Opportunities for Co-benefits in addressing Health and Climate Change in South Africa

T

Issue and Revision Record

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Abbreviations

AMR Antimicrobial resistance

BHP Better Health Programme

BI Behavioural insights

CFF Climate Finance Facility

CHAI Clinton Health Access Initiative

DAFF Department of Agriculture, Forestry and Fisheries

DALRRD Department of Agriculture, Land Reform and Rural Development

DBSA Development Bank of Southern Africa

DEA Department of Environmental Affairs

DFFE Department of Forestry, Fisheries and the Environment

DIB Development impact bond

DWS Department of Water and Sanitation

EHP Environmental Health Practitioner

ESG Environmental, Social and Governance

FCDO Foreign, Commonwealth and Development Office

GCF Green Climate Fund

GHG Greenhouse gases

HTA Health Technical Assistance

HNAP Health National Adaptation Plan

ICF International Climate Finance

IRR Internal rate of return

KZN KwaZulu Natal

LMIC Low- and middle- income countries

NCDs Non-communicable diseases

NDoH National Department of Health

NHI National Health Insurance

NHS National Health Service

NHSC NHS Consortium for Global Health

NICD National Institute of Communicable Diseases

SAMRC South African Medical Research Council

SIB Social impact bond

SUD Single use device

UHC Universal health coverage

V&A Vulnerability and adaptation

WCDoH Western Cape Department of Health

WHO World Health Organization

WWTP Wastewater treatment plant

1 Introduction

According to the World Health Organization (WHO), climate change is the single biggest health threat facing humanity today. It threatens the basic essential ingredients of good health – clean air, safe drinking water, nutritious food, and safe shelter – and undermines many of the social determinants of health such as access to health care and social support structures.1

South Africa is particularly vulnerable to climate change due to issues of water and food insecurity and is likely to become hotter and drier in the future. Permanent surface water is absent over much of the country, with approximately 50% of the country classified as arid or semi-arid, and around half of South Africa’s water supply is used by its industrial agriculture sector. Average temperatures have increased over the past 60 years, along with the frequency and intensity of extreme heat. Furthermore, nearly one-fifth of the country’s extensive coastline has some form of development within 100 m of the shoreline, risking damage from storm surges and rising seas.2

The impacts of climate change are anticipated to severely hamper economic growth and inequality in South Africa with its energy- and carbon-intensive economy. The World Inequality Report 2022 paints a picture of extreme inequality in South Africa, with the top 10% earning more than 65% of total national income and the bottom 50% earning just 5.3% of the total national income.3 This inequality is apparent in economic and educational opportunities, living conditions, healthcare, and all other aspects of society, and will only be exacerbated by climate change’s disproportionate impact on the most vulnerable populations. Poor health also impacts one’s economic opportunities (e.g., through reduced ability to perform job functions), perpetuating cycles of poverty.

The Better Health Programme (BHP) is an FCDO-funded health systems strengthening programme, delivered in South Africa by Mott MacDonald. BHP South Africa aims to address the rising burden of non-communicable diseases (NCDs) such as cardiovascular diseases, diabetes, cancer and chronic respiratory diseases, and improve equitable access to safe and quality healthcare. Ultimately, a healthier population contributes to inclusive economic growth and poverty reduction

FCDO has signalled strategic priorities towards health systems strengthening and climate mitigation and resilience. Future investments in South Africa’s development can utilise solutions that create multi-sector benefits in both of these spheres. Through this report, we aim to identify synergies between human and planetary health that can provide mutually reinforcing cobenefits in FCDO’s priority areas.

1.1 Health, climate, and the environment

Health outcomes are intrinsically connected to and impacted by other sectors. An individual’s health is affected by wider determinants than those which the health sector encompasses, such as the environment, housing conditions, food, water and air quality, community, education, and lifestyle factors.

1 World Health Organization. Climate change https://www.who.int/health-topics/climate-change (Accessed 26 September 2022).

2 The World Bank Group (2021). Climate Risk Country Profile: South Africa https://climateknowledgeportal.worldbank.org/sites/default/files/country-profiles/15932WB_South%20Africa%20Country%20Profile-WEB.pdf

3 Chancel L, Piketty T, Saez E, et al. (2022). World Inequality Report 2022. World Inequality Lab; https://wir2022.wid.world/www-site/uploads/2022/03/0098-21_WIL_RIM_RAPPORT_A4.pdf

The effects of climate change on health in South Africa have been described extensively in the literature4,5 and include heat-related death and illnesses, malnutrition, mental ill-health, allergies, cardiovascular and renal diseases, vector-borne diseases, pesticide poisonings, birth complications, increased risk of violence, and hazard-specific injuries and deaths from extreme weather events such as floods (see Figure 1). Climate change can damage healthcare infrastructure or the health system’s ability to cope with increasing demand for services, with wildfires, floods, and storms inflicting costly damage to infrastructure. To continue to serve the population, it is essential that health systems adapt to accommodate increases in climaterelated morbidity, and that interventions are implemented across sectors to mitigate these impacts wherever possible.

Figure 1: Major health risks associated with climate change6

Environmental factors such as biodiversity loss, land use change, and deforestation also impact both climate change and health. Different ecosystem types in South Africa have important roles in climate and human health. For example, indigenous forests provide carbon sinks and sources for wild foods, inland wetlands absorb flood waters and clean pollutants from freshwater, and dunes protect settlements from coastal storms.7 Damage to and reduction of these ecosystems,

4 Chersich MF, Wright CY, Francois V, et al. (2018). Impacts of Climate Change on Health and Wellbeing in South Africa. International Journal of Environmental Research and Public Health; https://doi.org/10.3390/ijerph15091884

5 Godsmark CN, Irlam J, van der Merwe F, et al. (2018). Priority focus areas for a sub-national response to climate change and health: A South African provincial case study. Environment International; https://doi.org/10.1016/j.envint.2018.11.035

6 World Health Organization (2021) Quality criteria for health national adaptation plans https://apps.who.int/iris/handle/10665/339454

7 South African National Biodiversity Institute (2019). National Biodiversity Assessment 2018: The status of South Africa’s ecosystems and biodiversity, Synthesis Report. http://biodiversityadvisor.sanbi.org/planning-andassessment/national-biodiversity-assessment-nba-2018/

through land clearing for agricultural crops, human settlements, plantation forestry, or mining, can have consequences to climate change resilience. Furthermore, human encroachment into natural habitats (e.g. deforestation for farming or urbanisation) can bring humans into closer and more regular contact with wildlife, increasing the possibility of animal pathogens jumping to humans and causing new disease outbreaks.

A cross-sectoral approach addressing climate change and health can produce positive effects for both sectors, called co-benefits, thereby increasing the total benefits of a programme (a “winwin situation”). The myriad connections between health and climate, or human health and planetary health, provide a wide range of opportunities to implement cross-sectoral programmes with valuable co-benefits for the population of South Africa.

1.1.1 Mitigation and adaptation

Interventions to address climate change can be grouped into two major categories: mitigation and adaptation. In simplest terms, mitigation addresses the cause, whereas adaptation addresses the effects.

Climate change mitigation involves reducing greenhouse gas (GHG) emissions to slow the progression of global warming. Examples of mitigation strategies include transitioning from coal to renewable energy sources, minimising waste, and halting deforestation. The healthcare system itself has a significant carbon footprint; globally, the healthcare sector contributes 4.4% of global net emissions.8 This includes energy consumption (primarily the combustion of fossil fuels), transport, and product manufacture, use, and disposal, with supply chain comprising the largest share of healthcare-related emissions.

Climate change adaptation involves altering our systems and behaviours to factor in the realities of climate change, to moderate or avoid harm or exploit beneficial opportunities. Adaptation interventions aim to facilitate adjustment to the consequences of climate change, and include considering extreme weather events in infrastructure design, creating an early warning system for heat waves, and improving water security and drought readiness, among many others.

1.1.2 Prioritising climate change and health in government

Both South Africa and the UK have committed to building climate resilient health systems and implementing health adaptation strategies. FCDO’s position paper on health systems strengthening9 describes climate change as a critically important challenge to which health systems must adapt in order to remain “effective, efficient, and responsive to the needs of the population in an increasingly unstable and changing climate”. This paper also identifies strengthening multisectoral engagement as a priority for FCDO’s approach to health systems strengthening. The UK government strategy for international development10, published May 2022, promises to “take forward our work on climate change, nature and global health” as one of four focus areas for international development. This includes doubling the International Climate Finance (ICF) contribution to at least £11.6 billion between 2021-2026, demonstrating that climate change is among the highest international priorities of the UK government.

8 Health Care Without Harm, Arup (2019). Health Care’s Climate Footprint: How the Health Sector Contributes to the Global Climate Crisis and Opportunities for Action https://noharmglobal.org/sites/default/files/documents-files/5961/HealthCaresClimateFootprint_090619.pdf

9 Foreign, Commonwealth & Development Office (2021). Health Systems Strengthening for Global Health Security and Universal Health Coverage https://www.gov.uk/government/publications/health-systemsstrengthening-for-global-health-security-and-universal-health-coverage

10 Foreign, Commonwealth & Development Office (2022). The UK Government’s Strategy for International Development. https://www.gov.uk/government/publications/uk-governments-strategy-for-internationaldevelopment

South Africa has published a number of climate-related policies, plans, and strategies over the previous two decades, as detailed in the figure below from the Climate Finance Accelerator, demonstrating the South African government’s commitment to addressing the important issue of climate change and reducing GHG emissions.

As shown in Figure 2, an enabling policy framework exists in South Africa for climate change and health, including the National Climate Change and Health Adaptation Plan for the period of 2014-201912. The implementation, however, has encountered barriers in funding, human resources, and siloed structures that challenge intersectoral programmes.

Stakeholder discussions with the Environmental Directorate within the National Department of Health (NDoH) revealed some implementation issues with the National Climate Change and Health Adaptation Plan, though they reported that the NDoH is working well with the Department of Forestry, Fisheries and the Environment (DFFE) to make progress. The NDoH and DFFE are in the process of finalising the next term of this plan, and Heat Health Action Guidelines are also in the final stages of review, to be published imminently. Importantly, a legally binding Climate Change Bill is under development and has been released for public comment. Helen Yaxley, the FCDO Climate and Health Policy Lead, noted that South Africa did not commit to a net zero carbon health system at COP26, but that they may be interested in the future.

