1. Chapter 18: Regional Action Plan for South-East Asia
Protecting our Health from Professionals Climate Change: a Training Course for Public Health
Chapter 18: Regional Action Plan for South-East Asia

2. Outline South-East Asia (SEA) countries most vulnerable
Regional consensus on need for climate action
National climate action plans
Conclusions

3. Map of the South-East Asia Region
The South-East Asia (SEA) Region consists of eleven countries: Bangladesh, Bhutan, Democratic People’s Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor Leste.
While only occupying 5% of the Earth’s surface, the SEA Region’s population was estimated in 2005 to be 1,696,550,000, 26% of the world’s population (WHO, 2008).
The challenges posed by climate change to human health concern the potential increase in respiratory illnesses, heat strokes, and injuries. But also widespread malnutrition due to food crisis and more cases of malaria and dengue. Land loss from sea level rise may trigger massive migration that would lead to social conflicts and psycho-social stress.
In low-income countries and areas where malnutrition is widespread, the level of education is poor and the infrastructure is weak. These areas will have the most difficulty adapting to climate change and related health hazards. The populations considered to be at greatest risk are those living in small islands, low-lying and coastal areas, mountainous regions, water-stressed areas, in mega-cities  particularly the large urban and periurban agglomerations in delta regions in the SEA Region. We are talking about communities depending directly from ecosystem service and resource delivery such as fishermen and farmers living in remote areas, mountain people, and ethnic minorities.

4. Hotspots of Security Risks Associated with Climate Change: The Asian Challenge
Source: WBGU, 2007
Most people in SEA countries are already burdened with a high incidence of environmental disasters. The cumulated effects of climate change on the Region’s socioeconomic development will in turn seriously undermine the health and the well-being of communities in those countries.
In Bangladesh, the production of rice and wheat might drop by 8% and 32%, respectively, by the year Recent studies suggest a 2% to 5% decrease in yield potential of wheat and maize for a temperature rise of 0.5 °C to 1.5°C in India (IPCC, 2007a). The net cereal production in South Asian countries is projected to decline between 4 and 10% by the end of this century under the most conservative climate change scenario. Some studies agree that higher temperatures and longer growing seasons could result in increased pest populations in temperate regions of Asia (UN Office for the Coordination of Humanitarian Affairs, 2007b).
Global warming will also affect sea temperatures. Increased frequency of El Niño events and future changes in ocean currents, sea level, sea-water temperature, salinity, wind speed and direction, strength of upwelling, the mixing layer thickness, and predator response to climate change have the potential to substantially alter fish breeding habitats and food supply for fish and ultimately the abundance of fish populations in Asian waters (IPCC, 2001).
According to the IPCC, 18 heat waves were reported in India between 1980 and A heat wave in 1988 caused 1,300 deaths, while another one in 2003 caused more than 3,000 deaths. Heat waves in South East Asia cause high mortality in rural populations, and among the elderly and outdoor workers. Examples are the reported cases of heatstroke in metal workers and in rickshaw pullers in Bangladesh (UN Office for the Coordination of Humanitarian Affairs, 2007a).

5. Hotspots of Security Risks Associated with Climate Change: The Asian Challenge (cont.)
Source: WBGU, 2007
In 2006, Bhutan reported an increased loss of life from frequent flash floods, glacier lake outburst floods, and landslides. Rises in flood-related diarrhoeal disease have been reported in India and Bangladesh (Faisal and Parveen, 2004). In 2007, four monsoon depressions – double the normal number – caused severe floods in Bangladesh, India, and Nepal; and also the Democratic People’s Republic of Korea, which resulted in death, loss of livelihood, and displacement of millions (Aggarwal, 2003).
In November 2008, tropical cyclone SIDR made landfall in Bangladesh, generating winds of up to 250 km/hour and torrential rains. More than 8.5 million people were affected and over 3,300 died. Nearly 4.7 million people saw their houses damaged or destroyed, most of them belonging to the poorest of the poor (UN Office for the Coordination of Humanitarian Affairs, 2007a).

