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 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

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.

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