1.2 The health sector in South Africa

The health sector in South Africa is a complex environment with a substantial private healthcare market and a public health system that faces operational and funding challenges. The provision of health services is driven by the country’s quadruple burden of disease: high burdens of

11 Climate Finance Accelerator (2022). Climate Finance Landscape: South Africa Summary https://www.nbi.org.za/wp-content/uploads/2022/02/Climate-Finance-Accelerator-South-Africa-ClimateFinance-Landscape-Summary-Report.pdf

12 Department of Health (2014). National Climate Change and Health Adaptation Plan 2014-2019 https://www.unisdr.org/preventionweb/files/57216_nationalclimatechangeandhealthadapt.pdf

Figure 2: Timeline of climate-related policy developments in South Africa11

HIV/AIDS and tuberculosis; high maternal, neonatal and child mortality; high levels of violence and trauma; and the growing burden of NCDs.13

Any critical review of the health sector in South Africa reveals a stark inequity in the funding and provision of care between the private and public sectors, with the public sector responsible for the provision and funding of care to over 80% of the populous, but with an annual budget that is only marginally higher than the total spend in the private sector, which provides care to those covered by medical schemes and in well-resourced private facilities.

A common perception is therefore that the distribution of resources between the public and private health sectors is disproportionate to the populations they serve. For example, in 2016 the national average number of beds per 1000 population was 2.7 in the public sector and 4.68 in the private sector, despite the private sector covering only 15% of the population 14 This imbalance in the provision of care is one of the driving factors behind the Government’s drive for Universal Health Coverage (UHC) through the development of the National Health Insurance (NHI) Fund.

1.2.1 The private health sector

Private health cover is prohibitively expensive for many South Africans, with only 8.9 million beneficiaries out of a population of 59.6 million in 2020 (15%).15,16

Almost all private health care is funded wholly, or in part, by a third-party insurer; mostly by medical schemes, which are mutual insurers that provide indemnity-based cover for most areas of care, including hospitalisation, chronic care, consultations, prescribed medicine and ancillary services such as dentistry, optometry, radiology and pathology.

Provision of care in the private sector is largely categorised into three distinct categories: health professionals, health facilities, and support services

Health professionals in the private sector (GPs, specialists, allied health professionals and nurses) operate within a series of fixed frameworks, generally set out within regulation. GPs, specialists and allied health professionals each run privately-owned practices, either individually or as groups and provide services that are generally reimbursed either in cash or, more frequently, by medical schemes as an insured benefit.

Practitioners that operate within a hospital or clinic environment (mostly specialist physicians) may run their practices within a hospital, but they are not employed by the hospital and do not draw any salary for surgical or medical services provided within the hospital. Instead, any fees arising from work done within a hospital are usually appended to a patient’s hospital bill or is issued separately directly to the patient or insurer.

Nurses, however, are almost always employed by a health facility or occupational health provider and are reimbursed via a basic salary. There are cases of some private nursepractitioners running an independent practice, but these would be exceptional cases.

Private health facilities (hospitals, clinics, day surgeries, etc) in South Africa are heavily concentrated in terms of corporate ownership and provide services almost exclusively to insured

13 Department of Health (2017). National Health Insurance for South Africa: Towards Universal Health Coverage https://www.gov.za/sites/default/files/gcis_document/201707/40955gon627.pdf

14 Competition Commission South Africa (2019). Health Market Inquiry: Final Findings and Recommendations Report. https://www.compcom.co.za/wp-content/uploads/2020/01/Final-Findings-and-recommendationsreport-Health-Market-Inquiry.pdf

15 Council for Medical Schemes (2021). Council for Medical Schemes Annual Report 2020/21, Annexure Q https://www.medicalschemes.co.za/cms-annual-report-2020-21/

16 Department of Statistics South Africa (2020). 2020 Mid-year population estimates. https://www.statssa.gov.za/?p=13453

patients. The hospital market is dominated by the three stock exchange-listed hospital groups in the country

Netcare, Life Healthcare, and Mediclinic – which have “a combined market share of 83% of the national South African private facilities market in terms of number of beds and 90% in terms of total number of admissions”.17

Support services such as radiology and pathology are run as independent practices, either located within a hospital facility or in dedicated, specialised facilities of their own.

1.2.2 Challenges in the health sector

In a 2019 global survey18 measuring healthcare system efficiency (the ability to deliver maximum outcomes at the lowest cost), South Africa was ranked lowest among the 15 countries19 studied.

There are a number of key challenges facing both the private and public health sectors which impact on the sustainability and efficiency of a healthcare facility. The most predominant one is that of the availability of skilled human resources to staff the facilities. This is a particular risk to the development of new facilities, and it is important to plan carefully for the recruitment of facility staff at the beginning of the process.

Another challenge is that of healthcare inflation where lower prices don’t necessarily translate into increased revenue; when building a financial model, it is important to understand how to address a cost inflation cycle whilst remaining a sustainable business, with particular focus on how inflation might affect the affordability and effectiveness of the provision of care to patients.

In the private sector, the current private hospital model can lead to fragmented care as doctors and allied healthcare professionals provide services to patients within the hospitals but are financially independent, making co-ordination of care difficult especially with the lack of multidisciplinary teams. This model has resulted in medical professionals feeling pressure to admit patients for inpatient care and unnecessary treatment due to incentives, a sense of disconnectedness from hospital operations, and a lack of truly integrated patient care. This lack of integration also leads to hospital inefficiencies that ultimately results in increased costs.20

The recent Health Market Inquiry by the Competition Commission listed the concentration of supply in the private health sector as a major factor in spiralling costs and hyperinflation in the sector. One of their recommendations was new licenses be granted mostly to new entrants and for those faculties that fulfil the “fit-for-purpose” gap - i.e. small, specialised facilities offering targeted care in communities without carrying large head office overheads.

1.2.3 The National Health Insurance Bill

The National Health Insurance (NHI) Draft Bill, published August 2019,21 sets out a new model of health care service funding for public and private sectors, with the objective to provide universal access to quality health care for all South Africans. There will be one pool of

17 Competition Commission South Africa (2018). Health Market Inquiry: Provisional Findings and Recommendations Report http://www.compcom.co.za/wp-content/uploads/2018/07/Health-Market-Inquiry1.pdf

18 Philips (2019). Future Health Index 2019: Transforming healthcare experiences https://www.philips.com/aw/about/news/future-health-index/reports/2019/transforming-healthcare-experiences

19 Australia, Brazil, China, France, Germany, India, Italy, The Netherlands, Russia, Saudi Arabia, Singapore, South Africa, Poland, United Kingdom, United States of America

20 Competition Commission South Africa (2019). Health Market Inquiry: Final Findings and Recommendations Report. https://www.compcom.co.za/wp-content/uploads/2020/01/Final-Findings-and-recommendationsreport-Health-Market-Inquiry.pdf

21 Minister of Health (2019). National Health Insurance Bill https://www.gov.za/sites/default/files/gcis_document/201908/national-health-insurance-bill-b-11-2019.pdf

healthcare funding for private and public healthcare providers, in order to effectively meet the health care needs of the entire population and distribute resources accordingly.

The NHI will act as a compulsory national medical insurance for all people in the country governed by an authority to be created by legislation. It will make available a prescribed set of services to be accessed at accredited public and private healthcare providers, with no fees at the point of care. This accreditation will be a pre-requisite for all providers to receive payments for rendering services to NHI patients, and will focus on efficacy, safety, quality of care, and cost-effectiveness The introduction of the NHI policy in South Africa provides an opportunity for the private sector to contribute significantly to improving coverage of quality health services to all South Africans.

The NHI Draft Bill suggests that, at a hospital level, a case-mix system for the reimbursement for hospital and medical specialist services will be developed. The payment will be related to services delivered and would be determined through a system of case-mix activity adjusted payments (such as Diagnosis-Related Groups). These type of alternative reimbursement models should be considered and factored in when creating a financial model for a new facility.

2

Methodology

2.1 Literature review

First, a review of the published literature on health and climate change in South Africa was conducted. The results included academic papers, international guidance, as well as policy documents and strategies for different levels of government in South Africa, from national to city level. Literature on cross-sectoral funding strategies was also explored. Documents were assessed for key themes and topics to inform the stakeholder discussions.

Additional resources (including draft policy documents) were gathered through the stakeholder meetings and helped to inform this report.

Key documents assessed in this review can be found in Annex 1.

2.2 Stakeholder engagement

The review team met with a diverse range of stakeholders across institutional types (government, donors, academia, private sector) and across technical sector groups (public health, healthcare, climate, wastewater, supply chain) either in-person (in London, Pretoria, or Cape Town) or virtually. The range of stakeholders was selected to represent different perspectives on the broad issue of climate change and health. Stakeholders consulted at the beginning of the engagement process provided recommendations for additional key players to contact, and meetings were arranged with those who were responsive.

Meetings were structured as open-ended discussions to explore each stakeholder’s perspective on ongoing work, challenges, gaps, and opportunities in the intersectoral space of health with climate change and environment.

The stakeholder engagement process consisted of the following 14 meetings:

Liezl Laubscher Head of Design

Helen Chorlton Senior Manager, Cities and Urbanisation

Etienne Dreyer Partner

Stephanie Terwin ESG Workstream Lead: Cities and Urbanisation

Rob Botha Chief of Party, Global Health Supply Chain - Technical Assistance

James Irlam Senior Lecturer - Evidence Based Health Care & Environmental Health

Bono Nemukula Deputy Director: Environmental Health

Belinda Makhafola Deputy Director: Environmental Health

Zamokuhle Mntambo Assistant Director: Environmental Health

Laura Angelettidu Toit Chief Director of Infrastructure and Technical Management

Krish Vallabhjee Chief Director of Strategy

Table 1: Stakeholders engaged

3 Findings

The following are findings that emerged from both the literature review and the stakeholder discussions. Gaps that stakeholders highlighted in South Africa’s existing response were especially interesting as they may provide opportunities for funders to implement important intersectoral programmes to improve health and climate related outcomes.

3.1 Climate vulnerability and adaptation (V&A) assessment

For most countries, the starting point for thinking through the vast topic of ‘climate change and health’ is to conduct a vulnerability and adaptation assessment.22,23 This assessment process and subsequent outputs helps stakeholders to unpack and understand the impact of climate change on health. The goal of the V&A assessment is to identify priority health risks and adaptation options to manage those risks. The identified priorities, and the data and information collected to inform the V&A assessment, can be used to select a first set of indicators.24 25 Guidance also exists at the healthcare facility level.26 27 A key output of these assessments is to produce Health National Adaptation Plans (HNAPs), aligned with the realities of the communities affected.

South Africa published its own National Climate Change and Heath Adaptation Plan 2014-2019. It was reported to us, however, that implementation was limited. A new plan, coordinated by the Environmental Health team within the NDoH, is currently in the pipeline. We understand that this latest iteration now includes a V&A assessment and is undergoing final review, formatting and sign-off by the Minister of Health.

While it was reported to us by some that there was a comprehensive consultative process, we also heard that engagement was not as wide-ranging or cross-sectoral as some may have hoped. The COVID-19 pandemic, political unrest, more pressing emergencies of extreme weather events and energy shortages, also meant that attention of senior policymakers was often diverted elsewhere.

In anticipation of a the new HNAP being approved and published, there may still be a need for additional technical assistance, support for coordination, and support to access additional funding, including finance that has been set aside for climate-related initiatives.

