Health National Adaptation Plan (HNAP) 2024, Bangladesh

1. Director, IEDCR, DGHS

2. Program Director

3. Program Manager, Climate Change Project, IEDCR From WHO country office:

1. Representative from WHO, In Charge of Environmental Health Unit (EHU), World Health Organization Bangladesh From VAALO avant-garde Ltd, Dhaka:

1. Team Leader and Health Expert

2. Climate Change Expert

3. Financial Expert

4. Technical Advisors

5. Technical Team i|Page Foreword Bangladesh, a country highly vulnerable to environmental changes due to its geographical location and socioeconomic status and is most vulnerable to the impacts of climate change, natural disaster as well, which has significant and multifaceted effects on public health and direct & indirect health hazard impacts. It is important to identify vulnerable populations and highlight key adaptation and mitigation strategies. The extreme weather change as well as climate change impacts are increasing and exacerbating the burden of different diseases and health outcomes on Bangladesh. These include increased risk of vector- borne diseases, such as malaria and dengue etc.; non-communicable diseases and health hazards due to extreme weather conditions; water-borne and water-related diseases, such as cholera and other diarrheal diseases; under-nutrition due to climate-related impacts on agriculture production; as well as deaths and injuries due to natural disasters; and impacts on mental health. To adapt to climate change and ensure the physical, mental, and social well-being of all people in Bangladesh, it is crucial to strengthen the resilience of individuals, communities, and the national health system. This includes such actions as increasing the awareness and communication of the health risks and health hazards due to climate change, promoting community-based health adaptation, building the capacity of the healthcare workforce, and climate-resilience healthcare facilities and infrastructure, among others. A comprehensive and multi-sectoral approach is essential for Bangladesh to address the growing health risks posed by climate change. This approach should involve strengthening healthcare systems, fostering sustainable development, and enhancing public awareness and resilience and climate change adaptation. The adverse effects of climate change—including rising temperatures, changing rainfall patterns, sea-level rise, and more frequent and extreme weather events such as severe cyclones, flooding, and droughts—threaten the health and well-being of millions of Bangladeshis. Vulnerable populations bear the greatest burden from these challenges, which manifest through both direct and indirect pathways. Bangladesh Health-National Adaptation Plan (HNAP) 2024 is a planned initiative aimed at enhancing the country's resilience to the health impacts of climate change. It will guide the health sector over the next five years and beyond byby promoting the integration of climate change and health risks into national health policies, plans, programmes, and monitoring strategies. Aligned with the broader National Adaptation Plan, Bangladesh (2022), the HNAP seeks to ensure coordinated efforts across sectors and stakeholders. Its goals include reducing the health burden of climate change in Bangladesh, enhancing the resilience of health systems, strengthening the health sector's capacity to anticipate, prepare for, and respond to these challenges and promoting inclusive and equitable access to healthcare services. These actions will contribute to the overall well-being and sustainable development of the country. The HNAP provides technical guidance to long term, medium-term and short-term resilience to climate change across communities, societies, sectors, economies, and ecosystems. Led by the Ministry of Health and Family Welfare (MOHFW), HNAP development processes involve a range of government and non-governmental stakeholders. The HNAP 2024 includes a cost benefit analysis with outlines strategies for resource allocation, both human and financial, with funding sourced from national budgets and external sources. The HNAP also provides opportunities to secure access to global climate-change funding for health adaptation, such as through the Green Climate Fund. This comprehensive framework aims to fortify Bangladesh’s health sector against the escalating risks posed by climate change. ii | P a g e Table of contents Contents

1. Introduction ...................................................................................................................... 1 1.1 Climate change and health in Bangladesh ................................................................................ 1 1.2 Rationale for Updating HNAP ................................................................................................... 6 1.3 Goal and Objectives of HNAP ................................................................................................... 6 1.4 HNAP Development Process ...................................................................................................... 7

2. Climate-related health risks in Bangladesh ....................................................................... 7 2.1 Vulnerability and Adaptation Assessments ............................................................................... 7 2.2 Water-borne and water-related disease..................................................................................... 9 2.2.1 Diarrhea .................................................................................................................................... 9 2.3 Vector-borne disease ................................................................................................................. 10 2.4 Climate Change Impact on Nutrition and Food Security ..................................................... 14 2.5 Non-Communicable Diseases ................................................................................................... 15 2.6 Mental health............................................................................................................................. 16 2.7 Extreme weather events ............................................................................................................ 17 2.8 Health Impacts of Air Pollution in Bangladesh ...................................................................... 19 2.9 Plastic Pollution: ....................................................................................................................... 19

3. Climate change and health-related institutional and policy framework ...................... 19 3.1 National Health Policy, Bangladesh 2011 ................................................................................ 19 3.2 4th Health Population and Nutrition Sector Program (HPNSP) 2017-2022 (+2 years)...... 20 3.3 Health population and nutrition sector development plan, OP (Operational Plan) ........... 20 3.4 Health Curriculum.................................................................................................................... 20 3.5 Relevant documents addressing climate change and health ................................................. 21 3.5.1 Eight Five-Year Plan (2020-2025) ......................................................................................... 21 3.5.2 Seventh Five-Year Plan (2016-2020) ..................................................................................... 21 3.5.3 Sixth Five-Year Plan (2011–2016) ......................................................................................... 21 3.5.4 3rd Health, Population and Nutrition Sector Development Plan [HPNSDP] (2011-2016) .......................................................................................................................................................... 21 3.5.5 Second National Communication (2012).............................................................................. 22 3.5.6 Vulnerability Assessment Aspect 2021.................................................................................. 22 3.6 Climate Change and Health Adaptation Strategy Report (2012) ......................................... 22 3.7 Bangladesh Climate Change Strategy and Action Plan (2008) ............................................. 22 3.8 Nationally Determined Contributions 2021 Bangladesh ....................................................... 22 3.9 National Adaptation Plan of Bangladesh (2023‐2050) ........................................................... 22 3.10 National Adaptation Plan Road Map (2014) ........................................................................ 27 iii | P a g e 3.11 National Adaptation Program of Action (2005) .................................................................... 27 3.12 Mujib Climate Prosperity Plan 2022-2041 ........................................................................... 27 3.13 Sustainable Development Goals (2030) ................................................................................. 27 3.14 Delta Plan 2100........................................................................................................................ 27 3.16 Key policy and implementation gaps for health adaptation ............................................... 28