6. Developing Climate Action Plans
The nature and significance of the challenges posed by climate change to human health are still being clearly identified and addressed in most countries of the Region. A major obstacle is the fact that the understanding of public health authorities on the linkages between climate change and health is still poor. Most SEA countries have set up national expert committees, often under the direct supervision of prime ministers, to formulate national plans for mitigation and adaptation to climate change. The active participation of the health sector in these initiatives is still negligible and needs to be improved.
Discussions on international health security and climate change and health by the health ministers of the Region in 2007, resulted in the Thimphu Declaration wherein the Ministers committed to addressing the health impacts of global warming and climate change (WHO-SEARO, 2007). They concluded that climate change is a major threat to health security in South-East Asia countries of the Region, and these countries should carry out systematic vulnerability assessments to develop and implement national plans of action incorporating a practical approach to mitigating and adapting to climate change.
As a follow-up to the Ministers meeting, national workshops in Bangladesh, Indonesia, India, and Nepal on human health and climate change, and a regional workshop were held in 2007, with WHO support.

7. Regional Action Plan to Protect Human Health from Climate Change
The regional plan has three broader objectives:
To increase awareness of the health consequences of climate change
To strengthen health system capacity to provide protection from climate-related risks and to substantially reduce health systems’ greenhouse gas emissions
To ensure that health concerns are addressed in all decisions on reducing risks from climate change taken by other key sectors
While the outputs of the national workshop are being used as inputs to the national climate change action plans in the concerned countries, they also incorporated in the drafting of the regional framework for action to protect human health from the effects of climate change, worked out in Bali in December 2007 by representatives of all SEA Region Member countries.
The goal of the regional action plan is to build capacity and strengthen health systems.
The regional plan has three broad objectives:
To increase awareness of the health consequences of climate change
To strengthen health system capacity to provide protection from climate-related risks and to substantially reduce health systems’ greenhouse gas emissions
To ensure that health concerns are addressed in all decisions on reducing risks from climate change taken by other key sectors.
In December 2007, SEA countries, with the support of WHO, prepared a regional action plan to protect human health from the effects of climate change.

8. Increasing Awareness of Health Consequences of Climate Change
Warmer temperatures will favour outbreaks of water-borne illnesses
Diarrhoeal diseases accounted for 20.1% of deaths in children less than five years of age in 2005 in the SEA region
SEA region countries plan to increase the awareness of health consequences of climate change by:
Undertaking studies on the health implications of climate change and sharing information to understand how to promote changes in individual and corporate behaviours that mitigate climate-related health risks, while protecting and promoting health.
Facilitating national working groups, nongovernmental organizations, and civil society to develop coordinated mitigation and adaptation plans, including relevant sectors, regions, and disciplines.
Developing awareness-raising programmes and learning materials to educate and engage a broad range of stakeholders, including local communities, health and other professionals, and the media on the potential health impacts of climate change and on appropriate measures to reduce climate-sensitive risk factors and adverse health outcomes.

9. Strengthen Health Systems Capacity
Develop national action plans for health, integrated with existing national plans
Incorporate current and projected climate change risks into existing health policies, plans, and programmes
Strengthen existing infrastructure and interventions, including human resource capacity
Strengthen public health systems and disaster/emergency preparedness and response activities, including psychosocial support
To strengthen health systems’ capacity to provide protection from climate-related risks, and to substantially reduce health systems GHG emissions, SEA countries will:
Develop and implement national action plans for health that are integrated with existing national plans on adaptation and mitigation to climate change.
Develop integrated strategies to incorporate current and projected climate change risks into existing health policies, plans, and programmes to control climate-sensitive health outcomes, including integrated vector management and disaster risk management.
Strengthen existing infrastructure and interventions, including human resource capacity, particularly surveillance, monitoring, and response systems and risk communication, to reduce the burden of climate-sensitive health outcomes. Key concerns vary by country. Common concerns include vector-borne diseases, air quality, and food and water security.
Strengthen public health systems and disaster/emergency preparedness and response activities, including psychosocial support, through increased collaboration and cooperation across sectors. This should include documentation, sharing, and evaluation of the effectiveness of local knowledge and practices.

