutional Structures and Good Governance 3.2 Disaster Preparedness 3.3 Risk sharing and Risk Transfer 3.4 Disaster Response and Recovery 3.5 Disease Control 4.0 Building Resilient Communities 4.1 Urban Policy Making and Compact Development 4.2 Economics and Finance 4.3 Cleaner Fuels 4.4 Lifestyle and Nutrition 4.5 Air Quality 4.6 Water and Sanitation 4.7 Early Warning System and Emergency Response 4.8 Sexual and Reproductive Health 4.9 Urban Violence 4.10 Regional and Municipal Cooperation Recommendations References Web Resources
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Foreword
LEAD Pakistan, in collaboration with the David and Lucille Packard Foundation, has launched Our World Women Leadership in Reproductive Health& Development, a project that aims to sensitize a cross-sectoral network of leaders and motivate them to raise the profile of reproductive health in the social development sector through public policy engagement and media. The goal of the project is to generate debate and dialogue with multi-sectoral experts, academics, intellectuals and policy makers on pertinent issues in the field of health, climate change and human development to enable informed policy-making. The project has developed a tiered-knowledge flow where each level of engagement produces knowledge products that enrich the proceedings of the following tier. The project has moved on from the first tier of sensitization of multi-sectoral experts about the inter-linkages between the thematic areas of population, health and climate change and reproductive health. The second tier was a stakeholder dialogue held in Lahore on 19 September 2012. The product of the stakeholder dialogue was a Discussion Paper, which in turn informed a series of small group meetings, and round table discussions culminating in this Occasional Paper. The stakeholders in their discussion in Lahore highlighted that the Climate change was a threat multiplier, putting tremendous stress on already crumbling state and informal infrastructure, especially in the area of health, Reproductive Health and child health else Pakistan will fail to comply with its commitment towards achieving its Millennium Development Goals. There was a need to prioritize health issues in official decision-making. It was emphasized that the existing health infrastructure must be upgraded and modernized to meet the challenges of climate change. Initiatives to do so must include better data collection and M&E capacity for more informed decision making, coordination intra- and inter-provincially for better coordination of Health, Population, Women's Development and Environment Departments and assessment of the cost of climate change to the health sector. This is not an extensive review of the literature on the subject. Its main purpose is to highlight and serve as the starting point for some relevant issues for discussion in the context of Pakistan. The 18th Amendment ushers new opportunities and challenges of policy-making and legislation at the provincial level. All stakeholders will need to work together in order to generate sufficient political will and capacity in provincial governments to fulfill their new constitutional obligations. Through this paper LEAD has attempted to highlight how institutional reform and research can pave the way for a better understanding of climate change and health issues through informed decision-making and Departmental coordination.
Ali T. Sheikh CEO, LEAD Pakistan
LEAD Pakistan Occasional Paper Series
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Executive Summary
The health impacts of climate change need to be taken into account at every level of policy and decision-making and institutional design. Climate Change is too large a subject and the health department cannot deal with it all alone.The three major effects of climate change are changes in disease patterns, extreme events or disasters and some emerging biological and social threats such as deterioration of quality of life, conflicts and violence, mental health and new diseases. Strengthening of healthcare system, better disaster management and building of resilient communities and urban design can largely offset these effects. In this backdrop, the following recommendations are made for future policy making in Punjab.
1. The policy focus needs to be shifted from clinical to preventive healthcare, from rural to urban disaster management, from communicable to chronic disease control and from centralization to devolution of authorities and responsibilities. 2. Health should be recognized as an important disaster management function. The health effects of climate must be carefully evaluated and its cost built in, in every sector and then reflected in planning of all development projects. 3. A strong coordination mechanism is needed among the health, disaster management and urban development agencies. 4. The district and local level institutions should be the most empowered and efficient institutions in terms of financial, human and technological resources for better service delivery and emergency response. 5. The strengthening of the existing healthcare system is needed to offset most of the climate effects. 6. The modulating influences need to be controlled such as rapid population growth, poverty, violence and urban sprawl. 7. The two instruments that have emerged to help decision makers worldwide in their efforts to contain climate change effects are the use of technology and risk sharing and management. The cultural, financial or political obstacles must be overcome in government leadership with the help of the private sector and market forces. 8. Without, ensuring the availability of reliable and quality data and implementation of effective surveillance systems for disease and disasters, no response system can be developed. 9. There is a dire need of public awareness and training of healthcare professionals on disaster management and climate effects on health. Without their involvement, no policy is expected to yield any results. 10. Innovative schemes need to be implemented for generating and pooling of financial resources for disaster management and health promotion. The role of the private sector and international funding channels is very crucial. 11. A health-in-all-policies strategy is needed.Useful tools for implementing a health in all policies approach include: integrated budgets and accounting, impact assessments, crosscutting information and monitoring systems, and legislative frameworks.
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1.0 Introduction
Climate Change is the game changer in the 21st Century. Therefore, there is a need that the health impacts and co-benefits of climate change are taken into account at every level of policy and decision-making and institutional design. Climate Change is too large a subject and the health department cannot deal with it all alone. Moreover, managing the disasters and extreme events is beyond the scope of health department under the current framework. In addition, the decentralization bandwagon puts city governments at the forefront of service delivery.Under the current institutional makeup, disaster management is a federal subject with provincial and district level presence, health is a provincial responsibility while most of the urban development function rests with district level authorities. synergies between health and other sectors could be achieved by framing the goals in such a way that their attainment requires policy coherence and shared solutions across multiple sectors: that is, a whole-ofgovernment or health-in-all-policies approach. After setting out the challenges posed by climate change to the health sector, the present paper will discuss policy options under three major heads:
a. Strengthening of Healthcare System b. Disaster Management c. Building Resilient Communities
Health-Related Climate Change Challenges In 2012, the Government of Pakistan approved the NCCP 2012, Pakistan's first climate change policy. The policy objectives of the NCCP 2012 are to integrate climate change policy with other related national policies; to focus on pro-poor gender sensitive adaptation; to strengthen interministerial and inter-provincial decision making and coordination mechanism on climate change; and to enhance the awareness, skill and institutional capacity of relevant stakeholders. It states that the important climate change threats to Pakistan are:
In this scenario, a restructuring of institutional framework will be needed at a very large scale for a proper response, which is not possible in the foreseeable future in countries like Pakistan. The easiest way forward will be to build a strong coordination mechanism among health department of Punjab, disaster management institutions and city governments. A hybrid approachwill fit well alongwith the provision ofrestructuring, increased financing, capacity building and coordination mechanisms among various concerned departments.
The three major effects of climate change are changes in disease patterns, extreme events or disasters and some emerging biological and social threats such as deterioration of quality of life, conflicts and violence, mental health and new diseases. Strengthening of healthcare system, better disaster management and building of resilient communities and urban design can largely offset these effects. Greater
1. Considerable increase in frequency and intensity of extreme weather events, coupled with erratic monsoon rains causing frequent and intense floods and droughts;
2. Projected recession of Hindu KushKarakoram-Himalayan (HKH) glaciers due to global warming and carbon soot deposits from trans-boundary pollution sources, threatening water inflows into Indus River System (IRS);
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3. Increased siltation of major dams caused by more frequent and intense floods.
4. Increased temperatures resulting in enhanced heat- and water-stressed conditions, particularly in arid and semi-arid regions, leading to reduced agricultural productivity;
5. Further decrease in already scanty forest cover from too rapid change in climatic conditions to allow natural migration of adversely affected plant species;
events such as floods are affected by interrupted access to health infrastructure and water-borne disease. Floods and increased rainfall increases the risks of diarrhea and cholera. On the other hand, draught conditions can reduce agriculture productivity and increase food insecurity and malnutrition, and also increase risks of respiratory disease. Unexpected and high intensity rains can alsocause flood conditions. On the other hand, erratic weather patterns again threaten agricultural productivity, food insecurity and increased malnutrition.
6. Increased intrusion of saline water in the Indus Delta, adversely affecting coastal agriculture, mangroves and breeding grounds of fish;
In forest areas, use of biomass for primary energy needs, such as heating and cooking indoors adds to deforestation and is also the cause of high indoor air pollution. Loss of forest cover and lack of access to biomass often see substitution of poor quality and carcinogenic fuel and energy sources, threatening increased levels of indoor air pollution.