4. Building a climate-resilient health system in Bangladesh .............................................. 29 4.1 Introduction to Operational framework for building climate resilient and low carbon health systems, 2023 ........................................................................................................................ 29 4.2 Operational framework for building climate resilient and low carbon health systems...... 30 4.3 Framework components for building climate resilient and low carbon health systems ..... 31 4.3.1 Component 1: Climate-transformative leadership and governance ............................. 31 4.3.2 Component 2: Climate-smart health workforce ............................................................. 33 4.3.3 Component 3: Assessments of Climate and Health Risks and GHG emissions............ 35 4.3.4 Component 4: Integrated Risks, Monitoring, Early Warning and GHG Emissions Tracking ....................................................................................................................................... 38 4.3.5 Component 5: Health and Climate Research .................................................................. 42 4.3.6 Component 6: Climate Resilience and Low Carbon Infrastructures, Technologies and Supply Chain ............................................................................................................................... 45 4.3.8 Component 8: Climate informed health programs ......................................................... 50 4.3.9 Component 9: Climate-related emergency preparedness and management ................ 52 4.3.10 Component 10: Sustainable climate and health financing ........................................... 55

5. HNAP HNAP Implementation Strategy .......................................................................... 58 5.1 Key Components of Implementation....................................................................................... 58 5.2 Coordination Mechanism ......................................................................................................... 60 5.3 HNAP Action Plan 2024-2029 .................................................................................................. 61 5.4 Costing of HNAP Implementation plan .................................................................................. 79 5.5 Cost Benefit Analysis of HNAP Implementation plan ........................................................... 80 5.6 HNAP Financing Strategies...................................................................................................... 82