3.2 Climate-resilient healthcare infrastructure

It is fair to say that, on the whole, new health infrastructure in South Africa is developed with what could only be called a cursory consideration for climate resilience. This holds mostly true

22 World Health Organization (2021). Country Support on Climate Change and Health - Visual Guide

https://www.who.int/publications/i/item/country-support-climate-change-health

23 World Health Organization (2021). Climate change and health: vulnerability and adaptation assessment

https://www.who.int/publications/i/item/9789240036383

24 World Health Organization (2021). Quality Criteria for Health National Adaptation Plans

https://www.who.int/publications/i/item/9789240018983

25 World Health Organization (2022). Measuring the climate resilience of health systems

https://apps.who.int/iris/handle/10665/354542

26 World Health Organization (2020). WHO guidance for climate resilient and environmentally sustainable health care facilities

https://www.who.int/publications/i/item/climate-resilient-and-environmentally-sustainablehealth-care-facilities

27 World Health Organization (2021). Checklists to assess vulnerabilities in health care facilities in the context of climate change

https://apps.who.int/iris/handle/10665/340656

for both the public and private sectors who face different challenges, but both are required to operate in environments with shortages of two mission-critical elements – water and power.

3.2.1 Extreme drought and health services

The delivery of quality healthcare is inextricably linked to the availability of fresh, running water in a health facility. In 2017 the Western Cape experienced its most severe drought on record, with a day zero event28 a very real possibility for large metro areas like the City of Cape Town, and the local government instituting strict water restrictions and monitoring policies to drive down household and business consumption. The Western Cape Department of Health (WCDoH) was facing a situation where radical change in water usage had to happen or facilities may face the prospect of closure.

In discussions with Laura Angeletti-du Toit (Chief Director of Infrastructure and Technical Management) and Krish Vallabhjee (Chief Director of Strategy) at the WCDoH, they noted that many staff in the health facilities needed the shock of imminent closure in order for staff to mobilise and take action. Once sufficiently motivated, it then became easier to instil practices and procedures to reduce overall consumption. Some of these interventions included:

• Process management to reduce required instances of hand scrubbing

• Sourcing of alternative water sources and development of osmosis treatment plant

• Strong collaboration and communication between health services and health infrastructure teams

• Visualisation and clear communication on usage goals and targets.

The challenge for the WCDoH has been to ensure the behaviours instilled during the drought continue to ensure such shortages are avoided in the future. Continued monitoring, visual tools and behavioural insights (BI) have been key in securing good habits, but systemic change is also needed to ensure there is a platform to address climate-related challenges proactively, as opposed to relying on crisis management.

In December 2021, the Western Cape Departmental Climate Change Forum was created and includes representatives from different sectors and universities to investigate and prioritise interventions that assist in developing the province’s climate change resilience.

3.2.2 Energy efficient facilities: the effect of load shedding

South Africa has been battling power shortages for over 12 years, with the last two years recording the greatest number of days of rolling power-cuts; this is termed “load shedding” and is a preventative measure implemented by the national power utility Eskom to stabilise the power grid when it is unable to generate sufficient power supply to meet the country’s demands (see Figure 3)

It is therefore unsurprising that the issue of load-shedding dominates any dialogue around energy efficiency, as it has become part and parcel of doing business in an environment where power is not only scarce, but costly as well. Furthermore, rising temperatures due to climate change are likely to increase peak load demands during hotter summers and reduce outputs of power generating stations due to limited cooling capacities.29

It is rare that any new health facility development is undertaken without the potential loss of power from the national grid in mind. Mitigating measures such as the installation of diesel

28 “Day zero” refers to the first day when municipal water supplies would be largely turned off and residents would likely need to queue for daily water rations.

29 The World Bank Group (2021). Climate Risk Country Profile: South Africa https://climateknowledgeportal.worldbank.org/sites/default/files/country-profiles/15932WB_South%20Africa%20Country%20Profile-WEB.pdf

generators and photovoltaic units with battery back-up have now become a standard requirement for uninterrupted operations across many facilities in the public sector and almost all hospitals in the private sector.

The use of back-up power solutions can be further supplemented with the installation of costeffective and energy-efficient electrical components, such as smart lighting and evaporative coolers, with smart metering to ensure areas of excessive power consumption can be identified and managed. The WCDoH noted that they had installed smart meters, donated by Microsoft, in a number of health facilities to monitor water and electricity usage.

*as of 11 July 2022

Figure 3: Annual days of loadshedding and gigawatt hours shed30

3.2.3 Environmental, Social and Governance

(ESG) considerations

While loadshedding has been a positive contributor to more households and businesses moving away from coal, back-up power solutions to ensure operations can continue uninterrupted are not informed by any overarching environmental regulation or mandatory ESG measures. It is also why the adoption of these interventions is often a “bare-minimum” exercise, as the installations need to meet strict cost/benefit thresholds, and long-term ESG return on investment is rarely considered.

This was explored in discussions with LTS Health, a laboratory design and capacity building company. Their clients initially like the idea of building to the maximum “green building” standards but tend to scale down the specifications to just power continuity once the upfront total cost is presented. Christian van Zyl, CEO of LTS Health, said that a compelling business case for the large-scale inclusion of energy-efficient components in a new build has yet to be developed. In his opinion, the solution has to be funding, as no one in Africa is going to undertake this extra work out of goodwill (although he noted the expertise already exists in South Africa) and governments are loathe to legislate it as they don’t want to create bottlenecks in critical areas such as health care delivery. Without legislation or funding, it is unlikely to ever become mainstream, and in most cases serious consideration to ESG goals is only considered if there is funding specifically earmarked for it.

30 Labuschagne H (2022). 2022 is already South Africa’s worst year for load-shedding with 170 more days to go. Mybroadband. https://mybroadband.co.za/news/energy/452132-2022-is-already-south-africas-worst-yearfor-load-shedding-with-170-more-days-to-go.html

This holds true most notably in facilities that are supported by private equity funds linked to foreign institutional investors or governments. Samaritan Healthcare, for example, are backed by the Summit Fund, which is comprised of several large European institutional investors, including British International Investment who have heavy mandates on the execution of their projects. Part of the fund’s mandate is to drive ESG measures within the greenfield projects they invest in. As such, Samaritan Healthcare have significant funding available to them for their new hospital builds to ensure there is “green-proofing” within the development, and the project’s performance is continuously monitored. Reporting to investors on ESG measures once the building is operational must be regular and linked to the project’s internal rate of return (IRR).

At the time of writing, there are no tax or other government incentives linked directly to the reduction in the use of fossil fuels, GHG emissions or the use of alternative power sources. It was noted by Samaritan that the lack of federal regulation on ESG measurables in South Africa is one of the factors that makes their projects executable, as additional requirements over-andabove the fund’s mandate would likely have a negative effect on the project’s IRR, and therefore would be unlikely to be funded in the first instance.

In our discussions with both LTS Health and Samaritan Healthcare, it was clear that infrastructure developers will only “go green” if there are earmarked funds or mandated ESG requirements. While government mandated ESG regulations are an important or even necessary step to encourage green building more widely, it may also disincentivise investment if strict requirements make funding less desirable. Therefore, these regulations need to be carefully aligned and utilise an investment case that shows compelling evidence for the longterm cost savings of green building. This investment case can be developed sooner in the absence of ESG regulations in order to stimulate progress in this space.

A thought piece by PWC South Africa from July 2022, in which representatives of eight healthcare subsectors were surveyed, found low priority given to environmental and climate related aspects of healthcare delivery 31 Its overall ESG finding is summarised as “The healthcare industry needs an increased focus on ESG initiatives and measurements”, further stating that “the impact of climate change and any mitigating actions taken by organisations rarely featured in the research.” Despite global ESG efforts in healthcare, 29% of the survey respondents reported having no ESG plan or focus for their organisation. Furthermore, there was a clear higher degree of importance given to the social and governance measures within the ESG plans, with the environment pillar being the only one to receive responses (6%) saying that it was not an important consideration

These results are unsurprising given the social and political environment of South Africa. It is currently recognised as the country with the highest level of income inequality, thus social development is a major priority, and corruption scandals are a common staple within political discourse, leading to calls for stronger governance frameworks across all sectors.

These findings corroborate the assertions of both LTS Health and Samaritan Health in terms of the low priority of the environmental and climate change-related aspects of healthcare delivery. Yogan Pillay, the Country Director of the Clinton Health Access Initiative (CHAI), said that there is still an unfair view of green infrastructure as “luxury”, but that there is increasing push towards “necessity”. In our discussion with James Irlam from the University of Cape Town, he noted that some engineers are championing a green agenda for hospitals, and more hospitals are being built with sustainable design principles in mind.

31 PwC South Africa (2022). South African Healthcare Reimagined: Industry Insights https://www.pwc.co.za/en/publications/south-african-healthcare-reimagined.html

3.2.4 Pandemic-resilient infrastructure

In addition to the climate considerations of energy and water, infrastructure will increasingly need to consider the risk of infectious disease transmission as climate change alters the landscape and interactions between humans, wildlife, and the environment, leading to increased opportunities for zoonotic diseases to infect humans. The frequency of pandemic events is predicted to increase in the coming decades, and the ‘slow-burn pandemic’ of antimicrobial resistance (AMR) threatens to render our arsenal of treatments ineffective. Similar to climate change, AMR is among the most pressing global threats, currently causing around 700,000 deaths annually. In our discussion with Gina Pocock from Waterlab, she raised the point that AMR is an important issue in South Africa particularly because of the number of immunocompromised people due to HIV/AIDS. Pandemic-resilient infrastructure will only become more important as the risk of new diseases emerging increases and effective treatments become more limited for an already at-risk population

Many infrastructure features that are impacted by climate change are also integral to infection prevention and control, such as water availability (clean drinking water, handwashing facilities), wastewater and solid waste management, and ventilation and air quality (mechanical ventilation, air filtration, air pollution). For example, vector-borne diseases such as malaria are predicted to increase as climate change could broaden the geographical distribution of the mosquito vector in South Africa, and therefore screens should be installed on openable windows to prevent mosquitoes and other insects from entering the building. Rodent-borne diseases are also an increasing concern with climate change, as they can be associated with flooding or damaged waste systems.

According to our stakeholder interviews, pandemic resilience features are not currently a consideration in building or retrofitting infrastructure. There is an opportunity to link some of these features with the increasing attention on climate resilience, as they are closely associated. Andrea Rother from University of Cape Town made the point that informal settlements and townships have drastically inadequate infrastructure to deal with health concerns including infection prevention and control.

3.3 Supply chain inefficiencies

A 2019 paper released by Health Care Without Harm in collaboration with Arup – “Health care’s climate footprint: How the health sector contributes to the global climate crisis and opportunities for action”32 – states that 71% of health care sector emissions come from the supply chain “through the production, transport, and disposal of goods and services, such as pharmaceuticals and other chemicals, food and agricultural products, medical devices, hospital equipment, and instruments”. Despite this, the supply chain is often not foremost in discussions relating to the impact of the health care sector on climate change.