7. Threat to coastal areas due to projected sea level rise and increased cyclonic activity due to higher sea surface temperatures;
8. Increased stress between upper riparian and lower riparian regions on sharing the water resources;
9. Increased health risks and climate change induced migration.
A number of factors link climate change to human health. Unexpected alterations in weather patterns can affect vulnerable rural communities unable to adopt farming practices. In some cases, families are left with no choice but to move out of the areas affected in search of more fertile land and water. These migrating populations and refugees experience greater vulnerability to malnutrition, illness and disease because of interrupted access to food and to health infrastructure.
Climate induced migration places stress on existing urban infrastructure, especially sanitation and sewage. Increased incomes associated with urban areas may distort poverty figures, as incomes will be diverted to healthcare costs associated with illness and disease. This will result in a demand for state-financed healthcare infrastructure. Urban poverty in Pakistan stands to be as much a health issue as a development challenge.
Climate change, thus, is not a discrete area of study. It is a threat multiplier placing additional burden on already overstretched resources and infrastructure.Climate change challenges also reveal the special vulnerability of women and children to climate change.
Communities affected by extreme weather
The National Climate Change Policy, 2012
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recognizes that, In Pakistan, women are likely to be strongly affected by climate change as majority of rural women are engaged in agriculture sector which is highly climate sensitive. Climate change is expected to increase the workload of women in agriculture production and other subsidence subsistence activities such as collecting fuel wood and water. Further, women are found to be more vulnerable during extreme climate events and disasters.
Child and maternal health are significant indices of social development. Pakistan still suffers from a high infant and maternal mortality, a double burden of diseases and inadequate healthcare facilities with high population growth. Mortality, morbidity and slow progress of indicators in the maternal and child health are major concerns in the progress towards achieving Millennium Development Goals.
increase vulnerability to water-borne disease. They are also significant obstacles to access to health facilities including access to contraception and adequate water and sanitation practices for women and children. Changes in soil productivity increase food insecurity, especially malnutrition in children. These vulnerabilities, given existing malnutrition in children, indicate that Pakistan will not be likely to meet MDG 1B (Achieving full and productive employment and decent work for all, including women and young people). RH and malnutrition issues account for some 50 percent of the BOD.
In relation to health, child health and RH, Pakistan's performance in these areas comes under Goals 4 and 5, namely reducing child mortality and improving maternal health. The MDG Report 2012, in relation to child mortality, states that Pakistan's progress in achieving Goal 4 is unsatisfactory and will be challenging, in particular, due to under-five mortality and infant mortality indicators, both of which need to be reduced by 45 percentage points by 2015. The MDG Report 2015 states this is highly improbable. In relation to Goal 5, the MDG Report 2010 notes that Pakistan had some success in improving the maternal mortality ratio from 350 in 200102 to 276 in 2006-07 but that is has considerable distance to go to meet MDG targets. The Report concedes that it will require herculean efforts for Pakistan meet the targets for Goal 5 by 2015.
Extreme climate events such as floods
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2.0 Strengthening of Healthcare System

The six core areas identified in the Punjab Health Strategy need strengthening by enriching and enlarging the scope of interventions and adding more themes in the core areas such as public education, disaster preparedness and response, food hygiene and nutritional supplementation, mental health care, resilient communities and inter departmental coordination. All this will require diversion of additional streams of funds into the health system to increase its adaptive capacity. It must be noted here that many of the projected impacts of climate change on health are avoidable or controllable through strengthening of the healthcare system. community in health care assessment, planning, implementation, monitoring and evaluation through specially designed health committees.
2.1 Service Delivery In line with the chronic issues service delivery issues identified in Punjab Health Strategy, the following areas need to be added or strengthened.
a. Themunicipalities must be involved for delivery of health services. The municipalities especially of big cities need to assess and suggest corrective measures to health department for delivery of quality health care services to citizens. Some best practices have been documented by WHO from countries such as Iran, Oman and Jordan. The key features of these programs include volunteerism, community participation, training of service providers, minimal cost, allocation of sufficient financial and human resources and decentralization. The emphasis is mainly on maternal and child health services, including family planning, disease prevention and control, and on reimbursement of costs of secondary and tertiary medical care at public and private health care facilities and high level of patient satisfaction (more than 90%). Another hallmark is the proactive system of risk assessment, surveillance and management by maintaining healthy family files, follow up, active participation of the
b. Thereformation of primary health care is neededto target the vulnerable communities and the poor living in slums for universal coverage of healthcare. Those most likely to experience difficulty accessing health services during or after an extreme event are individuals already considered vulnerable with respect to their health such as children, the elderly, pregnant women, and those who may need additional response assistance including people with disabilities. In addition, as those with the least resources often have low health status and the least ability to adapt, the poor and disenfranchised are also the most vulnerable to climate related health impacts. Extreme events can therefore exacerbate health inequalities. This is because, the high vulnerability and exposure are generally the outcome of skewed development processes, for example, environmental mismanagement, rapid and unplanned urbanization, failed governance, and a scarcity of livelihood options. Low health status due to inadequate access to health services can also contribute significantly to vulnerability. Levels of wealth, education, disability, and health status, as well as gender, age, class, and other social and cultural characteristics generally determine the vulnerability of people. Similarly, people living in informal settlements and structures are generally more exposed to extreme weather conditions.
c. The formal mechanism to seek cooperation of civil society, academia and private sector is needed for reducing health
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a. and climate issues, healthcare financing tools like insurance and urban development would all require a formal mechanism for involvement of private sector.
proper physical activity, healthy diets, use of recreational facilities and reversal of the trend of tobacco and illicit drug use.
d. The public health department needs to work with the education department to include information for awareness of the youth and future generations. The emerging health issues are mainly lifestyle problems, which require promotion of increased and Case Study Ghana- Tackling Maternal Mortality
With the improvement in the service delivery, the health system will be able to develop resilience to bear climate shocks. This will result in reduced level of vulnerability and exposure of the people to natural and manmade disasters.
Ghana, which had an estimated maternal mortality rate of over 500 deaths per 100,000 live births a decade ago, has been at the forefront of this battle on a national level. In 2004, Ghana introduced a national policy to exempt women from paying for delivery care in public, mission and private health facilities, with payments initially delivered through local governments and later through the health system. The exemption was funded from a debt relief fund under the Highly Indebted Poor Countries (HIPC) initiative. This was phased out gradually and ultimately taken over by the national health insurance scheme in 2000.
The exemption from delivery-care fees contributed to a drop in the maternal mortality rate from an estimated 500 deaths per 100,000 live births in 2000 to an estimated 350 per 100,000 in 2008 still behind the MDG target of 185 maternal deaths per 100,000 live births by 2015. One factor limiting the impact of the delivery fee exemption may be the stubbornly high number of Ghanaian women who continue to give birth without a trained birth attendant present. Indeed, the proportion of deliveries attended by skilled health personnel actually dropped between 2005 and 2007from 54% to 35%following a steady improvement in the figure during the decade between 1993 and 2003. Some experts speculate that this decline could be related to underfunding of the exemption policy and a strike by health workers in 2007.
Still, an evaluation of the delivery-fee exemption by the Initiative for Maternal Mortality Program Assessment (IMMPACT) found that the policy had increased the use of obstetric facilities and achieved some reductions in inequality of access to care between different income groups. Ghana's experiment with the delivery-fee exemption provides a number of lessons for countries looking to improve maternity care, including the importance of strong policy management or ownership within the relevant ministry (which was lacking in Ghana); tailoring exemptions to address the main household cost barriers, such as travel to hospital facilities; and reimbursing medical facilities for their costs. 2.2 Governance and Accountability a. Control and decision making in health systems is increasingly being decentralizedthe world over. After devolution in Pakistan, there is a need to further decentralize the authority, responsibility and budget of the health department up to district and municipality level. The City District Governments should be fully involved in future health framework in Punjab with enhanced role and authority in health system design. The decentralization should be in every area of healthcare including the operation and management of health facilities, finances
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and service delivery with effective oversight from the government. The decentralization will extend to pharmaceuticals as well for improved quantification of drug requirements, inventory control and prescription etc. There is also need to make innovative arrangements with third sector institutions in performing different health sector functions. Decentralization either as delegation or devolution can improve the responsiveness, quality and efficiency of health services. The problems, associated with decentralization include lack of capacity and increased corruption and cost, can be overcome by introducing coping mechanisms. This entails regulatory and institutional reforms to incorporate accountability at the executive level without recourse to the already choked judicial system of the country. The communities can be empowered and involved in the governance and accountability apparatus. This will help in identification of service package for the public healthcare, monitoring of community disease patterns before they become epidemics, introduction of public oversight mechanisms and even fund raising for public health system.
