1 00:00:04,137 --> 00:00:07,297 Alex Ergo: Hi everyone and welcome back to Health Systems Pathways. 2 00:00:07,577 --> 00:00:15,877 I'm Alex Ergo, PSI's Director of Health Systems, bringing you live episodes recorded at the Health Systems Research Symposium in Nagasaki. 3 00:00:16,054 --> 00:00:23,424 We've now reached the final day of this conference, and today's episode focuses on the topic of climate and health. 4 00:00:23,911 --> 00:00:30,441 Our first guest will discuss the process Pakistan is going through to develop a health national adaptation plan. 5 00:00:30,851 --> 00:00:36,271 She will also highlight some of the challenges that come from the high degree of decentralization in the country. 6 00:00:36,761 --> 00:00:46,791 Our second guest comes from Uganda and will share some reflections on the critical role of communities when it comes to making health systems more resilient to climate shocks. 7 00:00:47,227 --> 00:00:48,536 So, let's dive in. 8 00:00:52,538 --> 00:00:53,698 Hi and welcome back. 9 00:00:53,758 --> 00:00:55,928 I'm here with Dr Mujtaba. 10 00:00:56,448 --> 00:00:58,638 Let me first ask her to introduce herself. 11 00:00:58,638 --> 00:00:59,638 Dr. Mehreen Mujtaba: Thank you, Alex. 12 00:00:59,668 --> 00:01:02,108 I'm Dr Mehreen Mujtaba. 13 00:01:02,108 --> 00:01:07,918 I'm Director Climate Change, Nutrition and Health at the Federal Ministry of Health in Pakistan. 14 00:01:08,160 --> 00:01:16,570 Alex Ergo: Would you mind telling us a little bit about the journey that you're going through for the development of the health climate adaptation plan in Pakistan? 15 00:01:17,070 --> 00:01:22,550 Dr. Mehreen Mujtaba: So actually climate and health nexus is something new that the Ministry of Health is exploring. 16 00:01:22,970 --> 00:01:45,618 So, since COP 27 in Glasgow, where our minister was part of the negotiations for including health in the climate change negotiations and then in COP 28 when Minister Health from Pakistan was a signatory to the health declaration, the Ministry of Health has now a dedicated desk for climate change and health. 17 00:01:46,028 --> 00:01:52,948 We were supposed to submit our HNAP, which is Health National Adaptation Plan towards this COP. 18 00:01:53,338 --> 00:02:04,758 But unfortunately, because conducting climate risk and vulnerability assessments in a country which is comprising of four provinces and two federating areas is a very big endeavor. 19 00:02:05,058 --> 00:02:19,188 So that took a lot of time, and unfortunately, we could not submit our HNAP this year, but next year hopefully we will be able to submit our adaptation plan to the rest of the world at UNFCCC forum. 20 00:02:19,485 --> 00:02:22,335 Alex Ergo: And where are you in that process right now? 21 00:02:22,875 --> 00:02:35,735 Dr. Mehreen Mujtaba: So, the process started somewhere around last December with WHO supporting the ministry in conducting climate risk and vulnerability assessments in two of the big provinces, Punjab and Balochistan. 22 00:02:36,175 --> 00:02:52,051 And then FCDO also moved in, and they committed to conducting the same climate risk vulnerability assessments using the same methodologies and the tools developed by WHO to ensure uniformity in Khyber Pakhtunkhwa province. 23 00:02:52,941 --> 00:03:07,531 We are left with one of the major provinces, which is Sindh, which was devastated during the floods in 2022 and has very high levels of malnutrition because of droughts and flooding and salination off the soil. 24 00:03:07,891 --> 00:03:11,961 UNICEF has committed to conducting the CRVAs for us in uh, province Sindh. 25 00:03:11,991 --> 00:03:15,998 So, the journey is still going on. 26 00:03:16,120 --> 00:03:21,550 Alex Ergo: You've already mentioned the challenge of working in a country that has strong authorities at provincial level. 27 00:03:22,230 --> 00:03:24,223 What other challenges do you face? 28 00:03:24,373 --> 00:03:28,293 Dr. Mehreen Mujtaba: The biggest challenge is the fact that health is a decentralized subject. 29 00:03:28,623 --> 00:03:31,043 So, the implementation is with the provinces. 30 00:03:31,423 --> 00:03:37,373 The policies and the guidelines are made at the federal level, but the implementation is again at the provincial level. 31 00:03:37,623 --> 00:03:43,353 So there has to be a very robust cohesion between the national and the provincial governments. 32 00:03:43,903 --> 00:03:47,943 In some instances, it's very easy to work with the provincial governments. 33 00:03:48,183 --> 00:04:07,213 Then there are certain authorities and provincial authorities where we find it a bit difficult for them to understand that the guidelines and the policies have to come from the federal side, and the benchmarking has to be federal because climate change is per se not a devolved subject. 34 00:04:08,191 --> 00:04:11,781 And the benchmarking and the reporting has to go from the federal level. 35 00:04:11,781 --> 00:04:13,581 It can't be from the provincial level. 