6. HNAP Monitoring, Evaluation, and Reporting .............................................................. 85 6.1 HNAP review process................................................................................................................ 85 6.2 HNAP reporting ........................................................................................................................ 85 6.3 M&E Plan (2024-2029) ............................................................................................................. 86 iv | P a g e List of Figure Figure 1: Future Projected Annual Average Temperature (°C) ............................................................... 1 Figure 2: Deviation of yearly mean temperature during 1981-1990 (left), 1991-2000 (middle) and 2001-2010 (right) as compared with the previous decades based on local meteorological data ............ 2 Figure 3.1: Overview of climate hazard impact on health outcomes ...................................................... 4 Figure 3.2: Key health impacts of selected climate hazards on children................................................ 5 Figure 4: Distribution of Diarrheal Diseases in eight divisions of Bangladesh (Jan- Dec 2023;............ 9 Figure 5: Distribution of Diarrheal cases in 2023 (Jan-Dec; .................................................................. 9 Figure 6: Trends and monthly patterns for vector-borne diseases, 2011-17; ........................................ 10 Figure 7: Geographic distribution of vector-borne disease in 2011, ..................................................... 11 Figure 8: Rainfall Vs Malaria cases (2015-2019), ................................................................................ 11 Figure 9: Malaria Endemic areas in Bangladesh,.................................................................................. 11 Figure 10: Number of dengue cases (A) and deaths (B) reported by epidemic week from 2018 to 2023 [as of 5 August (epidemiological week 31) 2023] ................................................................................ 12 Figure 11: Seasonality of Dengue outbreak in Bangladesh from 2010- 2021; ..................................... 13 Figure 12: Division-wise Dengue case distribution in year 2022, ........................................................ 13 Figure 13: CHIKV infected patients in Dhaka city 2017 ...................................................................... 14 Figure 14: Major causes of death due to NCDs .................................................................................... 15 Figure 15: Mental Health impacts of the six weather-related events, ................................................... 17 Figure 16: The pie Charts showing the percentages of water-borne, water-washed and water-related disease occurrences by salinity and non-salinity areas (Coastal Bangladesh) ...................................... 17 Figure 17: Climate Stress Areas of Bangladesh .................................................................................... 18 Figure 18: The framework as a tool for building climate resilience and low carbon interventions in health facilities, ..................................................................................................................................... 30 Figure 19: Organogram for HNAP implementation.............................................................................. 61 List of Table Table 1: Climate stress area coverage and related hazards with potential impacts ............................... 24 Table 2: HNAP 2024-2029 Action Plan Outline ................................................................................... 62 Table 3: Costing of HNAP Implementation Plan .................................................................................. 79 Table 4: Proposed Cost and Benefit Analysis for climate change in Bangladesh ................................. 80 Table 5: Potential sources of funding for climate change adaptation ................................................... 83 Table 6: M&E Plan of HNAP Implementation ..................................................................................... 86 v|Page Abbreviations and Acronyms ADB Asian Development Bank BCCRF Bangladesh Climate Change Resilience Fund BCCSAP Bangladesh Climate Change Strategy and Action Plan BFD Bangladesh Forest Department BDRCS Bangladesh Red Crescent Society BHE Bureau of Health Education BMD Bangladesh Meteorological Department BNC Bangladesh National Nutrition BSEC Bangladesh Securities and Exchange Commission BNNC Bangladesh National Nutrition Council BRTA Bangladesh Road Transport Authority BUET Bangladesh University of Engineering and Technology CBHC Community-Based Health Care CC&H Climate Change and Health CCHPU Climate Change and Health Promotion Unit CDC Communicable Disease Control CMSD Central Medical Stores Depot CMSME Cottage, Micro, Small and Medium Enterprise COP-18 Conference of Parties COPD Chronic Obstructive Pulmonary Disease CSD Climate-sensitive Diseases CSO Civil Society Organization CSR Corporate Social Responsibility CVF Climate Vulnerable Forum DAE Department of Agricultural Extension DDM Department of Disaster Management DGHS Directorate General of Health Services DGME Directorate General of Medical Education DoE Department of Environment DPHE Department of Public Health Engineering ERD Economic Relations Division EWS Early-Warning System FY Finance Year GCF Green Climate Fund GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria HNAP Health National Adaptation Plan HEU Health Engineering Unit HED Health Engineering Department HPNSDP Health Population and Nutrition Sector Development Plan ICMH Institute of Child and Maternal Health icddr,b International Centre for Diarrhoeal Disease Research, Bangladesh IEDCR Institute of Epidemiology, Disease Control and Research INC Initial National Contribution INDC Intended Nationally Determined Contributions IPH Institute of Public Health IPHN Institute of Public Health Nutrition LCD Least Developed Countries LGED Local Government Engineering Department M&E Monitoring and Evaluation MODMR Ministry of Disaster Management and Relief MOEFCC Ministry of Environment, Forest and Climate Change vi | P a g e MOF Ministry of Finance MOHFW Ministry of Health and Family Welfare MoP Ministry of Planning MOU Memorandum of Understanding NAP National Adaptation Plan NAPA National Adaptation Program of Action NBR National Board of Revenue NCDC Non-Communicable Disease Control NDMC National Disaster Management Council NDC Nationally Determined Contributions NIPSOM National Institute of Preventive and Social Medicine NNS National Nutrition Services PHC Primary Health Care PMR Planning, Monitoring, and Research PPP Public-Private Partnerships PTSD Post-Traumatic Stress Disorder PFM Public Financial Management SDG Sustainable Development Goals SNC Second National Communication TOR Terms of Reference UHC Universal Health Coverage UNDP United Nations Development Program UNICEF United Nations Children’s Fund UNFCCC United Nations Framework Convention on Climate Change VAALO Value Attention Alternative Development Learning Options V&A Vulnerability and Adaptation VBD Vector-borne Disease WASH Water, Sanitation, and Hygiene WBD Water-borne Disease WHO World Health Organization vii | P a g e Definitions Adaptation refers to the process of adjustment to actual or expected climate and its effects. In human systems, adaptation seeks to moderate or avoid harm or exploit beneficial opportunities. This is applicable to human systems and natural systems in which human intervention can facilitate adjustment. (IPCC, Climate Change 2014: Synthesis Report.) Adaptive capacity is the ability of systems, institutions, humans, and other organisms to adjust to minimize harm from potential damage, to take advantage of opportunities, or to respond to consequences. (IPCC, Climate Change 2014: Synthesis Report.) Climate change refers to a change in the state of the climate that can be identified (e.g., by using statistical tests) by changes in the mean and/or the variability of its properties, and that persists for an extended period, typically decades or longer. (IPCC, Climate Change 2014: Synthesis Report.) Climate variability refers to variations in the mean state and other statistics (such as standard deviations, the occurrence of extremes, etc.) of the climate on all spatial and temporal scales beyond that of individual weather events.