10. Strengthen Health Systems Capacity (cont.)
Provide early warning systems to support prompt and effective responses to current and projected health burdens
Implement adaptations specific to local health determinants to facilitate the development of community-based resource management
Determined costs and benefits of different interventions
Establish climate change focal points
Establish programmes to reduce GHG emissions by the health sector
Provide early warning systems to support prompt and effective responses to current and projected health burdens. To achieve this end, national and regional climate forecasting information, including climate change projections, should be fully utilized.
Implement adaptations over the short-, medium-, or long-term; be specific about local health determinants and outcomes of concern; and facilitate the development of community-based resource management. The costs and benefits of different interventions should be determined.
Establish climate change focal points or mechanisms within the national health institutions to ensure the implementation, monitoring, and evaluation of health mitigation and adaptation actions, and ensure that health issues are adequately addressed in these actions.
Establish programmes to substantially reduce GHG emissions by the health sector, which could also serve as a best practice model for other sectors.

11. Reduce Risks from Climate Change in Other Key Sectors
Incorporate current and projected climate change risks into existing policies, legislation, strategies, and measures of key development sectors to control climate-sensitive health outcomes
Facilitate the health sector to actively participate in national communications to the United Framework Convention on Climate Change (UNFCCC), and include health issues as the core elements in the negotiation process
Ensure active health participation in the national climate change team
To ensure that health concerns are addressed in decisions to reduce risks from climate change in other key sectors, the following activities will be carried out:
Develop integrated strategies to incorporate current and projected climate change risks into existing policies, legislation, strategies, and measures of key development sectors to control climate-sensitive health outcomes. Examples include the promotion of public and non-motorized transportation, clean energy, and disaster risk management.
Facilitate the health sector to actively participate in national communications to the UNFCCC, and include health issues as the core elements in the negotiation process.
Ensure active health participation in the national climate change team.

12. WHO Support: Global Work Plan to Protect Health from Climate Change
Aim: Support health systems in all countries, identify strategies and actions, share knowledge and good practices
Provide awareness and capacity building in addressing the challenges posed to health by climate change for health-sector professionals, other key sector NGOs, youth groups, and consumer organizations and networks
Support the empowerment of local communities to become more climate change resilient
Strengthen health systems capacity and notably that of public health programmes that are already addressing climate-sensitive diseases
Engage in partnerships with other sectors and agencies at national, regional, and international levels
Promote and support the generation of scientific evidence through research

13. Creating Awareness: World Health Day 2008
World Health Day (WHD) 2008 focused on the theme “Protecting health from climate change” and was commemorated in all SEA region countries
WHO-SEARO (Southeast Asia Regional Office) produced an information kit containing materials to promote commitment and drive action for change among all sectors of society to work together and reduce the adverse impacts of climate change on human health
Most WHD 2008 celebrations in SEA countries saw the active participation of national health authorities who declared their commitment – such as in India, Maldives, and Myanmar – to engage the health sector much more in addressing the challenges posed by climate change
More at:
SEA countries are in the process of increasing health relate climate action. The following slides show some examples at the national level.

14. Bangladesh Objectives for health action:
To increase knowledge and awareness of the health consequences from climate change within and outside the health sector
To prepare mitigation and adaptation plans based on a vulnerability assessment of the national health systems
To ensure coordination with, and advocate for, decisions on climate change in other key sectors that enhance public health
While no national health impact assessments to evaluate the current and potential impacts of global warming climate change have yet been conducted, some countries have started to take action.
Bangladesh prepared a National Adaptation Programme of Action (NAPA) in 2002 (see: under the leadership of the Ministry of Environment and Forests. Although the health sector contribution during its preparation was limited, some NAPA activities have health benefits. The phase out of two-stroke three wheelers, the mandatory use of catalytic diesel particulate filters in cities, and the installation of 30,000 Solar Home Systems in rural households, are lowering the health burden from both indoor and outdoor air pollution. Several other health related projects – such as one aiming at securing drinking water from enhanced salinity due to sea level rise – are being developed. The country aims to mainstream climate change adaptation into policies and programmes across the different sectors, including health.
In 2007, a national workshop supported by WHO, focused on how to reduce the disease burden from current and projected risks due to climate change. National health authorities agreed:
To increase knowledge and awareness of the health consequences from climate change within and outside the health sector
To prepare mitigation and adaptation plans based on a vulnerability assessment of the national health systems
To ensure coordination with, and advocate for decisions on, climate change in other key sectors that enhance public health.