Conversely, health care supply chains’ resilience has a high probability of being severely impacted as climate change makes extreme weather more frequent and more severe, disrupting logistics, infrastructure, transport, and suppliers. Extreme weather events will become increasingly likely to disrupt supply chains internationally and domestically, as was the case during the recent floods in KwaZulu Natal (KZN). It was warned that the escalating medicine supply crisis in KZN could affect the rest of the country as key distributors, wholesalers and pharmacies were impacted by the floods, as well as the health facilities that were damaged or destroyed. There is also a risk that increasing intensity or frequency of storms at sea can damage sensitive medical equipment during sea transport.

32 Karliner J, Slotterback S, Boyd R, Ashby B, and Steele K (2019). Health care’s climate footprint: How the health sector contributes to the global climate crisis and opportunities for action https://noharmglobal.org/sites/default/files/documents-files/5961/HealthCaresClimateFootprint_092319.pdf

During the COVID-19 pandemic, medical supply chains were drastically disrupted as manufacturers and distributors worldwide struggled with the impacts of the pandemic. International supply chains were especially vulnerable to delays due to border closures and new measures imposed by governments. This has sparked renewed calls for domestic manufacturing and procurement, which also has a positive effect on reducing GHGs. Laura Angeletti-du Toit and Krish Vallabhjee at the WCDoH said that much of South Africa’s medical equipment is procured from overseas, especially China, and the transport of that equipment has a large carbon footprint; they would like to push the agenda for more local procurement and manufacturing of medical equipment. Local production of pharmaceutical ingredients could also negate the need to import many active ingredients, as is currently the case in South Africa.

Rob Botha, Chief of Party, Global Health Supply Chain - Technical Assistance at Guidehouse, said that there are many opportunities to improve efficiency and reduce waste and GHG emissions in the medical supply chains in South Africa. A significant inefficiency highlighted is the separate, parallel medical supply chains for the public and private health care sectors, which have different warehouses and deliveries. More direct delivery from the manufacturer or distributor, rather than using central storage warehouses, would shorten the supply chain and allow consolidation of the distribution network by combining deliveries to public and private facilities at the same time. Combined deliveries would mean fewer vehicles on the roads and less packaging material, though the drawback is that there is no backup in the event of a security issue. In addition, the veterinary and agricultural antimicrobial supply chains are almost entirely separate from human health supply chains, leading to further avoidable emissions in transport

The supply chain is not limited to distribution, but also includes the selection of medicines and medical devices, as well as the contracting and contract management of suppliers for these products. To curtail their supply chain emissions, health systems are considering putting pressure on their suppliers to move toward more sustainable practices. The NDoH (and in future the proposed NHI Fund) has major purchasing power and therefore the ability to influence suppliers in addressing their climate footprint through the contracting processes. In the UK, the National Health Service (NHS) requires its larger suppliers to report their greenhouse gas emissions through a standardised framework, benchmark them, and manage them with a goal of getting to net zero.

With respect to the selection of medical supplies, South Africa is currently developing the policy and processes for the routine implementation of Health Technology Assessment (HTA), with the introduction of the new Health Technology Assessment Methods Guide (funded through the FCDO) and a technical working group being set up to develop a national HTA strategy. There is currently international focus on whether the net impact on GHG emissions should be included routinely in these assessments. GHG accounting is not a recent phenomenon and at least some of the preconditions for ensuring the integration of the impact of GHG emissions into HEE/HTA have been met33 , and in principle, it appears that an HTA process could incorporate the impacts of GHG emissions into the decision-making processes when selecting medicines and medical devices.

This is particularly relevant when looking at the selection of single use devices (SUDs). As Mr Botha pointed out, there is extensive debate about SUDs and the reuse thereof. The reuse of these devices is increasing globally with both cost effectiveness and concern for the environment often being cited as reasons. In selecting devices for use in the health sector,

33 Pekarsky, B.A.K. The Inclusion of Comparative Environmental Impact in Health Technology Assessment: Practical Barriers and Unintended Consequences. Appl Health Econ Health Policy 18, 597

599 (2020). https://doi.org/10.1007/s40258-020-00578-5

consideration needs to be given to whether the devices have been tested for reuse or, at the very least, an evaluation has been done of the increased risk to patients

Another factor to be taken into consideration during both the selection and contracting processes, is the size of packages procured. Health facilities routinely waste millions of rands worth of medicines each year because the vials or packages are large and regulations prohibit them from being split between patients. Again the UK leads by example in that health facilities specifically order right-sized packages and only stock the amount of a medicine they need, to avoid having expired stock that must be disposed of.

Similarly, waste management of packaging material is an opportunity for improvement, as health facilities accumulate enormous amounts of waste from medical packaging. Suppliers could be motivated to rethink the type and quantity of packaging used, in particular cold chain packaging which contains polyurethane. According to Mr Botha, the South African government has pushed for patient-ready packs which reduces packaging material and costs, but these do still have secondary packaging. There is already an initiative to do away with secondary packaging of ARVs which could be expanded to other medicines. During the COVID-19 pandemic, a new measure was implemented in which the distributor remained responsible for the packaging material and took it back after delivering the goods, in order to reduce waste at the facility level and open the possibility to reuse certain packaging.

Overall, the NDoH does not currently include impact on climate in their supply chain processes, and a business case could be developed to provide the evidence base for the inclusion of these factors. There is opportunity to learn from the NHS in terms of how they have implemented sustainable strategies across the supply chain.

3.4 Wastewater surveillance and treatment

Wastewater surveillance is the monitoring of infectious or chemical agents in untreated sewage and can be used to track community spread of pathogens, identify threats such as antimicrobial resistance or toxic chemicals, and provide data for decision-making. This method can sample a community without requiring any action from individuals, making it a valuable tool for monitoring local trends. Many informal settlements in South Africa do not have sewer systems, and much of the waste flows into rivers; for these communities, information can be gained from river sampling upstream and downstream of the location. Gina Pocock, a specialist consultant at Waterlab, reported that this data is currently underutilised in terms of informing policy and decision-making.

Droughts and flooding present significant problems with sewers and wastewater treatment plants (WWTP), which were not historically designed for these events. When there is a water shortage, the higher proportion of solids in sewers causes blockages, and WWTP do not function normally. In areas where climate change is predicted to cause droughts, sewers should be designed with a steeper slope and wider corners to deal with these low-flow conditions.

According to Gina Pocock, funding is a significant barrier to improvement of wastewater systems. Management of existing WWTPs falls under local governments, including the budgets,

Case study: During the COVID-19 pandemic, wastewater surveillance has been used to track community spread of the SARS-CoV-2 virus in South Africa. The South African Medical Research Council (SAMRC) first conducted a proof-of-concept study in 5 WWTP, followed by more funding and extension of the study to additional WWTP once the methods showed positive results. An online dashboard for SAMRC’s wastewater surveillance research programme shows trends in monitored sites. The National Institute for Communicable Diseases (NICD) also has a dashboard displaying SARS-CoV-2 wastewater levels across numerous monitoring sites from their network of 10 testing laboratories.

SAMRC: https://www.samrc.ac.za/wbe/

NICD: https://wastewater.nicd.ac.za/

but money is not ringfenced for this purpose. Often WWTPs are not prioritised for funding and receive insufficient money for proper upkeep of facilities A large new WWTP would be funded by the national treasury.

The vast majority of WWTP in South Africa are not compliant with nationally recognised standards. In 2021, the Department of Water and Sanitation (DWS) re-launched the Green Drop Certification programme to audit wastewater networks and treatment works across the country, long after the previous report was published in 2013. The 2022 report shows that the state of wastewater systems has declined in the past decade, with a larger number of systems identified as critical (334/850), and fewer – alarmingly few – awarded the certification (22/850).34 WWTP often exceeded their design capacity, had ineffective disinfection equipment, and were generally non-compliant in treating sewage and sludge. Mr Senzo Mchunu, the Minister for Water and Sanitation, wrote that “It is of great concern that there are so many systems with scores below 31% [in critical condition], indicating a dismal state of wastewater management, posing a risk to both environment and public health.” If not addressed, this problem will only get worse with climate change as extreme weather events put additional strain on wastewater systems, threatening an already limited water supply with further contamination.

3.5 Antimicrobial resistance (AMR)

South Africa’s current National Action Plan for AMR, 2018-2024, was written and signed by the respective then-ministers of the NDoH and the Department of Agriculture, Forestry and Fisheries (DAFF). This document aimed to provide the strategic framework under which South Africa would tackle AMR using a ‘One Health’ approach. It also recognised the importance of AMR to South Africa, given its large immunocompromised population.

However, implementing the plan remains a challenge and ministerial leadership has changed. In 2019, the DAFF merged with the Department of Environmental Affairs (DEA) and two new departments were created – the Department of Forestry, Fisheries and the Environment (DFFE) and the Department of Agriculture, Land Reform and Rural Development (DALRRD) – further adding to challenges in coordination and coherence across sectors. From our stakeholder interviews, it was unclear if the multi-disciplinary intersectoral Ministerial Advisory Committee on AMR functions as set out.

Currently there is a mechanism to combine AMR data from both public and private human health facilities, led by the National Department of Health together with the National Institute of Communicable Diseases (NICD), to show a full heat map of AMR across the country Progress is being made to pass legislation to regulate the use of antimicrobial agents across all sectors (including in animals and in agriculture).

One cross-sectoral area identified through our discussion with Gina Pocock from Waterlab was the role for wastewater and river sampling for AMR, for both resistant organisms as well as antimicrobial by-products. Given the sampling that already takes place for COVID-19 and other infectious agents, there could be cost efficiencies to expand the scope of what is sampled. As noted, however, efforts should be coordinated through the relevant committee, involving both NDoH and DFFE.

Rob Botha from Guidehouse also noted that pharmaceutical waste may be getting washed into rivers in certain circumstances, which is a risk for the development of antimicrobial resistance. Most pharmaceutical waste must now go through incineration rather than being put in landfill, and pharmaceutical waste disposal organisations should theoretically be compliant with 34 Department of Water and Sanitation (2022). Green Drop National Report 2022. https://wisa.org.za/2022/04/01/green-drop-2022-report-release/

environmental regulations. However, retail pharmacies do not have contracts with the pharmaceutical waste disposal organisations, and their waste disposal is unregulated.

3.6 One Health and zoonoses

Climate change will alter the interactions between humans, wildlife, and ecosystems. Up to 75% of new or emerging infectious diseases in people are zoonotic in origin, meaning that they ‘jumped species’ from other animals to humans 35 With warming temperatures, many animals will shift their geographic ranges in the coming decades, and thousands of new contacts between different mammal species that haven’t met before are predicted to occur.36

These new encounters may lead to diseases jumping between species, which poses a risk for new diseases then spilling over into humans. Encounters between humans and wildlife will continue to increase due to habitat destruction and fragmentation, deforestation, agriculture and livestock farming encroaching into wildlife habitats, and expanding urbanisation. The consumption of bushmeat poses an additional threat in South Africa as another route that zoonoses may be introduced to human populations.