c. A true collaboration between the meteorological and health communities is needed to be developed for increased predictability of diseases, especially the communicable diseases. Take the following two examples:
Dengue is increasing in many parts of the world, driven by development and globalization the combination of rapid and unplanned urbanization, movement of goods and infected people, dispersal of mosquitoes to newer territories, spread and mixing of strains of the virus, and more favorable climatic conditions. There is currently no effective vaccine or drug for dengue. Control programs rely on environmental or chemical control of the vectors, rapid case detection and case management in hospitals for severe dengue. But these interventions are challenging, and there has been only very limited success in disease outbreak control within the most suitable transmission zones. Future initiatives are likely to depend not just on development of better interventions, but also on more effective targeting of control in time and space. In such scenarios, meteorological information can make an important contribution to understanding where and when dengue cases are likely to occur.With increased rainfall expected with climate change, there will be more mosquito-breeding sites as humidity increases mosquito survival and temperature affects parasite development rates. Mapping, forecasting and monitoring these variables, and unusual conditions that may trigger epidemics such as cyclones or the breaking of a drought in a region, enable health services to better understanding of the onset, intensity and length of the transmission season.
b. The restructuring of the health department and its functions and budgets should be carried out after accumulating the data of current and forecasted burden of communicable and non-communicable diseases in each district of the province. For effective data collection, technological capacity and solutions are already available with the Punjab government locally. These facilities can provide high-resolution weather and climate data to study the regional pattern of diseases, develop a high-resolution health impact model at the district level, make GIS maps of access routes to health facilities in areas prone to climatic extremes, prioritize geographic areas based on epidemiological data and the extent of vulnerability to adverse impacts of climate change and develop better response in a post epidemic scenario.
Cholera is one of the most severe forms of waterborne diarrheal disease. There are sporadic incidences of the disease in the
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developed world, but it is a major public health concern for developing countries, where outbreaks occur seasonally and are associated with poverty and use of poor sanitation and unsafe water. Extreme weather events, such as hurricanes, typhoons, or earthquakes, cause a disruption in water systems resulting in the mixing of drinking and wastewaters, which increase the risk of contracting cholera. Nearly eight hundred million people still lack access to water from such sources, and public health research has shown that billions are still using unsafe water. WHO is making a global information system on Health and Environment, plans to produce these maps on a real time basis, and with its in-built predictive tool also aims to contribute to an early warning system for diarrheal diseases. In its initial stage till 2015, it will focus on cholera.
inactivity. Changing the poorest communities' domestic energy technologies could reduce the 1.5 million annual indoor air pollution deaths. The critical next stage for the health community is a more direct and assertive engagement with the environment and economic sectors to ensure that healthsupporting technological and development choices are implemented.Interaction with other determinants (unreliable water and sanitation services, unplanned urbanization and globalization) means that climate effects on health system can be reduced only through cross-sectoral collaboration.
d. Many climatic risks to health lie at least partly outside the health sector's normal sphere of action. Some of the most effective actions by health professionals may therefore involve supporting other sectors' efforts to mitigate and adapt to climate change. The intersection of energy, transport, climate and health provides an example of this. According to a WHO assessment, feasible improvements in environmental conditions could reduce the global disease burden by more than 25%.14Similarly, climate change has the capacity to suppress agricultural yields,10 which causes malnutrition is already the largest single contributor to disease burdens at many places. Another example is energy practices. Much of the current burden is due to unhealthy energy and transport services. Changing these systems to reduce climate change could therefore also bring significant and largely unacknowledged public health gains. Improving access to public and active transport would greatly reduce CO2 emissions, while also cutting the 800,000 annual global deaths from outdoor air pollution, the 1.2 million annual deaths from traffic accidents, and the 1.9 million deaths from physical
e. The accountability within health department also needs a new model. It should be based on the impact of government spending and taxation on health. New parameters and indicators need to be developed and integrated in the current system accordingly. In view of changing climate, it will be more pertinent to assess the health costs in economic terms. Therefore, new policies and systems need to be developed within health department to monitor and reduce the economic loss due to burden of disease and disaster. One such method of costing is shown in figure1 on the next page:
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Climate related health stressors (floods, heat waves etc)
Human health effects Mortality + Morbidity
Short-term physical and mental health effects
Value of statistical life
Cost of illness (Sum of medical costs, out of pocket expenses + loss of work productivity)
Willingness to pay (This is added for a more accurate costing)
Figure 1: Costing of health impacts of climate change 2.3 Health Workforce a. Investment in human capital should be increased in view of rapid population increase and unemployment in every sector including health. and maternal mortality in which Pakistan is far behind the MDG targets.
e. Training on emerging diseases and emergencies should be part of the curricula even at the primary level.
b. The health worker to population ratio should be improved as per global standards. c. Uniform, competitive and market basedsalary package should be introduced to retain best professionals at secondary and tertiary levels.
f. The lessons learnt from the recent disasters in Pakistan (2010 floods and 2011 dengue epidemic) should be incorporated in the training manuals of health workers.
2.4Health Information Systems d. The primary health workers should be adequately paid and protected. There should also be programs on education, training of midwives and birth attendants to reduce child a. The health information system needstechnological and cultural reforms within health department. Data collection and analysis should be institutionalized within all
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health facilities including private and autonomous bodies for improved decision making. Technological solutions have been developed by international agencies such as HealthMap and WHO'sDisease Early Warning System (DEWS), which should be strictly implemented, especially in view of climate change,for rapid decision-making and effective response.
2.5 Drugs and Essential Medicines a. Most leading causes of death and disability in developing countries can be prevented, treated or at least alleviated with costeffective essential drugs. Good drug supply management is an essential component of effective and affordable health care services globally. Broad lessons that have emerged from this experience include: that national drug policy provides a sound foundation for managing drug supply; that wise drug selection underlies all other improvements; that effective management saves money and improves performance; that rational drug use requires more than drug information; and that systematic assessment and monitoring are essential.
b. The health surveillance and early warning systems need to be integrated into development planning and policy-making. Health surveillance systems can be used to trigger early warning systems, to create databases, which improve scientific knowledge about the health impacts of climate change, to identify and prioritize needs for intervention and adaptation measures, and to evaluate these measures. The surveillance system should be able to integrate data from other disciplines such as environmental aciences, behavioral sciences and demography to enable public health professionals to create cross-sectoral partnerships considering climate change as a concrete input parameter.
c. Climate and health modeling based on effective surveillance and response systems are essential in managing diseases especially under conditions of rapid change and disasters.These conditions include climatic shifts as well as increasing rates of movement of and contact between humans, pathogens and reservoirs. These conditions all require improved human health surveillance integrated with monitoring of climate and other environmental conditions that favor disease outbreaks, including disease in wildlife and agricultural animals. Climate change also strengthens the case for reinforcing response systems for infectious disease outbreaks, including predefined action plans and maintenance of the control resources and personnel capacity necessary to mount effective responses.
b. Clear goals, sound plans, effective implementation and monitoring of performance are essential ingredients in pharmaceutical sector development. Different levels of public private roles exist in different strategies for public drug supply systems including the traditional central medical stores system, autonomous supply agencies, the direct delivery system, the prime vendor system and fully private supply but all of them are intended to bring greater efficiency through competition. The success depends not only on choosing an appropriate option, but also on the way in which the option is implemented.
c. The list of essential medicines needs to be updated keeping in view of historical disease data of the province, the emerging disease patterns especially in view of climatic changes as well as the international list of 340 essential medicines to treat priority conditions such as malaria, HIV/AIDS, tuberculosis, diarrhea, reproductive health, cancer and diabetes. Medicines should be identified through an evidence-based process and quality, safety, efficacy and cost-effectiveness are key selection criteria. The Essential Medicines List can help rationalize the
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purchasing and distribution of medicines and reduce costs to the health system.To develop the new list of essential medicines, pharmaceutical industry may also be involved in view of potential impacts of climate change on this sector. Recently, some companies like Swiss Re, Accenture and GSK have proactively been researching and reporting on how the DEMAND SIDE of FINANCING is a tool health impacts climate change will affect that places purchasing power and provider their sector. choice in the hands of consumers; and helps shape healthy or desired behaviors. d. The government should be highly concerned with pharmaceutical prices. With or without price controls, price transparency should be a central objective to promote affordability. Use of generic drugs and price controls are the two most commonly pursued mechanisms.
and physical distribution may be integrated under the essential drugs program, while financing, quantification of needs and monitoring may remain under the management of the national control program.