15. Bhutan National health priorities are:
Overall awareness on climate change and climate variability and its adverse impacts on human health are increased and staff are trained
Emergency preparedness plans to reduce life loss and injury from flash floods are developed
The burden from disease vectors is reduced through the implementation of community-based, integrated vector management
Rural water quality and sanitation are improved and maintained by the concerned communities
Bhutan’s National Adaptation Programme of Action is available at:
Bhutan aims at strengthening existing health programmes that are already addressing climate-sensitive health outcomes. These include community-based clean water supply schemes, health hygiene campaigns, integrated vector management, and capacity building for emergency medical services.
To this purpose, a GEF/UNDP/WHO project has been enabled to strengthen the national capacity to identify and prevent adverse climate change and climate variability-related health outcomes in Bhutan.
Project outcomes
Outcome 1: Overall awareness on climate change and climate variability and its adverse impacts on human health is increased and concerned professional staff are trained
Outcome 2: Emergency preparedness plans to reduce life loss and injury from flash floods and glacier lake outburst floods (GLOF) are developed
Outcome 3: The burden from disease vectors is reduced through the implementation of community-based, integrated vector management
Outcome 4: Rural water quality and sanitation are improved and maintained by the concerned communities

16. Indonesia Priority activities outlined to be initiated:
Increase public awareness
Develop and disseminate IEC materials to minimize GHG emissions
Capacity building within the health sector
Expand research and development on climate change and health effects
Update national health policy to increase resilience to climate change issues
Adapt to potential health risks from water and food scarcity
Coordinate and network with relevant sectors and actors, with particular focus on health
Indonesia, the fourth most populous country in the world with more than 17,000 islands scattered over a large area, is vulnerable to climate change.
The UN International Conference on Climate Change, held in Bali in December 2007, helped generate impetus to address health concerns.
The National Climate Change Inter-sectoral Committee is led by the Ministry of Environment, with the Ministries of Forestry, Energy, Industry, Agriculture, Health, Planning Board, Public Work, and Universities as co-members. The Committee is currently incorporating health concerns and actions related to health implications from climate change into the new Five-Year National Development Plan. At provincial and district levels, these concerns are being streamlined into the Healthy Cities Programme.
Following are some of the priority activities outlined to be initiated:
Identify local evidences of health impacts from climate change, and use them as illustrations for increasing public awareness.
Develop and disseminate IEC materials and encourage communities and schools to minimize GHG emissions in daily activities.
Expand research and development on global warming, climate change, and health effects.
Capacity building within the health sector.
Update national health policy to increase resilience to climate change issues.
Focus on potential risks of water and food scarcity, and research adaptations to reduce disease burden from diarrhoeal diseases and under nutrition.
Coordinate and network with relevant sectors, government institutions, and private players concerned with climate change with particular focus to health.