Adopting a One Health approach, which unites human health, veterinary/animal health, and environmental expertise, for surveillance of new and emerging disease threats in wildlife, livestock, and humans, will be crucial to identifying and containing zoonotic disease threats. This surveillance effort will require decentralised laboratories for animal and human pathogens, and cross-sectoral collaboration between professionals in human, animal, and environmental health.

3.7 Violence and gender-based violence

Violence claims around 1.25 million lives each year globally, with South Africa among the top 10 countries in the world for the highest homicide rate.37 The crime statistics published in July 2022 show an increase of 11.5% in cases of homicide in South Africa as compared to the previous quarter, especially among women and children.38 The release of these statistics coincided with the release of a United Nations Report which concluded that climate change is likely to increase gender-based violence 39 The report noted substantial and mounting evidence of an increase in gender-based violence following climate-induced disasters, “especially in the light of the pandemic and the extreme weather events that have hit the Global South over the last three years.”

Evidence increasingly indicates that the risk of interpersonal violence increases with higher temperatures. A study using monthly data from 2001-2012 from all police wards in South Africa

35 United Nations Environment Programme (2020). Preventing the next pandemic - Zoonotic diseases and how to break the chain of transmission https://www.unep.org/resources/report/preventing-future-zoonotic-diseaseoutbreaks-protecting-environment-animals-and

36 Carlson CJ, Albery GF, Merow C, et al. (2022). Climate change increases cross-species viral transmission risk Nature; https://www.nature.com/articles/s41586-022-04788-w

37 World Health Organization (2020). Global Health Estimates 2019: Deaths by Cause, Age, Sex, by Country and by Region, 2000-2019 https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/gheleading-causes-of-death

38 South African Police Service (2022). Police Recorded Crime Statistics, Republic of South Africa: First Quarter of 2022/2023 Financial year (April and June 2022) https://www.saps.gov.za/services/downloads/April2022_23-presentation.pdf

39 United Nations Framework Convention on Climate Change: Subsidiary Body for Implementation (2022). Dimensions and examples of the gender-differentiated impacts of climate change, the role of women as agents of change and opportunities for women: Synthesis report by the secretariat https://unfccc.int/sites/default/files/resource/sbi2022_07.pdf

showed that there were higher levels of violent crimes during periods of higher temperature 40 An article in the South African Medical Journal concluded that “Countries like SA, which already have high levels of violence and a rapidly warming climate, may be particularly vulnerable to this underappreciated consequence of climate change. There may be a considerable increase in the number of cases of homicide and other forms of violence per year should the mean temperature rise by 1°C”.41

Although the SAMRC are instigating studies examining the impact of recent climate disasters in South Africa on gender-based violence, this aspect of climate change and health is relatively under-researched given the direct and severe effects on both the physical and mental health of individuals and communities.

3.8 Driving behaviour change

The need for profound behaviour change in addressing climate change is well established. Changes are needed not only on an individual level, but also in consumer action and as members of communities and organisations, and of high-emitting groups.42 The need for wide scale interventions that address multiple drivers of and barriers to behaviour change was one of the issues that repeatedly came to the fore in interviewing different stakeholders.

The WCDoH noted that, despite continued messaging through posters and strategically placed signage requesting staff across all facilities to rationalise their water usage during the severe drought, there was not a noticeable change in staff behaviour until individuals were directly impacted by water rationing in the homes in 2017.

What has proved to be difficult, according to the WCDoH, is the maintenance of staff habits of rationing water use after the drought was perceived to be over. They have had some success in utilising measurement and visual tools showing energy reduction across all health facilities. Staff can see how their facility compares to others in terms of saving on electricity, which helps to promote awareness and motivate staff to improve behaviours through a ‘gaming’ element in competing with other facilities.

Caradee Wright, the Senior Specialist Scientist leading the Climate Change and Human Health Research Programme at SAMRC, noted that in order for people to change their behaviour and use new solutions (such as new technologies), the local context must be taken into account from the beginning. Well-intentioned solutions may fail to take hold because of a lack of consultation with the local community before implementation about how the solution fits practically into their daily lives.

Moving forward, it will be increasingly critical to acknowledge the importance of behaviour change interventions in all climate mitigation and adaptation strategies.

40 Bruederle A, Peters J, Roberts G (2017) Weather and crime in South Africa. Ruhr Economic Papers No 739. https://econpapers.repec.org/paper/zbwrwirep/739.htm

41 Chersich MF, Swift CP, Edelstein I, Breetzke F, et al. (2019). Violence in hot weather: Will climate change exacerbate rates of violence in South Africa? South African Medical Journal, 109(7): 447-449. http://www.samj.org.za/index.php/samj/article/view/12655/0

42 Whitmarsh L, Poortinga W, Capstick S (2021). Behaviour change to address climate change. Current Opinion in Psychology, Vol 42: 76-81. https://doi.org/10.1016/j.copsyc.2021.04.002

4 Financing

The flow chart overleaf (Figure 4) is an expression of the South African climate finance landscape for the period of 2017-2018, published by the Climate Policy Initiative.43 The chart follows the flow of financing by source (public/private/blended) and traces it through to the sector where the funds are ultimately deployed. While green energy dominates the per-sector spend on climate finance, health is not represented in the chart and it is assumed that the health sector is represented in other defined sectors (e.g. the built environment, cross-sectoral).

Of note from the chart is the ratio of government spend vs private financing. Of the R63.1 billion total climate spend, only 19% is pure government spend. While government is represented in the blended financing options, these represent just under 8% of all climate financing. Private entities, including local commercial entities as well as NGOs, donors, and philanthropic organisations, are responsible for 56% of climate spend in South Africa.

An alternate mapping of the availability of climate finance through different categories of finance institutions was undertaken by the Climate Finance Accelerator and is reproduced in Table 2 below.44 It shows the availability of climate funding in the different stages of project initiation, project development, primary project funding, and secondary markets and refinancing. Approximately 85% of the identified funding support initiatives were directed towards advancedstage projects (e.g. providing operational support), and only 10% offered a degree of earlier stage funding such as pre-feasibility or feasibility studies. As expected, the analysis found a larger funding focus on mitigation rather than adaptation; mitigation is a more mature market for financing, whereas adaptation is lagging behind, and the financing options specifically for health and climate change are not well developed.

Key: Available Partially available

Source

Commercial banks

Institutional investors

Private equity

Corporate funders

Asset managers

Venture capital

Impact funds

Angel investors

Microfinance, credit unions

Government budget

Climate funds

Bilateral dev partners

Multilateral dev partners

NGOs, philanthropic orgs

Table 2: Availability of funding through different climate finance institutions

43 Cassim A, Radmore JV, Dinham N, McCallum S (2021). South African Climate Finance Landscape 2020 Climate Policy Initiative, Bertha Centre, GreenCape. https://www.climatepolicyinitiative.org/publication/southafrican-climate-finance-landscape-2020/

44 Climate Finance Accelerator (2022). Climate Finance Landscape: South Africa Summary https://www.nbi.org.za/wp-content/uploads/2022/02/Climate-Finance-Accelerator-South-Africa-ClimateFinance-Landscape-Summary-Report.pdf

Figure 4: The South African Climate Finance Landscape 2017-2018

4.1 Barriers and enablers

The Climate Finance Accelerator has identified barriers and enablers to accessing climate finance in South Africa through their analysis of the climate financing landscape.45 Key findings include the following:

Barriers

1. Misalignment between green economy vision, industrial policy, and structure of the financial system

2. Limited funding opportunities for early-stage projects, higher-risk projects, project development support, or progressing projects from development to commercialisation

3. Challenge to find funding options for mid-sized projects as the ticket size is either too small or too large

4. Limited focus on non-energy related low-carbon projects, i.e., outside the energy sector. Need diversification to fund a wider range of projects/interventions, including both mitigation and adaptation

5. High transaction costs for commercial finance of climate projects

6. Grant-based funding is constrained by unfavourable global economic conditions

7. Where dedicated financing facilities do exist, the criteria for accessing them may be unclear

8. Project sourcing and evaluation skills shortages in the financial sector

9. Lengthy development and approval of policies due to high levels of bureaucracy which impact investor certainty

10. Sophisticated tracking systems are required to keep track of stakeholders, funding channels, currencies, aggregation, co-financing, etc.

Enablers

1. High disbursement rate of committed climate finance (above global average)

2. Green economy policies are strong in South Africa

3. South Africa is prioritising decarbonisation of the electricity sector

4.2 Existing funding options

Funding options for climate and health initiatives in health in South Africa are limited, with a number of local stakeholders in both the public and private health sectors lamenting the lack of funds accessible for innovation and development in the adaptation space in particular. There are, however, existing climate finance initiatives for green infrastructure development and renewable energy projects that can be further explored in the health care sector, with energy representing the largest focus for climate finance investments in South Africa.

4.2.1 GCF, DBSA, CFF

The WHO is a delivery partner for the Green Climate Fund (GCF), from which South Africa qualifies for funding grants. The funding, however, is limited to $1 million USD per country per year with strict sub-limits for spend. Helen Yaxley, the FCDO Climate and Health policy lead, mentioned that the GCF has said there isn’t a lot of demand from the health sector, but also that she has heard that countries are having difficulties accessing the GCF.

The Development Bank of Southern Africa (DBSA), based in South Africa, is accredited by the GCF and “provides sustainable infrastructure project preparation, finance and implementation support in order to improve the population’s quality of life, accelerating the sustainable reduction

45 Climate Finance Accelerator (2022). Climate Finance Landscape: South Africa Summary https://www.nbi.org.za/wp-content/uploads/2022/02/Climate-Finance-Accelerator-South-Africa-ClimateFinance-Landscape-Summary-Report.pdf

of poverty and inequity, and promoting broad-based economic growth and regional economic integration”.46 The DBSA and the GCF co-finance the Climate Finance Facility (CFF), the first climate finance facility in Africa to use a “green bank” model, each committing matching investments of $55 million USD for a total of $110 million initial capital.

The CFF has the following 5 investment criteria:47

1. Low-carbon infrastructure, climate-related goals

2. Market transformation

3. Technically and economically feasible but unable to secure commercial financing

4. Demonstrate leverage and the ability to crowd in commercial investment

5. Address climate adaptation related goals particularly where they require water Green banks focus on facilitating private investment into climate-resilient infrastructure development, and thus the CFF is an important potential funder for the health care sector to investigate when planning new sustainable health care facilities.