2.6 Healthcare Financing The basic purpose of an effective healthcare system is to ensure access to healthcare services by the poorest in society and to ensure care for target groups. The level of public commitment for financing healthcare should be a matter of explicit public policy, based on an analysis of health care needs and financing options. Some of the mechanisms being used world over include:
i. Generic competition with price information is very effective. The strength of public policy commitment to generic drugs is a major determinant of the growth of generic markets. Four essential factors for success appear to be supportive legislation and regulation, reliable quality assurance, professional and public acceptance, and economic incentives.
a. The policy of free healthcare should be replaced by introducing user charges to supplement general government revenues or insurance premiums, and to help control use. User fees can complement government budgetary allocations. When fee mechanisms will be instituted at the provincial level, a topdown approach, starting with major hospitals, may have advantages in terms of equity, revenue potential, administrative capacity and impact evaluation.
ii. Various mechanisms exist to control producer prices and distribution margins. Wholesale and dispensing margins, based on cost plus a fixed professional fee provide a better incentive for rational dispensing than margins based only on a percentage.
e. The policy makers should support and involve the third parties while retaining some centralized functions such as drug registration, development of essential drugs lists and standard treatments, quality assurance and bulk tendering. Efforts are also being made in some countries to integrate supply systems for family planning, tuberculosis control, and other vertical programs into essential drugs programs. Resource intensive functions such as procurement, quality assurance, storage
b. External funding can prove invaluable to relieving immediate human suffering and can help in developing long-term solutions but they should not substitute efforts to develop sustainable financing mechanisms. International funding from climate specific mechanisms is not very lavish currently. A recent World Health Organization (WHO) review concluded that less than 3% of the international funding on climate change adaptation has been directed to projects with the specific aim of protecting health. Development loans through the World Bank and regional development banks may contribute to long-term development of the human and physical infrastructure for the health sector but they should not be used for financing of such heads as the cost of drug
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supplies or other recurrent expenses. ADPs, NFC and federal grants are the regular source in the hand of the provincial government to finance the healthcare system. However, increased pressure on public healthcare system due to population growth, increased burden of disease and climate change need further channels of funding such as Climate Levy and demand side financing to reduce the proportion of out of pocket expenditure.
c. A greater role may be sought for NGOs and other non-commercial entities including NGOs' health services, not-for-profit essential drugs supply agencies, professional associations, consumer groups, and specialized NGOs for additional funding for the public health system. The funding from CSR activities of businesses need to be tapped by the public health sector to supplement the government funding. This will require reducing corruption to enhance trust and increasing transparency and accountability. Case Study: Sehat Sahulat Card (SSC) by Contech d. Insurance is generally used as a common Contech International is private sector health tool increase access of healthcare for the careto consulting and research organization poor and calamity stricken people. In Pakistan, which works to improve health of vulnerable populations women and children). however, the(especially total number of people covered The organization piloted Sehat Sahulat Cards for disadvantaged women in Kasur and Rawalpindi to increase the accessibility of quality maternal, newborn and child health (MNCH) care. Targeting pregnant women from rural backgrounds, the SSC covers services such as antenatal care, delivery and post natal care and implements this through a public-private partnership. Funds for the pilot were provided through the Zahanat Foundation (a non-governmental charity organization). The selection criteria for the SSC is based on a poverty tool and the setup has served vouchers to around 1247 women in a year and referred 40 patients to district health centers. Following the success of the SSC pilot in Kasur and Rawalpindi, Contech plans to expand similar services in hard to access areas in Pakistan. Contech claims SSCs have been positively accepted in the low-income communities and help induce positive healthcare behavior.
by life insurance was just above 13.6 million in 2011, or about 7.8% of the total population. The rate is changing at the very fast rate and life insurancehas been increasing at the rate of more than 28% per year during the last five years.Recently, risk insurance is being introduced by NDMA partially, and some form of micro insurance is also being introduced for smart ID card holders by NADRA. The health department needs to introduce and promote health insurance and disaster related property insurance as major financing mechanisms to offset the climate effects and ensure universal coverage of healthcare. The involvement of insurance companies can be the easiest way to increase outreach to the public, overcome cultural taboos and decentralize the healthcare system without overburdening the health department with additional responsibilities.
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3.0 Disaster Management

3.1 Sustainable Institutional Structures and Good Governance A good institutional and policy structure has been developed at the national level after the deadly earthquake of 2005. National Disaster Management Ordinance, 2006 was promulgated under which the National Disaster Management Commission (NDMC) has been established as the highest policy making body in the field of disaster management. NDMA functions under Federal Ministry of Climate Change.The system envisages a devolved and de-centralized mechanism for disaster management. Accordingly, Provincial Disaster Management Commissions (PDMCs) and Authorities (PDMAs) have been established while similar arrangements have been made in AJ&K and Northern Areas. The District Disaster Management Authorities (DDMAs) have been notified across the country. The National Disaster risk Management Framework has been formulated to guide the work of entire system in the area of disaster risk management. The NDMA has the following nine priority areas for which National Disaster Management Fund has been established. management of the natural environment and human-induced climate change requires a long-term approach to reducing risk from natural events. An integrated and preventive framework embedded in development strategies would be most effective. The holistic approach to disaster management would require inter-provincial and interdepartmental coordination mechanism, capacity building and sufficient investment and funding for infrastructure development. The fragmented approach currently prevalent will have to be replaced with a more integrated approach with a greater role and responsibilities at the provincial and district levels. At present, the federal Ministry of Water and Power is responsible for flood management and development of infrastructure. Other organizations involved in Flood Mitigation include:
a. Provincial Irrigation and Drainage Authority (PIDA) b. Water and Power Development Authority (WAPDA) c. Provincial Relief Organizations d. Pakistan Army
a. Institutional and legal arrangements for Disaster Risk Management b. Hazard and vulnerability assessment c. Training, education and awareness d. Disaster risk management planning e. Community and local level programming f. Multi-hazard early warning system g. Mainstreaming disaster risk reduction into development h. Emergency response system, and i. Capacity development for post disaster recovery
e. Commissioner for Indus Water (CIW) f. Emergency Relief Cell (ERC) g. Federal Flood Commission (FFC) h. Flood Forecasting Division (FFD)
For earthquake related disasters, a separate Earthquake Recovery and Rehabilitation Authority (ERRA) works in the Prime Minister Secretariat.
Heightened disaster risk associated with poor
The focus of disaster management should remain tilted to floods and earthquakes and development of physical infrastructure for this purpose, as they have historically been the major disasters. However, the disaster
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management institutional framework should include health and other climate effects as important disaster management functions. For example, the Annual Flood Report, 2010 suggests the following lessons learnt after floods:
a. Meteorological Department b. Food and Agriculture Department c. Irrigation and Drainage Authority d. Water and Sanitation Agencies e. Department of Health f. Population Welfare
a. Better Early Warning System b. Better watershed management and forestation c. Storage dams d. Maintenance of embankments e. Evacuation routes, emergency shelters needed f. Safety of barrages by remodeling
g. Solid Waste Management Companies h. City Development Authorities (LDA, MDA etc) i. Housing and Urban Development j. Forestry Department k. Environmental Protection l. Rescue 1122 and Fire Brigade Department m. Transport Engineering and Planning Agency (TEPA) n. Urban Planning and Management Services Unit
The above lessons learnt do not include health and consequently excluded from the disaster preparedness and recovery mechanisms. There is a need that assessment of loss and damage from climate change should include impacts on social sectors especially human health, wellbeing and community resilience, as well as impacts to health care infrastructure and systems. Similarly, investment in climate mitigation and adaptation should be significantly increased on a rapid timescale.Post-flooding health effects can be reduced by adequately planned and funded health-sector responses, including interventions to control outbreaks of vectorborne and water-related diseases.
In a post disaster scenario, control on misappropriation of relief and a better governing system reduce the need for diversion of government funding from development programming to disaster response and the economic impacts of disasters. According to rough estimates, a dollar invested in disaster risk reduction is returned with two to four dollars in terms of avoided or reduced disaster impacts. So the disaster management institutional framework should bring forward legislation and other control mechanisms for better governance in case of disasters.
As the provinces gain more powers and responsibilities, the disaster management at the provincial and district levels needs to be strengthened. This is also essential because, disaster management is increasingly an urban development and management issue worldwide. City District Governments (CDGs) should be entrusted with developing and implementing disaster management policies and action plans in coordination with other departments including:
The capacity to meet the challenges of observed and projected trends in disaster risk is determined by the effectiveness of the risk management system. Such systems include government agencies, the private sector, research bodies, and civil society including community based organizations. A stronger emphasis on anticipation and risk reduction needs to be placed to improve the existing risk management measures and better adaptation to current extremes and risks.