( IPCC, Climate Change 2014: Synthesis Report.) Climate-resilient health systems are those capable of anticipating, responding to, coping with, recovering from, and adapting to climate-related shocks and stress, to bring about sustained improvements in population health, despite an unstable climate (WHO Operational Framework 2023) Climate-sensitive health outcome is any health outcome whose geographic range, incidence or intensity of transmission is directly or indirectly associated with weather or climate. (HNAP 2018) Climate-related risks are additional (exacerbated) risks that people and their livelihoods and assets face due to climate change. ese risks can be direct, such as in exposure to more frequent heat waves or floods; or indirect, such as when a drought negatively impacts food supplies (and prices) and in effect livelihoods and nutrition. (HNAP 2018) Climate resilient and low carbon health systems are those capable of anticipating, responding to, coping with, recovering from, and adapting to climate-related shocks and stress, while minimizing GHG emissions and other negative environmental impacts to deliver quality care and protect the health and well-being of present and future generations. (WHO Operational Framework 2023) Exposure is the presence of people, livelihoods, species or ecosystems, environmental functions, services, and resources, infrastructure, or economic, social, or cultural assets in places and settings that could be adversely affected. (IPCC, Climate Change 2014: Synthesis Report.) Low carbon health systems are those capable of implementing transformative strategies towards reducing GHG emissions in their operations, reducing short- and long-term negative impacts on the local and global environment. (WHO Operational Framework 2023) Resilience is the capacity of social, economic, and environmental systems to cope with a hazardous event or trend or disturbance, responding or reorganizing in ways that maintain their essential function, identity, and structure, while also maintaining the capacity for adaptation, learning, and transformation. (IPCC, Climate Change 2014: Synthesis Report.) Vulnerability is the propensity or predisposition to be adversely affected. Vulnerability encompasses a variety of concepts and elements including sensitivity or susceptibility to harm and lack of capacity to cope and adapt. (IPCC, Climate Change 2014: Synthesis Report.) viii | P a g e Executive Summary The Health National Adaptation Plan (HNAP)(2024) for Bangladesh is a comprehensive strategic document designed to build a low-carbon, sustainable, and climate-resilient health system. Recognizing the country's vulnerability to climate-related health risks, the HNAP aims to enhance the resilience of the health sector and protect public health from the adverse effects of climate change over the next five years and beyond The impacts of climate change are already evident in Bangladesh. These include rising temperature leading to heat stress, changes in seasonal patterns and air pollution spikes, and increasing frequency of extreme weather events like flash floods, droughts, severe tropical cyclonic storms, prolonged heat waves, rising sea levels, and intense rainfall. Such events pose significant threats to the health and well- being of millions of people especially pregnant women and children in climate vulnerable areas and are expected to intensify in the coming decades. Health vulnerability and adaptation assessments conducted in 2011, 2015 and 2021, have provided critical insights into the health risks posed by climate change in Bangladesh. The priority climate- sensitive health outcomes identified in these assessments include vector-borne diseases, water-borne diseases, airborne illnesses, skin diseases, and respiratory-related ailments and other health hazards aggravated by extreme heat. Additionally, the assessments highlight the growing burden of non- communicable diseases, mental health challenges, and the health impacts of extreme weather events, including under-nutrition, food insecurity, and effects on water, sanitation, and hygiene infrastructure and services. The objective of the HNAP 2024 is to provide strategic guidance to develop a health system capable of anticipating, preparing for, and responding promptly to climate-related health challenges, enhance the ability to design and implement adaptation measures to prevent and overcome existing and future health risks particularly for women and children associated with climate change, Incorporate climate change factors and health risks into national health policies, planning, programming strategies, and action plans, ensure the health sector works in collaboration and coordination with partners in environment, and other relevant sectors, develop climate-resilient health systems and community-led adaptation through participatory community engagement. The HNAP 2024 incorporates an expanded focus on climate- induced diseases and hazards (e.g., Dengue, malaria, heat wave, extreme weather evets, air pollution and air quality). It also addresses mental health challenges as well as the impacts of climate change on nutrition and food security. Furthermore, it will assist to decrease in the incidence of climate-sensitive diseases such as dengue, malaria, heat-related illnesses, and water-borne diseases, enhanced capacity of health systems to withstand climate shocks and stresses and thereby improve public health outcomes including equitable access to healthcare services, contributing to the overall well-being The HNAP 2024 was updated in collaboration with IEDCR, DGHS of Ministry of Health and Family Welfare and other key climate change and health-related stakeholders with technical support from the World Health Organization (WHO). The present updated version of Health National Adaptation Plan (HNAP) was developed due to evolving climate and health landscape changes over the past five years. This revision aligns with the WHO Operational Framework for Building Climate-Resilient and Low-Carbon Health Systems (2023). The HNAP 2024 considered the following 10 key components of the Operational framework for building climate resilient and low carbon sustainable health systems (2023). These components include: ix | P a g e Climate-transformative leadership and governance; Climate-smart health workforce; Assessments of Climate and Health Risks and GHG emissions; Integrated Risks, Monitoring, Early Warning and GHG Emissions Tracking; Health and Climate Research; Climate Resilience and Low Carbon Infrastructures, Technologies and Supply Chain; Management of environmental determinants of health; Climate informed health programs; Climate-related emergency preparedness and management and Sustainable climate and health financing. It provides a systematic and comprehensive approach to addressing the health impacts of climate change. It offers guidance on how the health sector can effectively and systematically manage these challenges, contributing to the development of health systems that deliver sustainable, cost-effective, safe, and high-quality care in the face of a changing climate. Additionally, a cost-benefit analysis has been included, to strengthen the economic rationale the proposed interventions. x|Page