36 00:04:13,991 --> 00:04:15,441 That is one of the challenges. 37 00:04:15,843 --> 00:04:29,701 And then another challenge is when you have developmental partners who go directly to the provinces for conducting the CVRAs rather than coming to the federal ministry. 38 00:04:30,201 --> 00:04:37,841 That also becomes a bit of a challenge because then the province is doing some work which the national authority is not aware of. 39 00:04:38,671 --> 00:04:40,011 So that's another challenge. 40 00:04:40,551 --> 00:04:45,351 Alex Ergo: And how about coordination across different ministries and sectors? 41 00:04:45,411 --> 00:04:46,381 Is that an issue? 42 00:04:46,555 --> 00:04:54,725 Dr. Mehreen Mujtaba: Just very recently, the Ministry of Health has constituted a steering committee, which is a multi-sectoral inter-ministerial body. 43 00:04:55,195 --> 00:05:12,295 It is going to have representatives from the Ministry of Climate Change, Ministry of Food Security, animal health, apart from that public works and all the ministries that are that the ministry does play a major role in climate change and health policies development. 44 00:05:12,342 --> 00:05:14,702 We have our technical working groups. 45 00:05:14,745 --> 00:05:18,225 We have representatives from Pakistan Med Department in that as well. 46 00:05:18,815 --> 00:05:22,505 We have from the infectious disease control cell as well. 47 00:05:22,885 --> 00:05:26,695 So, the coordination mechanism is going very well. 48 00:05:27,565 --> 00:05:32,925 And a lot of good ideas and policies are coming out of that. 49 00:05:33,135 --> 00:05:39,945 Alex Ergo: And if I understand correctly, the similar coordination mechanisms need to then be replicated at the provincial level or not? 50 00:05:40,059 --> 00:05:49,889 Dr. Mehreen Mujtaba: So, actually the technical working group and the steering committees that we have on climate change and health at the national level, they have representatives from the provincial level as well. 51 00:05:50,669 --> 00:06:17,234 So there is a cohesion between the government counterparts, but the only challenge, which I mentioned earlier, is that the government is working at one level at the national and provincial side, but then you have developmental partners who are just going in silo to a province and then they are going to people that are not aware of or are not members of our technical working group or members of the steering committee. 52 00:06:17,454 --> 00:06:33,384 So that kind of it makes it a little difficult to understand what's happening at the provincial level, but otherwise coordination mechanisms are very much in place, and we've been brainstorming and coming up with really good policies and initiatives for the future. 53 00:06:34,039 --> 00:06:34,499 Alex Ergo: That's great. 54 00:06:34,499 --> 00:06:35,459 Thank you for sharing that. 55 00:06:35,479 --> 00:06:36,449 Maybe a last question. 56 00:06:36,499 --> 00:06:38,989 This is the fourth day of the conference. 57 00:06:39,219 --> 00:06:44,509 What have been some of your impressions and some some things that you will take with you back to Pakistan? 58 00:06:45,289 --> 00:06:55,889 Dr. Mehreen Mujtaba: One of the things which was most striking was that we are talking in terms of just countries, whereas climate change is more of a regional sort of a concept. 59 00:06:56,239 --> 00:06:58,889 Let's just, for instance, talk about air pollution. 60 00:06:59,409 --> 00:07:05,299 So, when you talk about Punjab, you're talking about Punjab in India and Punjab in Pakistan. 61 00:07:05,749 --> 00:07:14,369 Okay, so people in India and people in Pakistan are breathing the same toxic air and the AQI is above 1400 in both the areas. 62 00:07:14,739 --> 00:07:20,699 So, climate change, you cannot just take it as a country-specific sort of a thing. 63 00:07:21,159 --> 00:07:25,169 It has to be more regional collaborations if we want to see differences. 64 00:07:25,459 --> 00:07:27,819 So we have to have regional benchmarks. 65 00:07:27,829 --> 00:07:30,259 We need to have regional knowledge sharing. 66 00:07:30,329 --> 00:07:35,459 We need to have regional synergies, and a regional hub. 67 00:07:35,459 --> 00:07:45,069 This was one of the ideas that I floated with our ADB and JICA partners also that we need to create a regional hub so that we can make regional policies. 68 00:07:45,252 --> 00:07:47,742 Alex Ergo: And you think that will happen? 69 00:07:48,662 --> 00:07:49,472 Dr. Mehreen Mujtaba: I think so. 70 00:07:49,792 --> 00:07:58,512 Because by the end of the day, whatever affects the me across the border or the populations living in Pakistan across the border. 71 00:07:58,612 --> 00:08:00,312 The same thing happens in India. 72 00:08:00,572 --> 00:08:07,352 So, we cannot talk just about Pakistan and not do something about India or India cannot just talk about India and not talk about Pakistan? 