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3.2 Disaster Preparedness a. Disaster risks are recognized as dynamic and should be mainstreamed and integrated into policy and strategy. Legislation for managing disaster risk must be supported by clear regulations such as the International Health Regulations that are enforced. DRM functions should be coordinated across sectors and scales and led by organizations at the highest political level. Risk should be quanti? ed and factored into national budgetary processes.
balance will require a stronger emphasis on anticipation and risk reduction. Existing risk management measures need to be improved as Punjab is poorly adapted to current climate risks, let alone those projected for the future.In more vulnerable and exposed districts with low capacity, more fundamental adjustments may be required to avoid the worst disaster losses.
b. Existing technologies and traditional and indigenous knowledge have been used for reducing disaster risk management especially in highly vulnerable countries like Bangladesh. The City District Governments (CDGs) should be tasked with collecting and applying such technologies and knowledge systems in the local context and health department should help and use these systems in developing its climate change action plan. The provincial government should provide the necessary funding for investment. To ensure that disaster risk management is accorded the appropriate attention, disaster reduction and adaptation programs must be an integral part of all sectoral development policies of the provincial government including the health.
c. Punjab has developed its Land Use Rules in 2009. The commercialization rules and building codes are also there. These rules and regulations should be better enforced. The political interference and corruption in the city planning and development should be curtailed to reduce the disaster risk. There is a need for better regulation for the construction and real estate industry for quality assurance and healthy city growth in view of rapid urbanization and population growth.
e. The impacts of current and future natural disasters could be reduced by the health sector defining integrated measures that address the root causes of vulnerability, and planning for effective responses after such events. For example, the health impacts of floods can be reduced by land management policies that reduce deforestation and conserve the integrity of watersheds and coastal zones, minimize the physical impacts of mudslides and storm surges, and decrease the chances of sewage contamination. For vulnerability assessment, various models exist. For example, the Vulnerability-Resilience Indicator Prototype (VRIP) model has been applied to the 26 Indian states on the basis of following indicators such as: economic capacity, human and civic resources, environment capacity, settlement/infrastructure sensitivity, food security, ecosystem sensitivity, human health sensitivity and water resource sensitivity. Economics would play a major role in combating the potential threat. Countries with good GDP would be able to introduce the best available tools of intervention and can fill up the lacunae in health system. All VBDs necessitate insight of disease epidemiology, ongoing interventions and socioeconomic change for determining exclusive burden due to climate change.
d. A new balance needs to be struck between measures to reduce risk, transfer risk and effectively prepare for and manage disaster impact in a changing climate. This
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Case Study- The World Bank Earthquake Disability Project The project took an integrated approach to reducing vulnerability and poverty of several marginalized groups by attempting to fill gaps in services for persons with disabilities. The project targeted capacity building of DPOs and networks to ensure they are able to support persons with disabilities, and can work alongside the government to progress a CBR model (World Bank, 2010). Participatory methods can help expose the interconnections between DRR, poverty reduction and climate change adaptation strategies and highlight the importance of implementing an integrated approach to disaster management (Schipper & Pelling, 2006). The strengthening of DPOs and social networks is also vital for addressing structural inequalities and for achieving vulnerability reduction through disability inclusive DRR and long-term development (IDRM, 2005).
f. The dissemination of knowledge on risk is very important as a disaster preparedness measure. There is a need to measure public awareness and attitudes towards current and projected adverse and inequitable health impacts of climate change, as well as the potential for significant health benefits and consequent cost savings from well-conceived climate control policies.Communication and social marketing plans should be designed to address perceptual and behavioral obstacles.The information on disaster risk to the people should be communicated to communities and the health sector through media, mobile phone technology and traditional community level information mechanisms. NDMA is already working on
including disaster management information in the national curricula. The education department in Punjab should be tasked with designing some information package to be included in the provincial textbooks at secondary and tertiary levels. This should be inclusive of the health effects of climate change and promote the health co-benefits of low carbon pathways. The Rescue 1122 is a good urban emergency service in Punjab. However, its public relationing needs improvement to enhance public information and cooperation in case of emergencies and disasters.
Case Study- WHO Initiatives for Disaster Awareness Since 2000, WHO has worked with the World Meteorological Organization and the UN Environment Program to raise awareness of climate change's implications for the health sectors of highly vulnerable regions. The necessary next step is to inform and support national health actors in taking concrete actions to protect health. For example, WHO is addressing this need by initiating a new project in 2006 on piloting approaches to protect health in a changing climate. In partnership with the UN Development Program and with funding from the Global Environmental Facility, this initiative is being implemented in seven vulnerable countries. In each, the national health ministry chairs an inter-sectoral team that has identified priority health risks from climate change given local environmental, socioeconomic and health contexts. Through the course of the initiative, this team will also identify, implement, monitor and refine interventions to minimize health risks. The project will thereby support targeted interventions in these countries, strengthen institutional capacity to address health risks, involve an increasingly informed and engaged health sector in adapting to climate change, and extract lessons that are applicable to other countries. It will also develop monitoring mechanisms to ensure that resources are applied effectively in adaptation projects within the health sector, and inform evaluations of support through this mechanism as compared with more general health or development aid. This initiative is important preparation for the wider action that will be necessary to meet the worldwide challenge of adapting to health risks from climate change.
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g. Deployment of effective early warning systems is another area in disaster preparedness. World Meteorological Organization and other international agencies are helping the health sector internationally with weather forecasts for effective preventive measures for floods and other extreme events. CDC, NASA, NOAA, and the WMO are excellent starting points for disaster and flood management. Limited usage was done during 2010 floods when facilities damaged were identified as at risk of damage in a flood hazard modeling analysis conducted by the Ministry of Health, Pakistan and WHO in 2008. WMO continues to work with the National Meteorological Service to improve their capability to forecast extreme events. The Famine and Early Warning System Network (FEWSNET) is a good example of a regional initiative aimed at monitoring vulnerability in case of famine. Since the financial and other constraints may hinder effective and comprehensive early warning systems in all the vulnerable sectors, the municipalities should be linked with national and international meteorological agencies to get updated with data on different climatic hazards and provide their analysis to health and other relevant departments well in time.It must be noted here that Early Warning Systems should be developed and linked to planning and policy-making and decisions should be informed by sound information using a range of tools and guidelines. Improved use of climate data is also needed to encourage more effective water management, agricultural planning and healthcare.
h. Appropriate structural interventions to reduce risk are needed. Forestation and maintenance of wetlands are very important for flood control and environmental protection. In Punjab the forest cover is only about 4 percentwhile almost half of the area of the Punjab province is under agricultural land use.Measures such as soil restoration, terracing, enforcement of appropriate building codes, retrofitting of schools, hospitals and other infrastructure should be taken to become more resilient to disaster shocks and moving human activities out of the path of disasters, etc. Pre-disaster preparedness measures also include community evacuation plans, food and water storage programs, backup plans for critical infrastructure and energy, etc., to aid better awareness of what to do when a disaster occurs. The pre-disaster preparedness is relatively low cost and can be helpful in 'disaster proofing' livelihoods. The science and technology can be used to develop appropriate livelihoods for populations at risk.
I. Greenhouse gas mitigation is needed to avoid more severe and frequent climate extremesand disease burden in future. Important steps include the use of clean and sustainable renewable energy and water sources; increase energy efficiency; air quality regulations; clean energy technologies to reduce harmful air emissions (e.g. cooking stoves).
Case Study- Bangladesh Bangladesh has adopted an effective government-led approach to risk management that balances the need for effective response capacity with longer-term efforts to reduce risk. It seeks to provide a strong platform for leadership by government, better co-ordination between key line-ministries, improved livelihoods in risk prone areas, strengthened response capacity at district and central levels and better understanding of the longer term implications of climate change on disaster risk.
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etc., to aid better awareness of what to do when a disaster occurs. The pre-disaster preparedness is relatively low cost and can be helpful in 'disaster proofing' livelihoods. The science and technology can be used to develop appropriate livelihoods for populations at risk.
avoid more severe and frequent climate extremesand disease burden in future. Important steps include the use of clean and sustainable renewable energy and water sources; increase energy efficiency; air quality regulations; clean energy technologies to reduce harmful air emissions (e.g. cooking stoves).