4.2.2 Funding sources

Pfunzo Mudau from the British High Commission Pretoria noted some existing initiatives in South Africa for climate change mitigation through decarbonisation, though these do not explicitly involve the health sector. The Just Energy Transition Partnership aims to accelerate the decarbonisation of South Africa's economy with an initial commitment of $8.5 billion USD from the UK, France, Germany, the European Union and the United States, “through various mechanisms including grants, concessional loans and investments and risk sharing instruments, including to mobilise the private sector.”48 A key part of the UK’s technical assistance under this partnership is the UK PACT programme (Partnering for Accelerated Climate Transitions), jointly funded by FCDO and the Department for Business, Energy and Industrial Strategy, which has been running since 2020 to help South African companies implement government policy on emissions reductions and renewable energy uptake. Furthermore, the NAMA Facility project ‘Energy Efficiency in Public Buildings and Infrastructure Programme’ is utilising EUR 20 million funding49 to scale up decarbonisation and transformative energy efficiency efforts in public buildings.50

In regard to funding of climate change and health programmes, Yogan Pillay at CHAI is working on a programme which aims to understand the effects of extreme heat on maternal, neonatal and child health in townships, and co-produce solutions with communities. While a small pilot was funded by CHAI for a single township, additional funding was being sought from the Wellcome Trust and the UK National Institute for Health and Care Research to expand the programme. Mr Pillay mentioned that although the government adaptation strategy has not really been implemented, it is good for potential funders to see that there is an enabling policy

46 Green Climate Fund. Development Bank of Southern Africa https://www.greenclimate.fund/ae/dbsa (Accessed 4 October 2022)

47 Convergence, DBSA, Coalition for Green Capital (2019). Case study: Climate Finance Facility https://greenbanknetwork.org/wpcontent/uploads/2019/07/Convergence__Climate_Finance_Facility_Case_Study__2019.pdf

48 Gov.uk (2021). Press release, Joint Statement: International Just Energy Transition Partnership https://www.gov.uk/government/news/joint-statement-international-just-energy-transition-partnership

49 The NAMA Facility is funded by the German Federal Ministry for Economic Affairs and Climate Action (BMWK), UK Department for Business, Energy and Industrial Strategy (BEIS), Danish Ministry of Climate, Energy and Utilities (KEFM), Danish Ministry of Foreign Affairs (MFA), European Commission, and Children's Investment Fund Foundation (CIFF)

50 NAMA Facility. South Africa – Energy Efficiency in Public Buildings and Infrastructure Programme (EEPBIP) https://www.nama-facility.org/projects/south-africa-energy-efficiency-in-public-buildings-and-infrastructureprogramme-eepbip/ (Accessed 30 September 2022).

framework. James Irlam at University of Cape Town mentioned that universities fund much of the climate research in South Africa.

Private Equity Funds, such as the Summit fund, are a prominent feature in new health facility developments, particularly in the private sector. Some of these, especially if there is foreign government or institutional backing within the fund, will drive an ESG mandate as part of the overall project; however, the environmental spend is likely to be focussed almost entirely on the security of energy supply.

4.3 Funding models to be explored

4.3.1 Co-financing models

A 2019 study by the London School of Hygiene and Tropical Medicine examined the adoption of co-financing models in the health sector to explore the potential of leveraging non-direct health sector funding that may impact social and non-biological determinants of health.51 Co-financing is defined in the paper as “the joint financing of a programme or intervention by two or more budget holders that have different sectoral objectives to jointly achieve their separate goals more efficiently.”

The paper further explains that the benefit of co-financing would mean “increasing the resource envelope for health spending by pooling funds with non-health sectors and thus leveraging additional investment in health, as well as more efficient purchasing of health-producing interventions beyond the health system”.

An example of this would be a Ministry of Health and Ministry of Education each allocating a portion of their budget to a school nutrition programme. The programme has both positive health and learning outcomes and the pooling of funds would mean a wider rollout to more schools for longer periods.

The types of financial mechanisms for co-financing, taken directly from McGuire et al., are:

• Revenue collection

o Pooled funds: At least two budget holders make contributions to a single pool for spending on pre-agreed services or interventions. This can be done at various levels (national, regional, local) and accessed in different ways (i.e. grants or regular budgetary system).

o Aligned budgets: Budget holders align resources, identify own contributions towards pre-specified common objectives. Joint monitoring of spending and performance, but management remains separate.

o Structural integration: Full integration of cross-sector responsibilities, finances and resources under single management or a single organisation.

• Purchasing

o Joint or lead commissioning: Separate budget holders jointly identify a need and agree on a set of objectives, then commission services and track outcomes. The commissioning itself can be done through a joint authority board or through one agency taking commissioning responsibility.

o Cross-charging: The mechanism whereby a cross-sector financial penalty is incurred for the non-achievement of a pre-specified target. Cross-charging compensates sectors who incur an external cost from another sector’s poor performance.

51 McGuire F, Vijayasingham L, Vassall A, Small R, et al. (2019) Financing intersectoral action for health: a systematic review of co-financing models. Globalization and Health, Vol 15. https://doi.org/10.1186/s12992019-0513-7

o Transfer payments: Sectoral budget holders make service revenue or capital contributions to bodies in other sectors to support additional services or interventions in this other sector.

The study identified 81 successfully implemented co-financing cases, with only five cases not involving the health sector. Over half of the cases were collaborations between the health and social care sectors, with education the next most frequent co-financing partner. Most of the successful programmes were identified in high-income countries, with only four executed in Africa. All African cases were promotion-based cases (single-sector investment in another sector to leverage resources and influence factors that affect its own outcomes) involving the health and education sectors. Financing also involved international donors and development agencies such as the World Bank, United Nations Development Programme, Japanese International Cooperation Agency, and Bill & Melinda Gates Foundation. Each of those agencies and donors are well represented in South Africa and may be good partners in exploring potential climate and health programmes in the country going forward.

4.3.2 Blended finance: Social Impact Bonds

An increasing number of investors are looking for new ways of meaningfully deploying their capital. Since 2010, several companies, private investors, organisations and governments have worked together to form "Social Impact Bonds" (SIBs), which are a form of impact investment that uses the money of private investors to fund programmes that accomplish socially beneficial goals.

Also known as Pay-for-Success Bonds or Social Benefit Bonds, these are outcomes-based contracts whereby the government contracts a financial intermediary to sell bond-like instruments to investors in order to pay for the upfront costs of implementing or expanding programmes that have pre-defined priorities and outcomes. In this way, beneficial and innovative programmes can be implemented which would otherwise not have been able to secure funding from government due to the financial risk and upfront costs. SIBs do not yield a fixed rate of return like conventional bonds, but rather the return to investors is paid out based on government savings resulting from the success of the programme Repayments cover the initial investment plus a financial return, depending on the project’s measurable outcomes. The innovative model means that each stakeholder has financial exposure, thus spreading the risk, and each stakeholder wins if the programme is a success (government saves money and can claim a successful programme that benefits society, investors make a return on investment, programme beneficiaries benefit from the positive impacts of the interventions).52

Given that an SIB is an outcomes-based contract, the framework for defining success and assessing results is very important. Metrics should be straightforward and measurable. While this may seem simple in principle, each stakeholder is likely to have their own views and interests. For example, governments have a political incentive to claim success, yet also an interest to set the bar high to maximise value for money Investors must balance between setting a goal low enough to secure financial returns, but high enough to ensure the integrity of the programme. An independent advisor will usually help to negotiate reasonable returns and success metrics with both sides as well as the service providers.

Table 3 presents advantages and disadvantages of SIBs, adapted from the paper Financing Healthcare Services for the Poor 53

52 Impact Investment Shujog Limited (2014). Financing Healthcare Services for the Poor https://www.issuelab.org/resources/23598/23598.pdf

53 Impact Investment Shujog Limited (2014). Financing Healthcare Services for the Poor https://www.issuelab.org/resources/23598/23598.pdf

Advantages Disadvantages

• Transfers majority of financial risk from government to investors

• Transfers upfront programmatic costs from government to investors

• Strong emphasis on social impact with third-party evaluation of results

• Exposure to broad set of investors

• Creates multi-stakeholder solutions with public and private support

• Incentivises innovative solutions that meet social needs

• Limited to programmes with clear, measurable impact and targets, in which savings from the intervention will exceed the project cost and return to investors

• Relies on public sector buy-in

• The backing government must be creditworthy

• Data-intensive nature requires support from a mature M&E system

Table 3: Advantages and disadvantages of social impact bonds

In emerging markets, SIBs are also called Development Impact Bonds (DIBs). A DIB model for energy efficiency was published by the Center for Global Development and Social Finance, outlining the case study for this investment.54 A significant barrier to implementing energy efficiency measures in LMICs is the substantial upfront cost of these measures, whereas the savings accrue over a longer time period. This makes it an attractive case for DIBs, as the relevant environmental (e.g. lower energy usage, GHG reductions) and monetary (e.g. cost savings) outcomes can be easily measured with existing technologies. The case study notes that “since this model can be financially sustainable, the gains to the DIB investors can be recycled into other investments, thereby increasing the impact”.

4.3.3 Project bonds for infrastructure

The need for building new health and energy infrastructure and updating existing infrastructure necessitates a large amount of funding. Stricter regulations on banks and their lending requirements after the financial crisis of 2007-2009 means that large infrastructure and energy projects can no longer be funded by traditional bank debt alone Project bonds are an alternative avenue to finance infrastructure projects, by offering a long-term and fixed-rate investment opportunity to finance a specific project where the return is paid from the revenue of the project. This type of funding model is attractive in the energy sector because of the likelihood of stable, long-term return on investment once the project is built and operational. There is, however, a level of risk inherent in construction of new infrastructure that some funders will not be comfortable with.

The first infrastructure project bond in South Africa was listed on the Johannesburg Stock Exchange in 2013 to finance a solar power project located in Touwsrivier in the Western Cape. The bond offers repayment terms of 11% over a 15-year period, allowing for the principal and interest to be repaid at the same time.55 Since reaching its commercial operating date in December 2014, the project is now one of the largest operating concentrated photovoltaic facilities in the world, and the electricity generated by the plant feeds into the national grid

54 Center for Global Development, Social Finance (2013). Investing in Social Outcomes: Development Impact Bonds. The Report of the Development Impact Bond Working Group. https://www.cgdev.org/sites/default/files/investing-in-social-outcomes-development-impact-bonds.pdf

55 Deloitte. Project Bonds: An alternative source of financing infrastructure projects https://www2.deloitte.com/za/en/pages/finance/articles/project-bonds-an-alternative-to-financinginfrastructure-projects.html (Accessed 30 September 2022)

operated by Eskom.56 Its success paves the road for more project bonds to finance infrastructure development in South Africa.

56 Theron A (2020). juwi awarded Touwsrivier CPV Solar Project O&M contract. ESI Africa. https://www.esiafrica.com/solar/juwi-awarded-touwsrivier-cpv-solar-project-om-contract/ (Accessed 30 September 2022).