1. Introduction 1.1 Climate change and health in Bangladesh Bangladesh is considered one of the most vulnerable countries in the world to the impacts of climate change. Vast coastal areas and a reliance on natural resources combined with high population density and high rates of poverty leave the population at high-risk of extreme weather events, including increasing temperatures, cyclones, erratic rainfall, flooding, drought, rising sea levels, and saltwater intrusion (World Bank, 2022). Bangladesh has a subtropical monsoon climate characterized by wide seasonal variations in rainfall, high temperatures, and humidity. There are four prominent seasons, including winter/northeast monsoon (December February); summer/pre-monsoon (March-May); southwest monsoon (June-September); and autumn/post-monsoon (October-November). January is the coolest of all months with average temperatures ranging from 18-22°C and April is the warmest month in most part of the country with average temperatures ranging from 33º-36º C. The country receives on average about 2,200 mm of rainfall per year with most areas receiving at least 1500 mm of rainfall per year (WBG Climate Change Knowledge Portal 2021). Figure 1: Future Projected Annual Average Temperature (°C) Source: (Ministry of Environment, Forest and Climate Change, 2022) *SWM: Southwestern coastal area and Sundarbans, SEE: Southeast and Eastern Coastal Area, CHT: Chattogram Hill Tracts, FPE: River, Floodplain and Erosion-prone Areas, HFF: Haor and flash flood Area, DBA: Drought Prone and Barind Area, NNW: Northern North-western Region, CBL: Chalan Beel and Low-lying area of the North-western Region, CHI: Char and Islands, URB: Urban Areas, BD: Bangladesh, BOB: Bay of Bengal and Ocean. National Guidelines on Heat-Related Illness, MOHFW mentioned about Bangladesh often has some of the warmest day highs in all of Asia, with an average monthly high of roughly 30°C and an average April high of 33°C, according to the UN International Strategy for Disaster Reduction (UNISDR) technical report (2015). The report stated that Bangladesh would soon face “emerging hot and humid seasons, in which the heat index exceeds 35°C.” In the last six decades, the average temperature has risen by 0.7–10 Celsius in Bangladesh. It may rise by 1.40 Celsius in the next three decades. Introduction 1|Page Hot ambient conditions and associated heat stress can lead to:  Increase mortality and morbidity  Increase adverse pregnancy outcomes  Effect on mental health  Reduce physical work capacity and motor-cognitive performances  Increase the risk of occupational health problems More than 71% of rainfall occurs during monsoon season (Shariot-Ullah, Akhter, Acharjee, & Hasan, 2024). In 2019, the highest relative humidity is observed in the South region, while the Central region shows the lowest humidity levels. The other regions have varying levels of relative humidity, mostly ranging between 76.1% and 80.0% (World Bank, 2021b). Tropical cyclones make landfall in Bangladesh on average once in every two to three years accompanied by heavy rainfall, very high wind speeds, and storm surges. Similarly, rainfall patterns are becoming increasingly erratic resulting in more frequent occurrences of both flooding and drought. Shifts in the intensity and timing of monsoon rains has led to several reoccurring flood events over the past decade, including a 21% reduction in rainfall during the monsoon period (June-August) in 2012. Figure 2: Deviation of yearly mean temperature during 1981-1990 (left), 1991-2000 (middle) and 2001-2010 (right) as compared with the previous decades based on local meteorological data Source: Vulnerability and adaptation assessment report. (WHO & IEDCR, 2012) Climate change significantly impacts health, in urban settings. The cities are vulnerable to various climate-related challenges, including extreme weather events, air and water pollution, and vector-borne diseases. Bangladesh is experiencing rapid urbanization, with 56% of its population projected to live in urban areas by 2050. . The current pace and pattern of urban growth have strained housing and urban services, including access to healthcare and education, significantly compromising the sustainability of both the natural and built environments (Roy, 2021). This rapid urbanization poses public health risks by contributing to environmental degradation, clogged drainage systems, and subsequent waterlogging. Compounding this issue is the urban heat island effect driven primarily by the absorption and re- emission of heat by urban infrastructure, reduced green spaces, and the concentration of human activities. This phenomenon results in elevated temperatures in urban areas exacerbating the health risks associated with heat waves. The loss of green spaces further exacerbates rising temperatures, increasing the frequency and severity of heat waves, leading to heat-related illnesses and deaths. Vulnerable populations, including the elderly, pregnant women, children, and those with pre-existing health Introduction 2|Page conditions, are at greater risk. According to UNICEF’s Children’s Climate Risk Index 2021, children in Bangladesh are at ‘extremely high risk’ to the impacts of climate change due to their vulnerability and exposure to climate and environmental shocks (UNICEF, 2021). According to the Children’s Environmental Health Collaborative, 116,452 years of healthy life lost due to high temperature in children under 20 years, in Bangladesh (CEH, 2024). The situation is worsened by poor air quality due to vehicle emissions, industrial activities, and construction, among other factors particular for infants and children. Climate change can worsen air pollution due to increase in dust storms, and wildfire smoke, which aggravate respiratory conditions like asthma and chronic obstructive pulmonary disease (COPD). Additionally, warmer temperatures and altered rainfall patterns create favorable conditions for the breeding of mosquitoes and other vectors. Urban areas may face water scarcity during dry periods, while excessive rainfall can overwhelm sewage and drainage systems, leading to contamination of water supplies and the spread of diseases. To address these challenges, Bangladesh must invest in resilient infrastructure, improve early warning systems for extreme weather events, and strengthen timely, equitable and quality healthcare services. Equally important are public awareness campaigns to educate communities about the health risks associated with climate change and promotion of strategies to mitigate its impacts and address to improve energy sources used in homes for cooking and power in rural areas. In rural areas of Bangladesh, the impacts of climate change on health are profound and multifaceted. These regions often are particularly vulnerable to climate-related health challenges. Flood prone regions in rural areas frequently experience flooding due to monsoons and cyclones. Floodwaters can contaminate drinking water sources with pathogens, leading to outbreaks of waterborne diseases like cholera, diarrhea, and typhoid. Cyclones and storm surges can cause injuries, fatalities, and displacement. The destruction of homes and infrastructure disrupts healthcare services, exacerbating health issues. Water scarcity and contamination affects the availability and quality of freshwater resources. Droughts can lead to water scarcity, while floods and rising sea levels can contaminate freshwater supplies with saltwater and pollutants, increasing the risk of diseases like diarrhea and skin infections. Changing temperatures and rainfall patterns create favorable conditions for the breeding of mosquitoes and the spread of vector-borne Diseases like Malaria and Dengue. Rural areas may also experience increased incidence of these diseases as the climate changes. Rural areas often have limited healthcare facilities and resources. Extreme weather events can damage infrastructure, making it difficult to access medical care. Climate change is transforming the landscape of morbidity and mortality and is already having profound impacts on human health and health systems. Figure-3 shows the cascading effects of climate events and provides valuable insights into the cause-and-effect relationship between climate impacts and health outcomes. Health outcomes involve both direct and indirect consequences of these events – some of which may not appear until months, or even years, after the event. Introduction 3|Page Figure 3.1: Overview of climate hazard impact on health outcomes Source: Oliver Wyman analysis. WEF, Quantifying the Impact of Climate Change on Human Health. INSIGHT REPORT JANUARY 2024. Introduction 4|Page Figure 3.2: Key health impacts of selected climate hazards on children Source: Threat to Progress, to capture MNCH specific outcomes UNICEF, 2023 Additionally, health services may be overwhelmed during and after such events, limiting the ability to respond effectively to health crises. Currently, 80% of health care facilities in Bangladesh already lack reliable access to electricity and 66% without basic waste management (CEH Collaborative, 2024); this can be exacerbated due to climate events. Rural communities in Bangladesh rely heavily on agriculture for their livelihoods and food security. Climate change impacts, such as changing rainfall patterns and increased salinity from sea-level rise, can reduce crop yields and lead to food shortages. This can cause malnutrition, particularly among children and pregnant women. Children are disproportionately affected because they are uniquely vulnerable to such environmental hazards as compared to adults. This is because of their unique vulnerabilities: they have developing immune and nervous systems, more surface area, higher internal heat, poorer sweating capacity, eat and drink more, and breath faster Introduction 5 | P a g e compared to adults. This all leads to them being more susceptible to the adverse effects of climate related hazards, and the impacts can last a lifetime (UNICEF, 2024) The loss of crops and livestock due to extreme weather events and shifting growing seasons can lead to economic hardship, impacting the overall health and well-being of rural populations. The uncertainty and stress caused by climate change impacts, such as crop failure, loss of income, and displacement due to natural disasters, can lead to mental health issues, including anxiety, depression, and post-traumatic stress disorder (PTSD).The impacts of climate change on health are severe, affecting millions of people in vulnerable areas of Bangladesh. 1.2 Rationale for Updating HNAP A concrete Health National Adaptation Plan (HNAP) is crucial for Bangladesh to address the climate change impact on public health. It will improve the understanding of the health impacts of and adaptation to climate change among relevant stakeholders, including health policy makers, professionals, workers, program designers, program implementers, civil servants, civil society members. The National Adaptation Plan (NAP 2023-2050), Bangladesh, was developed based on the National Adaptation Programs of Action (NAPA, 2005) that was designed to support Bangladesh to identify priority actions to respond to their urgent and immediate adaptation needs. The NAP is intended to provide support for medium- and long-term adaptation planning needs in Bangladesh. The health national adaptation (HNAP) will be the health component technical guidance document for the National Adaptation Plan (NAP 2023-2050), as an output of a detailed health adaptation plan designed to achieve the national health adaptation goals within a specific period and given available resources. (NAP 2022). Ultimately, the update of HNAP is necessitated by evolving climate and health landscapes including- •Emerging health challenges •Alignment with new frameworks •Integration with national policies •COP26 health commitments 1.3 Goal and Objectives of HNAP Goal: Building low carbon, sustainable and climate resilient health system in Bangladesh. Objective: Establish a robust framework to build a climate-resilient health system in Bangladesh that integrates low-carbon, sustainable practices, and effectively addresses health risks posed by climate change. . Specific objective of HNAP 2024