73 00:08:08,122 --> 00:08:16,272 Because you're in Islamabad, the cloud, which is up there with high AQI is all over Punjab, whether it's India, Pakistan. 74 00:08:16,412 --> 00:08:17,582 That doesn't make a difference. 75 00:08:17,972 --> 00:08:18,932 Alex Ergo: Yeah, very true. 76 00:08:19,182 --> 00:08:20,822 Thank you so much for joining us. 77 00:08:24,815 --> 00:08:25,735 Hi again, everyone. 78 00:08:25,805 --> 00:08:27,235 I'm now with Dr. 79 00:08:27,235 --> 00:08:36,350 Rawlance from Uganda, who's given a very interesting presentation that related to climate adaptation, climate resilience in his country. 80 00:08:36,700 --> 00:08:40,730 So, let me first start by asking could you please introduce yourself? 81 00:08:40,824 --> 00:08:41,134 Dr. Rawlance Ndejjo: Yes. 82 00:08:41,234 --> 00:08:41,624 Thank you. 83 00:08:42,144 --> 00:08:44,324 My name is Rawlance Ndejjo. 84 00:08:44,521 --> 00:08:48,001 I'm a lecturer and researcher at the School of Public Health, Macquarie University. 85 00:08:48,816 --> 00:08:57,646 where I'm doing work on climate change and health and a few other health topics such as non-communicable diseases and also epidemics. 86 00:08:57,971 --> 00:09:08,911 Alex Ergo: During your session, there were quite a number of questions relating to the role of communities and also what they actually already do when climate crisis happens. 87 00:09:09,161 --> 00:09:11,141 Could you say a few words about those discussions? 88 00:09:11,191 --> 00:09:11,651 Dr. Rawlance Ndejjo: Yes. 89 00:09:11,701 --> 00:09:16,981 There were questions that were asked about the community, which I felt were actually very important questions. 90 00:09:17,076 --> 00:09:28,686 Our presentations at the conference had focused more around issues to do with policymakers and the barriers that they face to actually build climate resilient health systems. 91 00:09:28,799 --> 00:09:33,146 But I think we had the opportunity to also discuss the community, which is really my passion. 92 00:09:33,676 --> 00:09:39,566 And I'm trying to think about the role that the communities play in climate change adaptation. 93 00:09:40,026 --> 00:09:46,516 So in a nutshell, I think communities is where everything starts and where all the action takes place. 94 00:09:47,046 --> 00:09:54,516 So communities should have a very important role in all the discussions we have around climate change and climate change adaptation. 95 00:09:55,086 --> 00:10:04,868 So, that we work with the communities to empower them so that they can build adaptive capacity to move towards resilience. 96 00:10:05,477 --> 00:10:15,077 Many times, when I talk about communities, we also talk so much about them supporting the ideas and solutions that we have. 97 00:10:15,607 --> 00:10:21,727 But I'm always interested in us flipping this around and looking at communities as solutions. 98 00:10:22,227 --> 00:10:28,087 We now experience a lot more extreme weather events in Uganda, but also in many parts of the world. 99 00:10:28,582 --> 00:10:33,512 But even before this communities have been dealing with these events for a very long time. 100 00:10:33,982 --> 00:10:39,692 They have slowly by slowly developed mechanisms through which they deal with these extreme weather events. 101 00:10:40,092 --> 00:10:51,907 They have ideas on how best to adapt to these events in a way that favors them, but also, in many of these communities you go and they also have information around early warning. 102 00:10:51,957 --> 00:10:57,607 There's a lot of indigenous knowledge around how communities can actually predict these extreme weather events. 103 00:10:57,917 --> 00:11:08,977 And some of the inspiring case studies I have seen, actually those that integrate the scientific modelling and prediction together with indigenous knowledge which gives us more precision. 104 00:11:09,347 --> 00:11:19,268 And also, building more trust in terms of communities getting to learn and appreciate, um, the different predictions that are made, but also seeing their role and stake within all this. 105 00:11:19,708 --> 00:11:30,019 So, in a nutshell, communities are here, they have been adapting we need to think about how do we work with them towards the solutions for climate change adaptation. 106 00:11:30,519 --> 00:11:34,749 There are several interventions that are usually implemented within the community. 107 00:11:35,249 --> 00:11:48,409 But sometimes you feel that the role of the community is not clear and communities are not brought at the center stage and these interventions cannot even be sustained because we can't implement things for others without giving them room. 108 00:11:48,849 --> 00:12:09,296 To actually be part of the brainstorming, be part of the implementation of these interventions, be part of the evaluation of these interventions to tell us what is working and what's not working and how we can think through some solutions together to have more sustainability and through some of these mechanisms, we can actually be able to move towards resilience. 