I. Greenhouse gas mitigation is needed to
3.3 Risk Sharing and Risk Transfer a. The governments can provide weather risk coverage directly to farmers and agribusinesses, protect exposure of the communitiesby offering catastrophic insurance and provide disaster aid to the affected population once disaster hits an area. However, for universal coverage of risk sharing mechanisms, an appropriate legislation and initiatives by the government for involvement of the private insurance companies will be needed. Weather related insurance mechanisms are evolving world over. For example, Alternative Risk Transfer is the term given to unconventional insurance arrangements. Alternative Risk Transfer (ART) markets should be developed. In advanced countries, insurers and large corporations are already experimenting with catastrophe bonds as an option. One of the commonest is captive insurance, where a large corporate places its risks within its own wholly-owned insurance subsidiary.Catastrophe (CAT) bonds are financial contracts, which pay out, not on
proof of a loss to the insured, but on the fulfillment of a trigger condition, for example when a severe flood hits an area. The new models of weather based crop insurance may also be introduced. Weather phenomena can be measured at official weather stations. Since no field inspections are required, weatherbased insurance should also have significantly lower administrative costs than crop insurance. Weather insurance is also more transparent and easier for farmers to understand than traditional crop insurance and can be marketed to farmers through banks, farm cooperatives, input suppliers and microfinance organizations. Farmers are not the only ones who might be interested in purchasing weather insurance. Agricultural traders, agro-processors, even shopkeepers or landless laborers, anyone whose income stream can be negatively affected by weather events, might benefit from purchasing weather insurance. CAT bonds have been promoted as a means for spreading low probability-high consequence catastrophic risks
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to risk takers around the globe. CAT bonds are relatively new instruments and involve significant development costs. Parametric CAT bonds, which trigger payments based on an objectively measured index of a natural event (e.g. Richter scale measurements, flood levels, wind speed, etc.), are likely to have the lowest development costs. Parametric CAT bonds can facilitate both the governments to provide emergency response in case of disaster and protect individuals against financial losses.
3.4 Disaster Response and Recovery a. A well-resourced and prepared response system with a focus on local capacity is needed in the province. Emergency response measures include effective implementation of evacuation plans, administering emergency relief to affected populations, etc. These measures include provision of clean water, tents, medical care, and other services. Postdisaster rehabilitation measures include rebuilding damaged infrastructure (bridges, roads, buildings); restoring normal economic and social activities (markets, telecommunications, etc.); and provide an opportunity to take disaster risk reduction measures and other ways of avoiding or reducing future loss and damage. In urban areas of Punjab have a well functioning rescue and emergency service in place. The 1122 system can be upgraded with training and providing equipment to deal with severe community level emergencies. In addition, disaster management should be included in the functions of relevant departments such as water and sanitation, health, housing and urban development etc.
need to develop clear rules for distribution of funds in case of a disaster to avoid serious inequities. For example, there must be rules that all developmentprojects should be startedafter full evaluation of its social costs.This is because resources should be used to generate more social benefits instead of shielding privately owned risky activities.Various indices of natural hazard risks are now being used to construct financial instruments. For example, the Richter scale is used to construct financial instruments based on earthquakes; wind speeds are used to construct financial instruments that protect against hurricanes; rainfall is used to protect against drought or flood. Since these indices can be represented by a probability distribution, parametric estimates can be made of the expected payoff (the pure premium) on the instruments.
b. The dependence on foreign aid should be minimized as often only particularly large disasters result in international emergency response. In case of smaller but devastating events, affected communities are left without help. One of the problems in Pakistan has been that thegovernment funded disaster assistance becomes highly political. There is a
Relative to current methods, there are many potential advantages to providing disaster assistance based on weather indices. The first is transparency. If the criteria for triggering disaster assistance have been well defined ex ante, politicians may find it more difficult to use disaster assistance as a means for transferring funds to favored regions of the country.The second potential advantage is that with sufficient years of accurate data, the parametric triggers can be set so as to normalize the expected value of disaster assistance across various regions of the country. This would reduce the perverse incentives inherent in disaster assistance programs that continually compensate those whose private decisions expose them to more risk. Furthermore, the information about relative differences in triggers across regions could be made publicly available. This would provide valuable information to both public and private decision-makers about the relative risk exposure to different extreme weather events in different regions of the country.
The use of technology has become very important in disaster relief and emergency
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response. The GIS based, mobile technologies are available and Punjab has used them in disaster reliefs in case of dengue epidemic in 2010 and floods of 2011. The Urban Unit of Punjab government has already developed technologies such Real-time Integrated Disaster Management System (RIDMAS) to bring precision to disaster management in a participatory manner. It facilitates the administrative authorities to take important decisions in an efficient and transparent way regarding rescue, rehabilitation, response and recovery. Emergency Response Geo-Meeting System (ERGMS) is another web-based realtime application designed to support effective decision making and coordination of different departments such as police, fire brigade, municipality, disaster management authorities, etc. to acquire process and analyze data judiciously, alleviate the effects of crises, coordinate the response and thus reduce suffering. It helps relevant personnel/decision makers to locate damaged buildings, injured residents for prompt response immediately after the catastrophe. The government can promote and build capacity of all the relevant departments for effective use of such technologies.
Change, the Global Framework for Climate Services and many progressive and advanced countries have all started recognizing the need to protect health from climate-related risks through, among others, the collaborative action on managing disaster risk, ensuring access to safe and adequate water and food, and strengthening preparedness, surveillance and response capacities needed for managing climate-sensitive diseases. In order to achieve these goals, decision-makers at all levels need access to the most relevant and reliable information available on the diverse connections between climate and health.
b. It is vital to note that the processes of DRM and preventive public health are closely linked, and largely synonymous. There is a need to develop a closer collaboration between the meteorological and health communities to provide the focused information necessary to best inform policy makers. The immediate requirement is to create multidisciplinary research teams bringing together skills in both climate and health modeling.The health- climate modeling will generate a better understanding of climate risks and better preparedness and response such as depicted in figure 4. c. Interdisciplinary research will also be
3.5Disease Control a. The UN Framework Convention on Climate
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needed, for example, to explore the interactions of behavior, environment and genetics in framing risks and determining outcomes. Such research will also need to focus on equity, and on the effects of gender and culture on risk, the effectiveness of interventions and access to health care. Ethical, social, cultural and sustainability issues must be addressed before emerging
interventions and technologies can be taken up by communities and incorporated into public-health and health-care systems. Data and research repositories will also be essential, and standardization, where possible, will allow international comparisons and help global partnerships.
4.0 Building Resilient Communities

The province of Punjab has a bustling population. Lahore will soon get the status of a metropolis but the concepts of healthy urban design, land use and building codes are not implemented. With the devolution in progress and new challenges of urban disaster management and disease control emerging due to uncontrolledsprawl, the role of municipalities is becoming ever more important in identifying local vulnerabilities, tracking environmental challenges and health threats, building resilient communities and climate smart design, utilizing local knowledge for disaster management and promoting education and public dialogue. environment and recognizes the importance of public spaces and comes with a change of pace, profile and urban functions.Productivity contributes to economic growth and development by implementing effective economic policies and reforms.Adequate infrastructure forhousing, water, sanitation, roads, information and communication technology are provided in order to improve urban living and enhance productivity, mobility and connectivity. Quality of life enhances the use of public spaces in order to increase community cohesion and better health, education and entertainment for all.Equity and social inclusion ensures the equitable distribution and redistribution of the benefits of a prosperous city, reduces poverty and the incidence of slums, protects the rights of vulnerable groups, enhances gender equality, and ensures civic participation in the social, political and cultural spheres. Environmental sustainability values the protection of the urban environment and natural assets while ensuring growth, and seeking ways to use energy more efficiently, minimize pressure on surrounding land and natural resources, minimize environmental losses by generating creative solutions to enhance the quality of the environment.
The following are the key areas for municipal policy making and action for climate resilient urban development and healthy population:
4.1 Urban Policy Making and Compact Development The policy making at the municipal level should be pro-people and promote a shared concept of urban development consisting ofproductivity, infrastructure, quality of life, equity and environmental sustainability. It should value the tangible and intangible aspects of development, promote inclusive economic growth, care for the natural environment, reduce disaster risks and vulnerabilities for the poor and build resilience to adverse forces of nature. The peoplecentered city maintains a sustainable
Moreover, the municipal authorities should go for compact urban development, which includes:
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a. Laws and incentives for energy efficient buildings b. Preservation of peri-urban farmlands and parks c. Mass transit d. Smart zoning e. Consumption control f. Recycling of solid waste g. Control of water runoff through taxation, water metering and tariff measures h. Land use planning and strict implementation of land use rules I. Sustainable internal migration j. Slums alleviation k. Removal of gated communities for functional and interactive cities l. Healthy water supply and sanitation services
deploy safeguards against the risks international markets may bring to bear on local socioeconomic conditions, deploying redistributive policies in close collaboration with provincial government in order to reduce income gaps and other local structural problems.
d. Health and environmental costs should be reflected in fiscal accounts of the government at municipal and provincial levels.
e. Market mechanisms emerging worldwide can be explored and developed for delivery of municipal and healthcare services and promotion of clean fuels.