1. Strengthen the capacity of health systems to prevent and manage climate-sensitive health risks by developing training programs and technical resources. Introduction 6 | P a g e

2. Integrate climate and health considerations into national policies, plans, and strategies to enhance system-wide climate resilience.

3. Develop and implement low-carbon and climate-resilient health infrastructure to mitigate environmental impacts.

4. Establish robust monitoring, early warning, and surveillance systems for climate-sensitive diseases and health risks.

5. Promote community-led adaptation initiatives to build local resilience and enhance public awareness of climate-health challenges.

6. Foster inter-sectoral collaboration to align health adaptation strategies with broader national and global climate goals.

7. Conduct regular assessments of climate-related health vulnerabilities to guide evidence- based policy and decision-making. 1.4 HNAP Development Process The HNAP was updated after initial meeting with WHO country office. An extensive literature review of all relevant policies, legislations, strategies, programs, and studies on climate change and health. The HNAP development was guided by relevant reports, strategic plans and other critical documents such as: HNAP 20218, National Adaptation Plan 2022, V&A assessment 2021, WHO Operational Framework 2023, WHO quality criteria for HNAP, etc. (a detailed list is provided in Annex 3). Key Informant Interviews (KII) were conducted with seven selected interviewees, involving representatives from both the government (five KI) and non-government sectors (two KI). Additionally, a technical workshop was conducted, with representatives from 12 non-governmental organizations working in the field of climate change & health and representatives of IEDCR and WHO. The HNAP update was finalized through a series of consultative meeting with technical advisors, technical experts (in health, climate and finance), the VAALO Technical team and, WHO experts. Shared with development partners, UN agencies and other sector partners to collect feedback and reflect on the final version.

2. Climate-related health risks in Bangladesh Bangladesh is highly vulnerable to the impacts of climate change, given its geographical location, low- lying topography, high population density, and socio-economic challenges. 2.1 Vulnerability and Adaptation Assessments 2.1. a. Vulnerability and Adaptation Assessment Climate Change and Health, Bangladesh, 2011 To better understand the health risks of and adaptation to climate change a vulnerability and adaptation assessment for Climate Change and Health was conducted in 2011. The study used qualitative and quantitative approaches based on data availability to explore associations between climatic variables and a range of climate-related health outcomes, including vector-borne diseases (Kala-azar, dengue, and malaria), water-borne diseases (cholera and diarrhea), and mental health, as well as impact from extreme weather events. The data showed significant co-relationship between climatic factors and Kala-azar incidence in Mymensingh, Tangail and Jamalpur districts, the three districts with majority of Kala-azar cases in Bangladesh. To quantify the extent of impact from climate change on diarrhea incidences, the report analyzed the relationship between temperature and admitted cases of diarrhea. These results were then used to establish scenarios as indicative measures of potential climate change impacts to diarrhea distribution

2. Climate-related health risks in Bangladesh 7 | P a g e in Bangladesh by 2030. Estimates presented in the report predict a 4.5– 5.5% increase of initial risk of diarrheal diseases by year 2030 for a 1 °C increase in temperatures for Bangladesh. 2.1. b. Vulnerability and Adaptation to Climate Change in Coastal and Drought Prone Areas of Bangladesh: Health and WASH, 2015 In 2015 a Vulnerability and Adaptation to Climate Change in Coastal and Drought Prone Areas of Bangladesh: Health and WASH was conducted to better understand the vulnerabilities of the communities due to the impact of climate change and its links to WASH and health in Bangladesh (Mahmood, Kabir, Rutherford, Islam, & Chu, 2015). The study used both qualitative and quantitative methods, field sites were pre-selected to include both flood and drought prone areas based on expert judgment. A total of three communities were selected: one from a drought-prone area and two from coastal regions. Drought prone areas were identified as the most vulnerable to changes in climate due to reduced rainfall and reliability of seasons which have adversely affected drinking water supplies, agricultural production, and livelihoods, further exacerbating poverty. Coastal communities, on the other hand, are vulnerable to climate changes associated with increased rainfall, more frequent and severe flooding, extreme temperatures (hot and cold), shifting seasonal patterns and rising sea-levels. 2.1. c. Health Vulnerability and Adaptation Assessment of Climate Change Impact in Bangladesh, 2021 In 2021, the Ministry of Health and Family Welfare (MOHFW) conducted the Health Vulnerability and Adaptation Assessment of Climate Change Impact in Bangladesh to assess the health vulnerabilities caused by climate change and extreme weather events in five distinct geographical regions. These regions included drought-prone areas, flood-prone areas, coastal zones prone to cyclones and storm surges, hilly areas susceptible to landslides, and urban areas facing specific vulnerabilities. The study summarized findings from household surveys, focus group discussions (FGDs), and community meetings conducted in these regions. Respondents widely reported noticeable climate changes, including rising temperatures, longer summers, and shorter winters. These observations were corroborated by meteorological data, which showed a 0.2–0.4°C increase in maximum summer temperatures (April–September) in the study areas. Community members also noted changes in rainfall patterns, with more erratic rainfall events, consistent with available rainfall data. They further reported an increase in new insect species affecting agriculture and a decline in freshwater availability, both of which have implications for food security. These changes are adversely affecting health, as specific health issues were found to be linked to the changing climate. The analysis of waterborne and vector-borne diseases highlighted the effects of temperature and rainfall variability on health. For instance: Diarrheal cases peaked in June in Ullapara due to high temperatures and low rainfall; in Birampur and Dhaka, cases spiked in April; in Patuakhali, in May; and in Rangamati, in December. Malaria cases were most common between June and August, attributed to high rainfall, humidity, and temperature. Further, the study found that health vulnerabilities were nearly equal among men and women in the surveyed areas.Dhaka city shows low vulnerability compared to the other study areas, especially rural areas, due to its more advanced healthcare infrastructure and systems.. Key findings indicate that rural health systems and other sectors that have direct/indirect impact on health outcomes (e.g., sanitation, food security, water) need more attention from the government to adapt to the adverse impact of climate change and variability. While the transportation infrastructure has improved, enabling quicker access to hospitals, hard-to-reach areas remain a challenge. Most participants expressed satisfaction with outpatient department and inpatient