5 Other considerations

5.1 Alignment with NHI agenda

It is clear that climate change will exacerbate the pressure felt by already under-resourced and struggling health facilities. Climate change will very likely increase the burden of respiratory diseases, water- and vector-borne infectious diseases, heat-related illness, mental illness, disaster-related injuries as well as incidence of violence. Climate change will also heavily impact health service infrastructure, working environments and conditions, and may even affect the way in which people access health services. It is therefore important that the implementation of a health policy as wide-reaching as the proposed National Health Insurance will need to factor in the impact of climate change on the health services.

Although the NHI White Paper published in 2017 referred to climate change, it was purely in the context of the proposal of using carbon tax (as part of South Africa’s efforts to mitigate climate change) to help fund the NHI.57 The NHI Bill published in 2019 does not mention climate change at all.

Preparations for the implementation of NHI are currently underway and it is critical that considerations for the impacts of climate change, such as increases in climate-sensitive conditions, are factored into the package of services. The focus of NHI on primary health care is significant in that the majority of climate-related illnesses will be treated in primary care settings Furthermore, a focus on community-based primary health care and a move away from hospitalcentric care is an opportunity to encourage shorter supply chains that would contribute to the reduction of health sector GHG emissions.

The proposed NHI information system will also provide a unique opportunity for tracking and monitoring disease trends and feeding this information back into the services offered in different areas. This will also enable a faster and more targeted response to changing disease patterns and outbreaks.

Crucial to the NDoH’s responsibility to mitigate and adapt to climate change is funding. Given that the NHI is predominantly a funding mechanism designed to purchase services on behalf of the people of South Africa, consideration must be given to how funds could be channelled to include the health impacts of climate change, and where the responsibility lies for ensuring the health system is resilient. For example, as the new entity responsible for the licensing of new health facilities, the NHI Fund could consider the implementation of a set of standard “green building” criteria for any new-build health facility.

However, the health sector cannot do this alone and needs to work closely with different sectors, such as environmental affairs, power and water sectors, housing and settlements, education, and trade and industry.

GIZ, the German agency for international cooperation, has recently issued an RFP (September 2022) for the development of a health sector climate change adaptation strategy in collaboration with the NDoH and the DFFE. It is through creating partnerships at this level that the NDoH and the NHI Fund will be better equipped to manage the impacts of climate change.

57 National Department of Health (2017). National Health Insurance for South Africa: Towards Universal Health Coverage https://serve.mg.co.za/content/documents/2017/06/29/whitepaper-nhi-2017compressed.pdf

5.2 Coordination and information sharing

A common theme throughout stakeholder discussions was the need for greater coordination between different government departments, different levels of government, and private and public sectors. It was reported by multiple stakeholders that, as is the case in many countries, health and climate are largely addressed in siloes, with few formal coordination mechanisms between different national departments or provincial, district, and city governments on the broad intersectoral issue of climate change and health. In some cases, political tensions and lack of agreement across government departments (e.g. energy and environment) may be a barrier to cooperation. Building synergistic, integrated systems is complex and takes time but can greatly reduce inefficiencies.

The NDoH and DFFE are already coordinating on climate change and health, as DFFE holds the funding for climate change and health programmes and so NDoH must engage with them in order to secure funding for projects. The WCDoH also reported ongoing collaboration on a provincial level for interdepartmental priorities such as public safety.

At the national level, the Presidential Climate Commission was set up to create an independent multi-stakeholder governance structure for climate policy, to facilitate a “just and equitable transition towards a low-emissions and climate-resilient economy”.58 Unfortunately, the NDoH is not represented among the appointed commissioners, despite 10 other government departments having their ministers on the commission.

Stakeholders in academia suggested that there may be many more projects involving climate change than they are aware of, as this is increasingly a hot topic for funding, but there is no central database or repository of projects so it is difficult to know the full picture of what is happening in the field. It was suggested both by stakeholders and in the literature that a database of adaptation and mitigation interventions and projects would be a helpful resource for collaboration; in other words, an information sharing platform for all climate and health projects in the country.

5.3 Piloting interventions before scaling up

In stakeholder discussions, Yogan Pillay of CHAI and Caradee Wright of SAMRC emphasised the importance of doing small-scale pilot projects prior to investing in implementation of interventions at scale. Small pilot projects are easier to fund, provide a proof-of-concept for what works, and generate evidence for then securing additional funding to scale up interventions. With a more manageable small-scale project, close monitoring of progress can identify any unanticipated challenges which can then be solved before expanding the programme. It also provides an opportunity for community engagement at a local level, to co-create solutions that are more likely to be successful in the local context.

5.4 NHS Consortium for Global Health

The UK’s National Health Service (NHS) is a world-class and globally renowned brand for delivering quality UHC. Initially established as a strategic partner to the BHP, the NHS Consortium for Global Health (NHSC) continues to look for opportunities to expand partnerships around the world. Crucially, engagement is simplified through a central Secretariat.59

Currently, the NHSC has access to over 200+ subject matter experts across UK national health bodies through the Consortium Technical Advisory Service. In South Africa, the UK’s Care Quality Commission has been supporting South Africa’s Office of Health Standards Compliance

58 Presidential Climate Commission. https://www.climatecommission.org.za/ (Accessed 30 May 2022).

59 The NHSC Secretariat is currently housed in Health Education England (HEE). Kevin Miles (kevin.miles@hee.nhs.uk) is the Senior Lead and focal point for engagement.

to revise their national hospital and primary care inspection strategy, and England’s Parliamentary and Health Service Ombudsman has agreed to enter a twinning partnership with South Africa’s Office of the Health Ombud

Among their services, the NHSC can provide inputs through the UK Health Security Agency to prevent and manage disease outbreaks and AMR, build resilience to humanitarian crises and climate change, and develop One Health approaches to building health system resilience. These services align with the UK Government’s recent International Development Strategy that highlights climate, nature and health as priorities going forwards.

NHS England, through its Greener NHS programme,60 can also engage in national dialogue for Net Zero health services. Their flagship report “Delivering a ‘Net Zero’ National Health Service”61 was praised by WHO and featured as a case study in WHO’s COP26 Special Report on Climate Change and Health.62

60 Greener NHS programme: https://www.england.nhs.uk/greenernhs/

61 NHS (2020). Delivering a ‘Net Zero’ National Health Service. https://www.england.nhs.uk/greenernhs/publication/delivering-a-net-zero-national-health-service/

62 World Health Organization (2021). COP26 special report on climate change and health: the health argument for climate action. https://www.who.int/publications/i/item/9789240036727

6 Conclusion

During our extensive stakeholder discussions and literature research, we identified major challenges, current initiatives, and opportunities for further exploration in the intersectoral climate change and health space in South Africa.

6.1 Current climate and health initiatives

There are several areas in the climate change and health sphere that are currently being tackled with some success in South Africa Importantly, a series of policy documents at multiple levels of government from national (e.g. National Climate Change and Health Adaptation Plan) to city (e.g. City of Cape Town Climate Change Action Plan) establish an enabling policy framework for action.

6.1.1 The move to renewable energy

Funding initiatives for decarbonisation exist in South Africa, such as the CFF, Just Energy Transition Partnership and NAMA Facility. Furthermore, the slow but steady proliferation of photovoltaic energy backup systems, both at a commercial and household level, will gradually lessen South Africa’s reliance on coal. Diesel generators are currently a more accessible and popular option for power-backup solutions, and more work is needed on the affordability of renewable power sources.

The mining of coal is a major economic contributor, however, and much work needs to be done around the long-term mitigation of potential job losses and export volumes should mining activities be negatively impacted.

6.1.2 Climate change and health indicators

The NDoH and DFFE are working together on establishing national climate change and health indicators for South Africa. As a baseline, they have taken the relevant DHIS indicators, but SAMRC is pushing for additional bespoke indicators that would be more useful to the South African context. This may be an opportunity for a consultant to help develop these indicators further, and NDoH stakeholders reported that they are putting together terms of reference to procure a service provider for the indicators project but that additional funding is needed.

6.1.3 Research programmes and initiatives

Direct climate and health initiatives, such as the small consortium (including SAMRC, University of Pretoria, and CHAI, as reported by Yogan Pillay) to address the effect of extreme heat on maternal and child health, are critically important yet underfunded. Additional studies mentioned during stakeholder discussions included a University of Leicester study examining the uses for low-cost air quality sensors in Soweto and Agincourt, a SAMRC-funded study looking at the impacts of climate change on interpersonal and gender-based violence in Limpopo province, and an Eskom-funded cohort study to research air pollution (this study was unfortunately halted by the COVID-19 pandemic). Additional funding for these research and implementation programmes is being sought via international donor funders and this could be a potential area for FCDO involvement going forward.

6.1.4 Sustainable healthcare education

James Irlam from the University of Cape Town is working on an initiative to update the curriculum in medical schools to include climate change. This initiative aims to integrate themes of environmental stewardship and sustainability as related to the health care sector in the

curricula of allied health scientists, clinicians, and all other medical professionals. Within the South African Association of Health Education, a special interest group already exists for education for sustainable healthcare.

6.1.5 Driving behaviour change and habit creation

The importance of driving specific behaviours and creating habits that lead to more efficient use of resources has been a key part of the Western Cape’s success in ensuring continued water security in their health facilities. Transforming crisis-era practices into long-term sustained habits across a large employee base has been a focus of the WCDoH’s central hospital management, who are now planning to roll out these initiatives into the wider health sector.

Discovery, the largest medical insurer in South Africa, reported that they are currently working on a project to incentivise behaviour change around reducing members’ personal carbon footprints and encouraging green behaviours. It is in the early phase of research and development, as their conventional rewards/incentives model (in which cost savings from improved health will come back as incentives) does not work for climate-related behaviour change, because reducing emissions is a population-level benefit.

6.2 The challenges of addressing climate change and health in South Africa

Addressing the issue of climate and health in the South African context is complex and multidimensional. Recent extreme climate events such as the drought in the Western Cape and devastating floods in KwaZulu-Natal have brought the issue of climate change into the forefront of public consciousness, but mitigative and adaptive actions are constantly pitted against the country’s socio-economic reality.

6.2.1 Socio-economic landscape

According to the World Bank’s statistical measure of income inequality, South Africa has the highest level of income inequality in the world63, supplemented by an unemployment rate of 34.5%64. This extreme inequality is accompanied by the side-effects of widespread poverty: high crime rates, food insecurity, unequal access to basic services such as running water, safe housing, and health care, and under-resourced schools. This is compounded by the everpresent spectre of loadshedding – rolling power cuts to alleviate the national power grid that constantly struggles to generate sufficient energy supply to meet demand. In this socioeconomic landscape, it is especially challenging to address issues of climate change mitigation without first addressing the basic needs of the population which are understandably perceived as much more urgent.

6.2.2 Energy supply

Almost all engagements on climate-related topics in South Africa prioritise efficiency gains in energy utilisation, which is a necessity due to loadshedding. Large health infrastructure such as hospitals are required to have back-up energy provisions to ensure continuation of services during the power cuts, and the facility’s electrical infrastructure must be optimised to ensure maximum running time from the back-up system, be it photovoltaic or a diesel generator. The reality of an unreliable energy supply is ever-present in infrastructure planning in South Africa.