17. Multicentric studies are required to assess: respiratory diseases sensitive to climate change, links between water quality and diarrhoeal disease and climate change (Bay of Bengal, Ganges - Brahmaputra river basin, a priority area)
the impact of Global warming and Ultra Violet Radiation (UVR) exposure on ocular health
vulnerability assessment and impact of climate change on Malaria,Dengue, Chikungunya and JE, to provide evidence for taking proactive measures. 
How to develop infrastructure at Primary Health centre level to handle the psychiatry cases due to loss of property and life.
Indian Agricultural Research carrying out impact assessment of climate change on major crops to to map adaptive capacity by farmers.
National authorities plan to improve supply food during drought.
Institutes/persons have been identified for undertaking studies on vulnerability assessment and adaptation needs.
Multicentric studies are required to assess: respiratory diseases sensitive to climate change, links between water quality and diarrhoeal disease and climate change (Bay of Bengal, Ganges - Brahmaputra river basin, a priority area)
the impact of Global warming and Ultra Violet Radiation (UVR) exposure on ocular health
vulnerability assessment and impact of climate change on Malaria,Dengue, Chikungunya and JE, to provide evidence for taking proactive measures. 
How to develop infrastructure at Primary Health centre level to handle the psychiatry cases due to loss of property and life.
Indian Agricultural Research carrying out impact assessment of climate change on major crops to to map adaptive capacity by farmers.
National authorities plan to improve supply food during drought.
Institutes/persons have been identified for undertaking studies on vulnerability assessment and adaptation needs.
Multicentric studies are required to assess: respiratory diseases sensitive to climate change, links between water quality and diarrhoeal disease and climate change (Bay of Bengal, Ganges - Brahmaputra river basin, a priority area)
the impact of Global warming and Ultra Violet Radiation (UVR) exposure on ocular health
vulnerability assessment and impact of climate change on Malaria,Dengue, Chikungunya and JE, to provide evidence for taking proactive measures. 
How to develop infrastructure at Primary Health centre level to handle the psychiatry cases due to loss of property and life.
Indian Agricultural Research carrying out impact assessment of climate change on major crops to to map adaptive capacity by farmers.
National authorities plan to improve supply food during drought.
Institutes/persons have been identified for undertaking studies on vulnerability assessment and adaptation needs.
India
The National Climate Change Action Plan  considers eight missions, but no specific one focuses on health concerns
A Task Force has been set up to prioritize health action, inter alia by conducting multicentric studies to assess:
Respiratory diseases sensitive to climate change
Links between water quality and diarrhoeal disease and climate change (Bay of Bengal, Ganges – Brahmaputra river basin, a priority area)
The impact on ocular health
Vulnerability assessment of malaria, dengue, chikungunya, and Japanese encephalitis (JE), to provide evidence for taking proactive measures vis a vis climate change effects
How to develop infrastructure in primary health centres to handle psychiatry cases due to loss of property and life
Impact of climate change on major crops, to map adaptive capacity and improve supply food during droughts
Institutes/persons have been identified for undertaking studies on vulnerability assessment and adaptation needs
The national Climate Change Action Plan considers eight missions, but no specific one focuses on health concerns. A Task Force has been set up to prioritize health action:
Vector borne diseases: Studies on vulnerability assessment and impact of climate change on Malaria being undertaken. Studies on dengue, chikungunya, and Japanese encephalitis (JE) need to provide evidence for taking proactive measures. 
Eye diseases: Multi-centric Collaborative Study on the impact of global warming and ultra violet radiation (UVR) exposure on ocular health. Adaptation measures would be suggested accordingly.
Mental health: Use the lessons learned from management of disasters. Need for research (short- and long-term) and develop infrastructure at Primary Health centre level to handle the psychiatry cases due to loss of property and life.
Respiratory diseases: Multicentric studies are required to assess respiratory diseases sensitive to climate change. This can be done through collection of data from OPD attendance, patterns of indoor admissions, mortality variation from different respiratory diseases, pulmonary function changes in different climatic conditions, and monitoring of temperature and pollutants in different areas of the country.
Malnutrition: The Indian Agricultural Research Institute is carrying out an impact assessment of climate change on major crops and integrated vulnerability assessment to map the kind of adaptive capacity that farmers can implement to adapt. National authorities plan to supply food grains at affordable prices during droughts, improve storage systems, and work through the “Drought Relief Cells” established by State governments and NGOs.
Diarrhoeal diseases: Multicentric studies are required to assess links between water quality and diarrhoeal disease. The Bay of Bengal, which forms the site of the Ganges - Brahmaputra river basin, is a priority area as it is also influenced by the effect of climate change on the Himalayan glaciers.
To address the issue of climate change and health in comprehensive perspective, institutes/persons have been identified for undertaking studies on vulnerability assessment and adaptation needs. Some are the National Vector Borne Disease Control Programme and the National Rural Health Mission in the Ministry of Health and Family Welfare. The World Bank sponsored project on vector borne disease control was implemented in 139 districts of 11 states for malaria and kala-azar.