2. Climate-related health risks in Bangladesh 8 | P a g e department of the hospital, and health professionals noted that the health system is prepared for extreme weather events such as floods or cyclones. However, the household survey revealed that the local health system's response to extreme weather events, at the local level, remains insufficient The report also examined vulnerability and adaptation in the context of WASH programs in the selected areas, highlighting the need for targeted interventions to address climate-related health challenges. 2.2 Water-borne and water-related disease Climate change and variability, particularly impacts from drought, flooding, and tropical cyclones, pose a substantial threat to water security and are projected to increase the potential of waterborne infectious diseases in Bangladesh, including cholera and other diarrheal diseases. Climate change significantly exacerbates the prevalence and spread of water-borne and water-related diseases in Bangladesh. Cholera outbreaks, which often occur during seasonal monsoons could become a regular phenomenon in the future due to climate change (Shahid, 2009). Extreme weather events have the potential to damage water and sanitation infrastructure, disrupt health services, and create overcrowding situations resulting in serious waterborne disease risks to the affected population. This combined with other factors, such as high rates of urbanization and land-use change, put a significant strain on freshwater supplies and can lead to further risk of water-borne and water-related disease. 2.2.1 Diarrhea Increased temperatures and changing rainfall patterns can lead to the proliferation of other bacteria in water bodies. Flooding, which often follows cyclones and heavy monsoons, can contaminate drinking water supply, exacerbated by concurrent severe flooding events in the community water sources, leading Figure 5: Distribution of Diarrheal cases in 2023 (Jan-Dec; Figure 4: Distribution of Diarrheal Diseases in eight divisions of Source: Health Emergency Operation Center & Control Bangladesh (Jan- Dec 2023; Source: Health Emergency Room, 2023 Operation Center & Control Room, to outbreaks by these bacteria or virus. Infection (e.g., Cholera, Hepatitis, Salmonella) Flooding and inadequate drainage systems can overwhelm sanitation facilities, causing sewage to contaminate water supplies. In the baseline year 2008, there were an estimated 25 500 diarrheal deaths in children aged under 15 years. Under a high emissions scenario, diarrheal deaths attributable to climate change in children aged under 15 years are projected to comprise about 8% of the over 8000 deaths projected in

2030. Although diarrheal deaths are projected to decline to just under 900 by 2050, the proportion of deaths attributable to climate change will rise to 13% (HNAP 2018). Limited access to safe water and sanitation contributes to the risk of developing diarrheal disease. Children in poor rural and urban slum

2. Climate-related health risks in Bangladesh 9 | P a g e areas are at high risk. Transmission of enteric pathogens is higher during the rainy season. Drainage and storm-water management is important in low-income urban communities, as blocked drains are one of the causes of increased disease transmission. There have been significant gains in the provision of improved sanitation and safe water supplies over the past few years. Figure-4 shows cases of diarrheal diseases distribution in eight divisions with maximum cases in Dhaka and Chattogram divisions and Figure-5 shows post-monsoon rise of diarrhea cases in Bangladesh. 2.3 Vector-borne disease The transmission of vector-borne disease, particularly mosquito-borne diseases, are sensitive to climatic factors such as increases in temperature and humidity and changes in rainfall patterns, more frequent and intense interrupted rainfall can create favorable conditions for breeding, which affect both the mosquito lifecycle and the number of breeding sites (Kovats, Bouma, Hajat, Worrall, & Haines, 2003). An assessment supported by the World Bank using monthly surveillance data in regions of high- incidence of vector borne disease found strong seasonality and statistically correlation between short- term climate variability and vector-borne disease. For malaria and dengue, climate variables, including temperature, rainfall, and humidity, had a strong correlation with disease caseload, both current and lagged. For Kalaazar, only temperature was significantly correlated increases in transmission diseases. (Mani & Wang, 2014) With the increased temperatures in climate change there are changes in precipitation patterns. The intense rainfall has contributed to round the year of Dengue in Bangladesh. Bangladesh is also vulnerable to other emerging climate-sensitive vector-borne diseases, e.g., Chikungunya, an arboviral disease transmitted between human beings via the bites of infected female aedes mosquitoes (Aedes aegypti and Aedes albopictus). The Figure-6 shows monthly (2011-2017) case distribution of vector born disease in Bangladesh. Figure-7 depicts the geographic distribution of Malaria, Dengue and Kala-azar in Bangladesh, (2011). In 2017, a major outbreak of Chikungunya was reported in Bangladesh with 984 cases confirmed and more than 13 176 clinically confirmed cases in 17 of 64 districts, including the capital Dhaka (Kabir, Dhimal, Müller, Banik, & Figure 4: Trends and monthly patterns for vector-borne diseases, 2011-17; Source: Haque, 2017). The outbreak NKENMCP, 2017 was anticipated based on the distribution of the aedes vector, suitable climatic conditions, and unusual, excessive rainfalls. Limitations in testing infrastructure and resources delayed containment efforts. Climate model projections under both high and low emissions scenarios suggest the likelihood of expansion of transmission-suitable areas in many parts of the world (Tjaden et al. 2017).

2. Climate-related health risks in Bangladesh 10 | P a g e Figure 7: Geographic distribution of vector-borne disease in 2011, Source: Mani & Wang, 2014 2.3.1 Malaria: The National Malaria Control Program is a vertical program coordinated by the Communicable Disease Control Program of the Directorate General of Health Services. Advances in diagnosis and treatment have contributed to reductions in severe malaria cases. Figure-8 depicts the pattern of Figure 8: Rainfall Vs Malaria cases (2015-2019), Source: icddr,b, n.d. malaria cases during 2015-2019 corresponding to total rainfall. A major challenge for this program is that malaria hyper-endemic forested and hilly areas are remote, inhabited by largely undeveloped and very poor people. The mainstay of prevention for populations at risk is the provision and use of insecticide-treated nets. Climate change will impact on the epidemiology of malaria in Bangladesh if the distribution of infected mosquitoes’ changes so that non-immune populations are exposed. It is projected that by 2070 over 147 million people will be at risk of malaria, assuming a high emissions scenario. If emissions decrease rapidly, this could decrease to 117 million people (WHO 2015a), Figure-9 shows the distribution of malaria endemic areas in Bangladesh. the pattern of national malaria cases during 2015- Figure 5: Malaria Endemic areas in Bangladesh, Source: Haque et al., 2010 2019 corresponding with total rainfall.