4.3 Cleaner Fuels Reducing greenhouse gas emissions can be good for health. Automobiles are increasingly becoming the predominant means of transport, shifting to more walking and cycling and discouraging private car use in urban centers will lower carbon emissions, increase physical activity (which will reduce obesity, heart disease and cancer), reduce trafficrelated injuries and deaths, and result in less pollution and noise. Solid fuels are the predominant form of household heating and cooking energy, addressing inequitable access to cleaner fuels and providing more efficient stoves will lead to fewer illnesses and deaths related to indoor air pollution.
4.2 Economics and Finance a. Pro-poor growth strategies include adjustments in the local institutions and power structures in favor of the poor, by giving them greater access to productive assets such as land and livestock and facilities for acquiring education and skills. Other important elements will include increase in the non-farm employment in rural areas through small and medium enterprises and greater stability in food prices.
b. Funding and investment for programs to support and protect health in urban areas should be significantly increased.
4.4 Lifestyle and Nutrition The World Bank Group's quarterly Food Price Watch report emphasizes that policy options for promotion of healthier behaviors include imposition of taxes, bans or restrictions on certain foods and awareness campaigns. To control the obesity epidemic and under nutrition, following policy options have been advocated in the report.
c. Cities can devise a number of safeguards against a variety of socioeconomic risks including health and disasters. Municipal authorities can prioritize expenditures on social security nets, local/regional infrastructure and other types of development, with a view to securing longer-term growth while stimulating consumption and/or employment in the short term. Cities can also
a. Partnership for Agricultural Market
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Information System (AMIS) is an internationally available technology solution to improve food market transparency and help governments make informed responses to global food price spikes.Technological solutions are also available now to help governments and local leaders to control heart disease, obesity and other high-risk conditions. WHO's Urban HEART (Health Equity Assessment and Response Tool) is simple and user friendly, and can be used by a wide range of people to assess and respond to urban health inequities. It promotes the use of alreadyavailable data, which are then disaggregated into socioeconomic groups, and geographical areas or neighborhoods. Urban HEART considers health determinants and their interactions in multiple domains of urban life, and encourages policy responses and interventions that will be sustainable in the long term. UNHABITAT's UrbanInfo is a software tool that helps users store, analyze and communicate results for an array of urban indicators, both global and user defined.
ii. 30% reduction of low birth weight
iii. 50% reduction of anemia in women of reproductive age;
iv. Increase exclusive breast feeding rates in the first six months of life up to at least 50%;
4.5 Air Quality Comprehensive, long-term air quality management programs are needed in the cities to ensure tolerable levels of pollution are not exceeded and that the population exposure is reduced to acceptable levels. Such a program involves a wide range of local authorities, industry, transport, and local communities. Assessment of exposures to air pollutants are also needed which refers to the analysis of various processes that lead to human contact with pollutants after release into the environment. The routes of exposure to air pollutants include not only inhalation, but also ingestion, and dermal contact with pollutants that have been deposited or settled on soil, surfaces, foods, and other objects
b. The government should support improved nutrition among vulnerable groups through community nutrition programs aimed at increasing use of health services and improving care giving. The provision of school meals every day to children in low income countries is also an option in line with the Scaling Up Nutrition (SUN) Framework for Action to address under-nutrition.
Controlling air pollution through improvements in both the efficiency and renewability of energy supplies and use, as well as monitoring and modeling air quality, holds substantial benefits now and in the future for both health and climate. Better use of available technologies, policies and measures to reduce short-lived air pollutants could generate immediate, significant benefits in human well being, the climate system and the environment. For example, switching to cleaner and more efficient energy sources can markedly reduce the level of climate-changing pollutants released from millions of households as well as improve health.
c. Improved collaboration in the generation and sharing of knowledge in the areas of agriculture, food security and nutrition by developing knowledge platforms.
d. Adherence to global nutrition targets for 2025, agreed at the World Health Assembly in May 2012 which among others include:
i. 40% reduction of the global number of children under five who are stunted;
Efforts must not be limited to combating only outdoor pollution; rather improvement in cooking and heating facilities should also be
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carried out to reduce exposures occurring indoors and through improvement of fuel use efficiency. The overall aim is the improvement of ambient air quality. Replacing rudimentary stoves globally with cleaner technologies such as advanced combustion stoves could avert over 8 per cent of all childhood mortality annually. WHO tracks the use of polluting fuels and technologies, and their health impacts, and monitors the health benefits from shifts to less polluting alternatives. Together with WHO's Air Quality Guidelines, these resources support policies and interventions for improving air quality and health. The WMO through its Members gathers, disseminates and assesses information on the chemical composition of the atmosphere and its relation to climate change and to air pollution. Capacity development for air quality modeling and forecasting services provides authorities with information to take appropriate actions to avert health risks. The evidence-based knowledge provided by WHO and WMO is used for the design and implementation of effective policies and interventions.
Four National Taps to ensure a robust and sustainable supply of water. The strategy entails using water from different water sources: water catchment, recycled water, desalinated water and imported water.
Some Arab cities are also able to meet their water requirements because of the high political priority given to the provision of this public good. City authorities have improved water security through increased supplies, demand management, conservation and desalination.
4.7 Early Warning System and Emergency Response Emergencies in urban areas require expertise often in short supply: adapting water and sanitation projects to complex, dense and underserviced urban environments; conducting urban vulnerability and community resilience analyses and plans; developing land use management plans and tenure guidelines; removing debris; reconstruction of urban housing; resettlement of affected populations from emergency shelter and trauma surgery to name a few.The Hyogo Framework for Action, which was adopted by 168 Member States at the World Disaster Reduction Conference in Kobe, Japan in 2005, describes the work that is required from all different sectors and actors, including health and climate communities, to reduce disaster losses. The capacity of health and other sectors must be strengthened to save lives reduce illness and injury in emergencies by assisting health emergency response operations, for example, by providing early warnings of extremely hot and cold temperatures; providing seasonal forecasting and early warning systems to enable planning and action; determining which populations and health care facilities are at risk of hydrometeorological hazards using risk assessment tools; applying climate change models to forecast the long- term effects of climate change, information which could be used, for
4.6 Water and Sanitation Scaling up water and sanitation services and providing point-of-use disinfection would reduce the current burden of disease and ameliorate the health impacts of decreasing water supplies. Such interventions already have a very high costbenefit ratio; the threat of climate change makes these preventive health measures an even wiser investment. As water stresses intensify, the government can protect health by strengthening and enforcing the regulatory frameworks to ensure the safe use of new water sources and the use of wastewater, excreta and grey water in agriculture and aquaculture.
Success stories exist in many parts of the world. Singapore succeeded in meeting local water demand because of effective water governance. The specialized agency has developed a long-term strategy known as the
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example, to decide where to locate new health facilities away from high risk areas; and, providing real-time meteorological and hydrological data, properly integrated with related health services data and information, to support local and national decision-making.
4.8 Sexual and Reproductive Health Young people require special attention, including comprehensive sexuality education, as well as protection from sexual violence and abuse.Family size is a key component of population policy-making. Providing women with contraceptive choices is therefore crucial. Population policies also need to mainstream gender considerations to ensure that responses to phenomena such as migration and urbanization take into account the specific needs of women and children. Furthermore, policies concerning population dynamics need to be formulated in a way that not only addresses people's needs, but also proactively protects and respects human rights and women's choice (according to the International Conference on Population and Development [ICPD] Program of Action).Education of girls and women is a crucial building block for improving women and children's health. Equally, women who are empowered through education and good health generally choose to have fewer children and are able to invest more in the health and education of their children, thereby creating a positive cycle for growth and development. Schools can also encourage the early adoption of healthy behaviors, including abstaining from tobacco use, increasing physical activity, avoiding alcohol, and encouraging healthy dietary habits. Sexuality education has a beneficial impact on sexual and reproductive health.
in urban settings.Urban violence is inextricably linked with poverty and urban sprawl. Therefore, the future development planning should be based on Population-HealthEnvironment (PHE) model. Better urban design and zoning can also help reduce the crime while technological solutions are also available for better oversight and control of crime in dense urban settings. Intelligent real time integrated GIS based technologies can help law enforcement and emergency response agencies to monitor and respond to urban violence in a cost effective and time efficient way. For example, the Lahore Metro Bus Service (MBS) has established a state of the art traffic command and control center for monitoring and surveillance of 27-kilometer long MBS corridor. This command and control center can be used for multiple purposes including the control of traffic, law and order and emergency response in case of accidents and urban disasters. The system has been developed indigenously and can be upscaled for overall urban security purposes in all the major urban centers of Punjab.