18. Nepal
Improve the understanding of public health authorities on the linkages between climate change/variability and health
Conduct research for evidence generation
Assess vulnerabilities and identify interventions for mitigation and for adaptation
Identify adaptation needs and options derived from the challenges posed by future sudden and/or large climate changes
Improve current public health programmes in intersectoral collaboration with the Ministries (water, agriculture, urban development, etc.)
Strengthen institutions and mechanisms that can systematically promote interactions among researchers, policymakers, and other stakeholders
The national workshop on health and climate change that was held in December 2007 established priority actions (see text in slide). To achieve them, a series of immediate and short-term actions were proposed:
Establish a focal point/coordination unit for environmental health/climate change and health in the health sector
Organize consultative meetings every six months
Train health professionals to understand the threats posed by climate change and contribute to build the capacity of national and local institutions, including negotiation skills
Conduct research to fill out the knowledge gaps and reduce uncertainties
Develop and implement programmes for mitigation and adaptation to reduce vulnerability
Involve communities in monitoring climate change impacts and help them to employ appropriate measures
Establish or strengthen surveillance, reporting, and response systems for infectious diseases
Promote cooperation and coordination of different sectors on climate change research and strengthening alliances for sustainable development

19. Maldives Maldives revised its NAPA in 2009
The main health components focus on:
Assessing health vulnerability and identify adaptation measures
Adapting to sea-level rise
Conserving water and harvesting rainwater
Implementing sanitation and sound waste management
Implementing an integrated approach to manage disease vectors
Preparing to respond better to health impacts from extreme weather events
Source: earthobservatory.nasa

20. Thailand
Build capacity to adapt and reduce vulnerabilities to climate change
Promote greenhouse gas mitigation activities based on sustainable development
Support research and development to better understand climate change, its impacts, and adaptation and mitigation options
Raise awareness and promote public participation
Build capacity of relevant personnel and institutions, and establish a framework of coordination and integration
Support international cooperation to achieve the common goal of climate change mitigation and sustainable development
Thailand is taking action to reduce of GHG emissions in absolute terms by incorporating state-of-the-art technologies and a careful adoption of energy efficiency measures. The specific policy instruments to reduce GHG emissions include: (1) regulations; (2) fiscal incentives; (3) information; and (4) research, development and demonstration, and will contribute to health gains in terms of air quality, physical activity, and reduction of road injuries.
Thailand is taking action to reduce greenhouse gas emissions in absolute terms by incorporation of state-of-the-art technologies and careful adoption of energy-efficiency measures. The Ministry of Natural Resources and Environment has developed a Strategic Plan on Climate Change for 2008–2012 with six elements:
Build capacity to adapt and reduce vulnerabilities to climate change
Promote greenhouse gas mitigation activities based on sustainable development
Support research and development to better understand climate change, its impacts, and adaptation and mitigation options
Raise awareness and promote public participation
Build capacity of relevant personnel and institutions, and establish a framework of coordination and integration
Support international cooperation to achieve the common goal of climate change mitigation and sustainable development.

21. Conclusions
While the awareness that climate change is happening now has increased immensely in the last two years in most SEA countries, health professionals have not yet fully understood the implications for health and the urgency for action
National climate action plans have been prepared by most countries, yet the health dimensions are still neglected
At the same time, there are national experts in many countries who have gathered evidence on health impacts and prepared proposals for action

22. Conclusions (cont.)
Most actions focus on awareness building, capacity development, and research and policy development; few focus on supporting community resilience
Health sector does not yet fully participate in national, regional, or global debates on climate change
The actions plans developed with support from WHO need to be integrated into national plans and institutionalized to ensure their implementation
A positive step forward is this course!