63 The World Bank. Gini index https://data.worldbank.org/indicator/SI.POV.GINI (Accessed 30 September 2022).

64 Department of Statistics South Africa (2022). Key findings: P0211 - Quarterly Labour Force Survey (QLFS), 1st Quarter 2022 https://www.statssa.gov.za/?page_id=1856&PPN=P0211&SCH=73289

6.2.3 Lack of government-backed incentives

Currently, there are no government-backed incentives for climate-friendly (e.g. decarbonisation, clean energy) initiatives at either an individual or corporate level in South Africa, making the business case for widespread climate initiatives difficult when faced with the challenges outlined above. As such, financing options for climate change development are limited, with a large proportion coming from foreign donors or equity firms with strict ESG targets. Private industry still needs to be convinced of the medium-to-long-term financial benefits (both direct and indirect) of investing in the environmental aspects of their ESG deliverables.

6.2.4 Breaking down siloes

There is not yet a well-established coordination structure between climate change and health between levels of government in South Africa, other than the established links between NDoH and DFFE at the national level. Encouragingly, stakeholders at the NDoH reported that a climate change and health steering committee will oversee implementation of the new Climate Change and Health Adaptation Plan. They also reported that various cross-sectoral collaboration mechanisms already exist in the country, though their usage can be improved. The Presidential Climate Commission, set up to create an independent multi-stakeholder governance structure for climate policy, did not include a representative from the NDoH. Ideally, health should always have a seat at the table for climate discussions.

6.3 Opportunities for further exploration

Although there are seemingly endless options for intersectoral climate change and health projects in South Africa, the following ideas were the most prominent in stakeholder discussions and can lay the groundwork for future innovation and progress.

6.3.1 Green investment case for health care infrastructure

Throughout our stakeholder interviews, it was clear that a compelling business case for “green” infrastructure has yet to be developed but is sorely needed in South Africa. Because of the upfront cost of investing in more energy-efficient elements of a new build, these are usually scrapped to focus on the more pressing immediate needs such as reliable backup power for loadshedding, without considering long-term cost savings.

Development of a green investment case for health care infrastructure is an important priority if new builds are to consider this in the planning stages in the absence of strict ESG requirements. One possibility is that business cases can be developed separately for the private and public sectors, the private sector being more focussed on return on investment and operational efficiencies, and the public sector more focussed on securing the future with renewable energy. An evidence base could be established by working with current foreign equity funds investing in health care projects in South Africa that do have strict ESG requirements, to understand the cost/benefit thresholds of the environmental spend. Similarly, an investment case can be made for climate-resilient health care infrastructure focusing on adaptation rather than mitigation, which will be essential as extreme weather becomes more frequent. Mott MacDonald has developed an approach to enable asset owners and investors to understand the climate risks on infrastructure projects and assess their resilience, called the Physical Climate Risk Assessment Methodology.65 This has been outlined in a publication by the Coalition for Climate Resilient Investment, and demonstrates the positive returns from investment in climate resilience

65 Coalition for Climate Resilient Investment (2022). CCRI and Mott MacDonald launch a powerful new tool that rewards investment in climate resilience. https://resilientinvestment.org/ccri-and-mott-macdonald-launch-apowerful-new-tool-that-rewards-investment-in-climate-resilience/

6.3.2 Project information sharing platform

There is currently no way to identify all of the ongoing projects for climate change and health in South Africa. Caradee Wright from SAMRC noted that there may be many more adaptation projects than we are aware of, but it is difficult to know since there is no centralised database and many projects may not have an internet presence. An online platform to log and share information about all projects in this space would improve coordination and knowledge-sharing, reduce duplication of efforts, and provide visibility for under-resourced projects that may benefit from collaboration. The platform could also include available funding opportunities and guidance on how to access them (see below).

6.3.3 Facilitate access to funding mechanisms

It was reported that the GCF and funds promised at COP26 are not easily accessible. Supporting climate and health initiatives in South Africa to apply for this funding would unlock additional financing options for important projects that can have wide-reaching positive impacts, such as the improvement of national climate change and health indicators. This could include, for example, a reference document on how to access available funds for ESG in the health sector (including Private Equity funding), investigating potential co-financing partners for crosssectoral projects, or helping governments and partners to develop project proposals that would align well with the GCF.

6.3.4 Support to develop ESG and climate-resilience standards at the national level

Health infrastructure must adapt to the realities of climate change in order to deliver services efficiently. If climate-proofing is not part of new health infrastructure such as health care facilities, they will face significant problems in the future with the increase in extreme weather events.

On the mitigation side, a policy gap exists for ESG requirements at the NDoH level for all new health facilities built in South Africa. Provincial departments of health have different ESG standards for new-build health infrastructure which are often not consistent. National standardised requirements would reduce confusion and ensure consistency across the country.

For both the mitigation and adaptation aspects of new build health facilities, resource constraints must be factored into any new requirements, in order to ensure that measures are realistic.

6.3.5 Support to improve efficiency of medical supply chains

Considering that the largest share of health care sector emissions comes from the supply chain, improving the efficiency of medical supply chains has the potential to significantly reduce GHG emissions. There are multiple avenues that can be explored, such as consolidation of public and private medical supply chains, increasing direct deliveries from the manufacturer or distributor to health facilities, improving capacity for demand planning and demand forecasting, innovations in packaging waste management, or consolidation of veterinary, agricultural, and human antimicrobial supply chains.

6.3.6 Human resource capacity building for environmental health

Ensuring that there are sufficient human resources to implement interventions and that they are fully capacitated to carry out their work is crucial for the success of any strategy. Stakeholders at NDoH reported that there are insufficient human resources to fully implement climate change and health policies, though strategies are developed with this constraint in mind.

Environmental Health Practitioners (EHPs) are the main implementers for environmental health issues at the community level and are a potential key resource for helping communities adapt to

climate change66; however, EHPs already have numerous duties and there needs to be due consideration for how to share or appropriately designate additional responsibilities. For example, during the COVID-19 pandemic the EHPs took on additional responsibilities for contact tracing, investigation of suspected cases, monitoring of the management of human remains and high-risk healthcare waste, and health education.67 Recruitment and training of additional EHPs could help to ease the burden on existing practitioners and broaden the package of services delivered at the community level.

Furthermore, Andrea Rother from the University of Cape Town noted that data is not routinely collected from EHPs to feed back into policy making, and this could be a potential resource for learning how well programmes are running after implementation or what could be improved.

6.3.7 Support for expansion of climate and health research projects

Many research projects in the climate change and health sphere may benefit from support such as technical assistance and/or monitoring and evaluation. Small pilot projects, once shown to be successful, may require support for expansion to additional locations or scaling up the measurables and impact parameters. Research is crucial for providing evidence that can be used in policy and decision-making in South Africa, and so it is important to ensure that relevant research projects are capacitated to generate useful data. This is not only limited to academia but can also include, for example, support to the environmental team within NDoH for implementation pilots.

66 Shezi B, Mathee A, Siziba W, Street RA, et al. (2019). Environmental health practitioners potentially play a key role in helping communities adapt to climate change. BMC Public Health, Vol 19. https://doi.org/10.1186/s12889-018-6378-5

67 Mbele S (2022). COVID-19 Contact Tracking and Tracing in the City of Johannesburg Metropolitan Municipality. Environmental Health Practitioners News: Newsletter for the Professional Board for Environmental Health Practitioners.

https://www.hpcsa.co.za/Uploads/EHP_2019/Newsletter/EHP_Board_newsletter_15092022.pdf

Annexes

Annex 1: Key documents reviewed

The following key documents provided the foundation for our investigation into climate change and health in South Africa. Additional documents are included in footnotes throughout the report.

Chersich MF, Wright CY, Francois V, et al. (2018). Impacts of Climate Change on Health and Wellbeing in South Africa. International Journal of Environmental Research and Public Health; https://doi.org/10.3390/ijerph15091884

City of Cape Town (2021). City of Cape Town Climate Change Action Plan

https://www.capetown.gov.za/Work%20and%20business/Greener-business/Cape-Townsgreen-future/lets-act-against-climate-change

Climate Finance Accelerator (2022). Climate Finance Landscape: South Africa Summary

https://www.nbi.org.za/wp-content/uploads/2022/02/Climate-Finance-Accelerator-South-AfricaClimate-Finance-Landscape-Summary-Report.pdf

Department of Environment, Forestry and Fisheries (2019). National Climate Change Adaptation Strategy: Version UE10.

https://www.dffe.gov.za/sites/default/files/docs/nationalclimatechange_adaptationstrategy_ue10 november2019.pdf

Department of Health (2014). National Climate Change and Health Adaptation Plan 2014-2019

https://www.unisdr.org/preventionweb/files/57216_nationalclimatechangeandhealthadapt.pdf

Foreign, Commonwealth & Development Office (2021). Health Systems Strengthening for Global Health Security and Universal Health Coverage.

https://www.gov.uk/government/publications/health-systems-strengthening-for-global-healthsecurity-and-universal-health-coverage

Foreign, Commonwealth & Development Office (2022). The UK Government’s Strategy for International Development. https://www.gov.uk/government/publications/uk-governmentsstrategy-for-international-development

Godsmark CN, Irlam J, van der Merwe F, et al. (2018). Priority focus areas for a sub-national response to climate change and health: A South African provincial case study. Environment International; https://doi.org/10.1016/j.envint.2018.11.035

McGuire F, Vijayasingham L, Vassall A, Small R, et al. (2019) Financing intersectoral action for health: a systematic review of co-financing models. Globalization and Health, Vol 15.

https://doi.org/10.1186/s12992-019-0513-7

Rother HA, Godsmark CN, Deignan C (2018). Literature Review Assessing Climate Change

Risks and Impacts on the Health Sector in the Western Cape, South Africa. University of Cape Town Division of Environmental Health;

https://www.westerncape.gov.za/eadp/files/atoms/files/Health%20%26%20CC%20Literature%2 0Review%2020180702.pdf

The World Bank Group (2021). Climate Risk Country Profile: South Africa

https://climateknowledgeportal.worldbank.org/sites/default/files/country-profiles/15932WB_South%20Africa%20Country%20Profile-WEB.pdf

World Health Organization (2020). WHO guidance for climate resilient and environmentally sustainable health care facilities https://www.who.int/publications/i/item/climate-resilient-andenvironmentally-sustainable-health-care-facilities

World Health Organization (2021). Climate change and health: vulnerability and adaptation assessment https://www.who.int/publications/i/item/9789240036383

World Health Organization (2021). Country Support on Climate Change and Health - Visual Guide https://www.who.int/publications/i/item/country-support-climate-change-health

World Health Organization (2021). Quality Criteria for Health National Adaptation Plans

https://www.who.int/publications/i/item/9789240018983

World Health Organization (2022). Measuring the climate resilience of health systems

https://apps.who.int/iris/handle/10665/354542