109 00:12:09,906 --> 00:12:12,786 So, in a nutshell, there's no way we're making any progress. 110 00:12:13,261 --> 00:12:21,231 In dealing with climate change, there's no way we make progress in thinking about adaptation mechanism without bringing communities on board. 111 00:12:21,398 --> 00:12:22,318 Alex Ergo: Yes, absolutely. 112 00:12:22,318 --> 00:12:30,328 So, you really have this bottom-up approach, which is nice because very often when we hear about country's efforts it's, it starts very much top down. 113 00:12:30,328 --> 00:12:32,098 So, it's really nice to compliment that. 114 00:12:32,488 --> 00:12:41,808 Just a question, I believe that Uganda has already developed health national adaptation plan, which is now to be implemented. 115 00:12:42,338 --> 00:12:45,758 How will what you just described be part of that? 116 00:12:45,758 --> 00:12:50,678 So basically, how will the community be involved in this implementation? 117 00:12:50,808 --> 00:12:51,238 Dr. Rawlance Ndejjo: Yes. 118 00:12:51,278 --> 00:12:52,128 That's important. 119 00:12:52,128 --> 00:12:54,858 I think with the many other stakeholders that Uganda now has. 120 00:12:54,918 --> 00:13:02,578 This is a health national adaptation plan, actually the second country among the low and middle-income countries to develop this plan after Nepal. 121 00:13:03,088 --> 00:13:09,848 So, it is a really good place to be to have this plan for 2025 to 2030. 122 00:13:10,348 --> 00:13:17,258 First of all, I am impressed with the process of developing this plan because it involved the community and several other stakeholders. 123 00:13:17,258 --> 00:13:24,318 Different sectors were involved but the role of the community was also clear, and also views and ideas from the community were incorporated. 124 00:13:24,718 --> 00:13:36,638 In terms of the implementation of this plan, which I think matters the most now that we have the plan, we really also need to think about the clear role of the community in terms of providing solutions to how we deal with the climate change. 125 00:13:37,058 --> 00:13:42,648 We're thinking about building climate resilient health systems across the globe within the country. 126 00:13:43,088 --> 00:13:45,528 But a lot of this cannot happen without the community. 127 00:13:45,661 --> 00:13:55,821 So, the whole point is even as we think through the interventions, we need to think about having a community voice so that we continuously consult with the communities. 128 00:13:55,991 --> 00:13:59,881 We continuously co design the interventions we want to implement with the communities. 129 00:14:00,391 --> 00:14:09,901 We continuously think through and work with stakeholders to implement interventions that favor communities so that the communities can adopt some of these interventions. 130 00:14:10,201 --> 00:14:15,911 Whether we are thinking about how do we reach communities that are hardly hit by extreme weather events? 131 00:14:16,361 --> 00:14:24,211 If we think about potential outreaches that we need to do at the health facility level, we need to think about the central role of how communities support this. 132 00:14:24,651 --> 00:14:34,261 The role of community health workers has also been key in a lot of the work that we have seen, including the work we have done in Uganda, in terms of bridging that gap between the communities and the health facility. 133 00:14:34,581 --> 00:14:50,076 So, we need to get the community health workers on board, we need to support them, we need to facilitate them, and we need to ensure that they work very closely with the communities to bridge any gaps in healthcare access that may happen before, but also in the aftermath of extreme weather events. 134 00:14:50,636 --> 00:15:05,319 There are also very good case studies around community health workers bridging the gap around access to commodities, family planning commodities that we have seen but also support in treatment of children, uh, for malaria and uh, diarrhoea and pneumonia within the community. 135 00:15:05,679 --> 00:15:18,849 And these are some potential mechanisms that we can expand to really work closely with the community health workers and build their capacity and also support bridging that gap so that we can ensure continuity of services. 136 00:15:19,224 --> 00:15:29,104 The other aspects around the community that I could maybe mention is, we need to go back and rethink the role of health promotion in terms of disease prevention generally. 137 00:15:29,594 --> 00:15:49,392 And still the community stakeholders, the leaders, the religious leaders, the other community workers and the community health workers are key in providing information to to, to these communities to help them prepare to prepare better but also to give them the information that they need to deal with potentialities maybe disease incidents that may happen. 