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

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.

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

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

Department of Health (2014). National Climate Change and Health Adaptation Plan 2014-2019 https://www.unisdr.org/preventionweb/files/57216_nationalclimatechangeandhealthadapt.pdf https://www.gov.uk/government/publications/health-systems-strengthening-for-global-healthsecurity-and-universal-health-coverage

Foreign, Commonwealth & Development Office (2021). Health Systems Strengthening for Global Health Security 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 https://doi.org/10.1186/s12992-019-0513-7

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.

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