4.10 Regional and Municipal Cooperation Cities must connect to regional and global business networks, enhance quality of life, improve basic infrastructure and communication networks, address public transport deficiencies and environmental conditions, and respond to inequality and poverty issues, if they are to turn into real engines of national growth and prosperity. Better connectivity, mobility and accessibility and well planned integration of land-use, density and transport have the potential to reduce energy consumption drastically, making cities more sustainable. New or strengthened, more effective local and regional institutions, new linkages and alliances across the three tiers of government, together with a comprehensive vision and clear plans favoring inclusiveness, are all crucial for equitable development and climate inclusive prosperity.
4.9 Urban Violence Political stability, enforcement of law and better governance are the key ingredients to overhaul the security framework to restore the confidence of aid workers and health workers
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The recent city level cooperation for infrastructure development in Punjab with Turkey is a good step forward. More city level development partners can be identified and involved. For example, the US State Department is increasingly being engaged in development cooperation with rising metropolises of the South.These cities are new hubs of economic growth and innovation and
ties are being strengthened with their key political and business leaders to developenergy-efficient buildings, advanced power facilities, transport and telecommunications. To follow the trend, the cities in Punjab can explore these opportunities to meet their needs of rapid urbanization.
Recommendations
1. The policy focus needs to be shifted from clinical to preventive healthcare, from rural to urban disaster management, from communicable to chronic disease control and from centralization to devolution of authorities and responsibilities. needed among the health, disaster management and urban development agencies.
The health policy of the Government of Punjab should recognize the need for change in institutional approach to the health sector and incorporate changes accordingly;
Punjab Rules of Business, 2011 should be
4. As decentralization is a global trend in every sphere of governance, therefore in Punjab also, the district and local level institutions should be the most empowered and efficient institutions in terms of financial, human and technological resources to control the ambient air pollution and reduce, reuse and recycle the solid waste, reduce and treat the municipal water.
amended so as to include a climate change cell in every Department of government. These cells should coordinate climate related information and data so that all government departments are kept up-todate regarding climate change issues.
5. Most of the climate related health effects can be overcome by efficient service delivery and funding. The strengthening of the existing healthcare system is needed on emergency basis.
2. Health should be recognized as an important disaster management function. The health effects of climate must be carefully evaluated and costed in every sector and then reflected in planning of all development projects.
The Government of Punjab should move to computerize health related information. This Health Management Information and
system can act as a database of health incidents and will allow for up to date and accurate information for policy decisions.
Health Department in coordination with
Environment Protection Department should carry out an assessment of the health effects of climate change.
6. The modulating influences need to be controlled such as rapid population growth, poverty, violence and urban sprawl.
3. A strong coordination mechanism is
7. The two instruments that have emerged
28
to help decision makers worldwide in their efforts to contain climate change effects are the use of technology and risk sharing and management. The cultural, financial or political obstacles must be overcome in government leadership with the help of the private sector and market forces.
implemented for generating and pooling of financial resources for disaster management and health promotion. The role of the private sector and international funding channels is very crucial.
8. Without, ensuring the availability of reliable and quality data and implementation of effective surveillance systems for disease and disasters, no response system can be developed.
9. There is a dire need of public awareness and training of healthcare professionals on disaster management and climate effects on health. Without their involvement, no policy is expected to yield any results.
11. A health-in-all-policies strategy is needed that establishes health as a shared goal across the whole of government and as a common indicator of development.Useful tools for implementing a health in all policies approach include: integrated budgets and accounting, impact assessments, crosscutting information and monitoring systems, and legislative frameworks. However, the most important next step is to combine incentives with the use of executive power to bring different ministries and sectors together, without which business as usual is unlikely to change.
10. Innovative schemes need to be
References
1. Association of British Insurers. (2004). A Changing Climate for Insurance - A Summary Report for Chief Executives and Policymakers. www.abi.org.uk/climatechange 2. Cruickshank, E. W., Schneeberger, K., Smith, N. (2012). A Pocket Guide to Sustainable Development Governance. Commonwealth Secretariat Stakeholder Forum. 3. DFID. (2006). Poverty Reduction in a Vulnerable World: Policy Paper. 4. Government of Pakistan. (2010). Annual Flood Report, 2010. 5. Govt of Pakistan, MoEnv. (2009). Land Use Atlas of Pakistan. 6. Hainesa, A., Kovatsa, R.S., Lendrumb, D.C., Corvalanb, C. (2006). Climate Change and Human Health: Impacts, Vulnerability and Public Health, London School of Hygiene and Tropical Medicine, London. Vol 120:7 7. Hormats, Robert, D. (2013). Metro Diplomacy, Foreign Policy Magazine, can be accessed at http://www.foreignpolicy.com/articles/2013/03/28/metro_diplomacy 8. Huntingforda, C., Hemmingb, D., Gasha, J.H.C. Gedneyc, N. Nuttalld P.A. (2007). What is required of climate modellers?, Transactions of the Royal Society of Tropical Medicine and Hygiene, Volume 101, Issue 2. 9. IDRM. (2005). 10. IRIN. (2013). Analysis: Preparing for urban disasters - Challenges and Recommendations, Report, accessible at: http://reliefweb.int/report/world/analysis-preparing-urban-disasterschallenges-and-recommendations 11. Lendruma, D. C., Corvalna, C., Neiraa, M. (2007). Global climate change: Implications for International Public Health Policy.http://www.climate-
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insurance.org/upload/pdf/Varangis2002_Weather_Indexes_for_Developing_Countries.pdf 12. NaseerMemon(25th Dec, 2013) Daily Dawn can be accessed at http://dawn.com/2012/12/25/insecure-aid-workers/ 13. Stakeholder Forum. (2012). Doha Declaration on Climate, Health & Wellbeing Outreach Magazine, December 3 issue. 14. The Economist Intelligence Unit (2012). The Future of Healthcare in Africa. http://www.managementthinking.eiu.com/sites/default/files/downloads/EIUJanssen_HealthcareAfrica_Report_Web.pdf 15. The World We Want. (2013). Health in the Post-2015 Agenda- Report of the Global Thematic Consultation on Health, Can be accessed at www.worldwewant2015.org/health 16. Tong S. & McMichael, A.J. (2011). Encyclopedia of Environmental Health. 17. Varangis, P., Skees, J and Barnett, B. (2000). Weather Indexes for Developing Countries, World Bank, University of Kentucky and University of Georgia.http://www.climateinsurance.org/upload/pdf/Varangis2002_Weather_Indexes_for_Developing_Countries.pdf 18. WHO. (2012). Atlas Of Health And Climate: Realizing The Potential To Improve Health Outcomes Through the Use Of Climate Services. 19. WHO. (1998). Essential Drugs Monitor Double Issue No 25 & 26. 20. WHO. (2009). Global Health Risks, Mortality and Burden of Disease Attributable to Selected Major Risks. 21. WHO. (2012). Good Practices in Delivery of Primary Health Care in Urban Settings, Community based Initiative Series. 22. WMO. (2012). Atlas of Health and Climate. 23. WHO & UN-HABITAT. (2010). Hidden Cities- Unmasking and Overcoming Health Inequities in Urban Settings.
Web Resources
1. http://www.southasianfloods.icimod.org/contents.php?country_code=PK&c_id=11 2. http://www.worldbank.org/en/news/press-release/2013/03/27/food-prices-decline-stillhigh-close-historical-peaks 3. www.scalingupnutrition.org
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Incorporating Climate Change Considerations in Health Policy of Punjab (Pakistan)

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Incorporating Climate Change Considerations in Health Policy of Punjab

Rafay Alam & Arshad Rafiq

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Ali T. Sheikh CEO, LEAD Pakistan

LEAD Pakistan Occasional Paper Series