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

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