138 00:15:49,922 --> 00:16:11,392 Sometimes when we have these weather events, we actually also experience epidemics of infectious diseases and there's no way some of these can be clearly and appropriately be dealt with without proper information to the community, without a clear involvement of community stakeholders and community health workers and without adequate support from the health facility level. 139 00:16:11,892 --> 00:16:29,386 We need to clearly continue to implement this plan, working with the communities, evaluate the interventions, get community feedback, and continue to work with them to improve the interventions and see how best we can tailor these to their needs for a climate resilient health system. 140 00:16:29,555 --> 00:16:30,065 Alex Ergo: Excellent. 141 00:16:30,075 --> 00:16:34,725 These are all important points, and it would be really nice to see how this unfolds in the years to come. 142 00:16:35,045 --> 00:16:40,361 Just maybe a last question, any big takeaway that that you got from this conference? 143 00:16:40,535 --> 00:16:51,237 Dr. Rawlance Ndejjo: Yeah, of course there are several takeaways, but I was particularly interested in learning about adaptation mechanism at both community and health facility levels from other countries. 144 00:16:51,777 --> 00:17:18,907 And by attending some presentations in some sessions, sharing some lessons from many low and middle-income countries, I was impressed to see that there are a lot more efforts in terms of thinking about climate smart health systems or climate smart health facilities in terms of thinking the whole infrastructure of how we construct health facilities, which I think is good, but also rethinking the whole building blocks of a health system to actually start to move towards a climate resilient health system. 145 00:17:19,337 --> 00:17:44,297 One of the challenges that I think we have or we have been having in climate change discussions when we talk about health systems, has really been around a synopsis of what the issues are or the problems are, and and not getting towards real tangible solutions around how do we bridge the gaps that we see or that we experience in terms of infrastructure in terms of commodities in terms of the health workforce and preparing them much better. 146 00:17:44,697 --> 00:17:50,017 And I feel that this this conference has provided a lot of discussions and solutions. 147 00:17:50,497 --> 00:18:07,247 That brings together a lot of these building blocks, whether it is thinking about better training for health workers and building their capacities and approaches that we can use and take whether it is thinking about how we work with the different sectors to develop solutions, the engineering solutions, and we will not provide those as health services. 148 00:18:07,777 --> 00:18:33,103 Policy and system researchers, but we need to work with the other fields and sectors to actually start to move towards the solutions and some examples have been shared, whether it is about energy efficiencies and how we can reduce carbon emissions from facilities, but also how we can broadly Increase adoption of renewable energy at facility levels and some of these examples were broadly inspiring at the conference. 149 00:18:33,183 --> 00:18:40,813 Aspects of data and how we can further interpret climate change and health and try to bridge the evidence gaps that we have. 150 00:18:40,913 --> 00:18:43,553 So, I leave this conference quite energized. 151 00:18:43,603 --> 00:19:09,990 I'm also interested in furthering and digging much deeper into some of the solutions that have been suggested so that we start seeing what can we contextualize for some of our different settings and continue the learning so that by the time we meet the next time, we're actually sharing lessons from implementing some of these solutions, which I think are broadly inspiring and giving us hope for the future, but also for climate resilient health systems. 152 00:19:10,793 --> 00:19:11,083 Alex Ergo: Great. 153 00:19:11,133 --> 00:19:17,823 Thank you so much for sharing these reflections and also for joining our podcasts and have a safe journey back to Uganda. 154 00:19:21,889 --> 00:19:23,099 Thank you to Dr. 155 00:19:23,129 --> 00:19:24,759 Mujtaba and to Dr. 156 00:19:24,759 --> 00:19:40,079 Rawlance for these great insights relating to the development of a health national adaptation plan and also to the importance of involving communities, including in the development and implementation of such plan, if we really want to build resilient health systems. 157 00:19:40,238 --> 00:19:43,638 Thank you everyone for tuning into Health Systems Pathways. 158 00:19:43,638 --> 00:19:50,438 If you enjoyed this episode, please don't forget to subscribe or follow us wherever you get your podcasts. 159 00:19:51,078 --> 00:19:53,398 Until next time, I'm Alex Ergo. 160 00:19:53,808 --> 00:19:57,968 Let's keep working together to build stronger health systems that work for people.