2. Climate-related health risks in Bangladesh 11 | P a g e 2.3.2 Dengue Dengue is becoming high endemic in major cities in Bangladesh. The burden of disease is high, although it is difficult to quantify as only hospitalized patients are reported. Dengue incidence is related to precipitation, humidity and temperature. Although cases occur year-round, peak incidence occurs in post-monsoon season. Climate change is expected to affect the epidemiology of dengue via various mechanisms. Changes in rainfall pattern, particularly longer rainy seasons, will increase the sites where Aedes mosquitoes breed. Increasing urbanization will increase breeding sites near human habitation. Population migration will alter the underlying immunity to dengue serotypes or contribute to changing geographical serotype distributions, which can lead to outbreaks. Extreme weather events will disrupt health systems and the capacity to perform surveillance of, and manage, outbreaks. Although it is difficult to quantify the projected burden of dengue under future climate change conditions, data from the Directorate General of Health Services of Dhaka city show that it is likely that the rapidly growing urban and peri-urban regions where public health measures (vector control, public education, Figure 6: Number of dengue cases (A) and deaths (B) reported by epidemic week from 2018 to 2023 [as of 5 August (epidemiological week 31) 2023] Source: WHO, 2023a surveillance) are compromised or neglected will be particularly affected. A recent year-round surveillance study found that the abundance of Aedes mosquito larvae in Dhaka varied in different months, and the highest and lowest number of Aedes larvae were found in the months of June and February, respectively (Kayesh, Khalil, Kohara, & Tsukiyama-Kohara, 2023). The Figure-10 shows the Number of dengue cases (A) and deaths (B) reported by epidemic week from 2018 to 2023. From 1 January to 7 August 2023, the Ministry of Health and Family Welfare of Bangladesh reported a total of 69 483 laboratory-confirmed dengue cases and 327 related deaths, with a case fatality rate (CFR) of 0.47%. Of these, 63% of cases and 62% of the deaths were reported in the month of July 2023. Although dengue is endemic in Bangladesh, the reported dengue surge was unusual in terms of seasonality and the early sharp increase in comparison to previous years, where the surge started around -late June. Figure-11 shows the seasonality of Dengue outbreak in Bangladesh from 2010- 2021. The CFR was also relatively high compared to previous years for the full-year period. The pre-monsoon Aedes survey shows that the density of mosquitoes, and the number of potential hotspots is at the highest level in the past five years. The higher incidence of dengue is taking place in the context of an unusual

2. Climate-related health risks in Bangladesh 12 | P a g e Figure 7: Seasonality of Dengue outbreak in Bangladesh from 2010- 2021; Source: Hossain, Noman, Mamun, & Mosabbir, 2023 episodic amount of rainfall, combined with high temperatures and high humidity, which have resulted in an increased mosquito population throughout Bangladesh (WHO, 2023b). Between the first (2000– 2010) and the second decade (2011–2022), dengue cases have increased by 8.3 times, and annual deaths have increased by 2.2 times in Bangladesh. Figure-12 reflects the Division-wise Dengue case distribution in year 2022. This growth of cases may partly be explained by global warming, with an increase of 0.49°C annual temperature as well as changes in Figure 8: Division-wise Dengue case distribution in year 2022, Source: ATDCP, 2022 duration and length of the rainy season. Unusual early or late rain in and beyond the monsoon season likely contributed to extending the length of the dengue transmission season in Bangladesh. The monthly mean temperature and monthly total rainfall of the first-lagged month and second lagged months showed a large influence on the monthly DENV cases in Bangladesh (Hasan et al. 2024).

2. Climate-related health risks in Bangladesh 13 | P a g e 2.3.3 Chikungunya The threat posed by chikungunya stands to increase significantly due to climate change: nearly a billion additional people could become at risk for Aedes- borne arboviral diseases, such as chikungunya, by 2030 as a direct result of climate change. Figure-13 reflects chikungunya infected patients in Dhaka city, 2017. Rising temperatures and changing rainfall patterns have provided increased habitats for vectors harboring deadly diseases, while deforestation and urbanization have altered transmission dynamics. Chikungunya has recently experienced an alarming spread— beyond typical geographic areas and outside of normal seasonality—largely attributed to changes in climate and population movement (Love Eliza et. al 2023). Chikungunya continues to be a major public health concern in Bangladesh. Following the initial outbreak in 2008 and a significant Figure 9: CHIKV infected patients in Dhaka city 2017 Source: epidemic in 2017, recent research has Hossain et al., 2018 shown that about 2.4% of the population has been exposed to the virus, with higher exposure rates in central and southern regions. This indicates that a substantial portion of the population remains susceptible to future outbreaks. Additionally, the study found that men and individuals previously infected with dengue are at higher risk for chikungunya (Sam W. Allen et al., 2024). To mitigate the impact, efforts are focused on enhancing surveillance and mosquito control, including preventing standing water that serves as breeding sites for Aedes mosquitoes and improving the integration of epidemiological, clinical, and laboratory data for more effective public health responses. 2.4 Climate Change Impact on Nutrition and Food Security Climate change significantly impacts nutrition and food security in Bangladesh, a country particularly vulnerable to environmental changes due to its geographic location and socio-economic conditions. Livelihood of many people in Bangladesh depends on agriculture and rural-based economic activities. Any changes in weather and arable land will lead to food insecurity and more poverty. This requires coordinated efforts across sectors, including agriculture, health, infrastructure, and social services. Long-term planning and international cooperation are also crucial for building resilience. Vulnerable groups, especially children, pregnant women and elderly, risk further deterioration into food and nutrition crises if they are exposed to extreme weather events. Without considerable efforts to improve climate resilience, it has been estimated that the risk of hunger and malnutrition could increase by up to 20% by 2050.

2. Climate-related health risks in Bangladesh 14 | P a g e The effects of climate change on agriculture, food production, and overall food security in Bangladesh include: 2.4.1 Agriculture and Crop Yields Increased temperatures can stress crops, reduce yields, and alter the growing seasons for key staples like rice. Heat stress can also reduce the productivity of livestock and fisheries, crucial components of Bangladesh's food system. Changes in rainfall patterns, including erratic monsoons, droughts, and reduced freshwater availability, can adversely affect irrigation, crop growth, and soil fertility. Floods and droughts can lead to crop losses and decreased agricultural productivity. Rising sea levels contribute to saltwater intrusion into coastal agricultural lands. This increased soil salinity hampers crop production, particularly affecting rice paddies, which are sensitive to salinity, disrupt food supply chains, and destroy infrastructure. These events can lead to temporary or long-term food shortages and increased food prices. 2.4.2 Fisheries and Aquaculture Warmer waters can impact fish populations by altering breeding cycles, reducing fish stocks, and affecting the availability of certain species, crucial for the local diet and economy. Increased salinity and pollution from coastal flooding can affect aquaculture, reducing the quality and quantity of fish and shrimp produced. 2.4.3 Livestock Rising temperatures can reduce livestock productivity, affecting milk production, growth rates, and overall health. Changing climate conditions can lead to an increase in vector-borne diseases affecting livestock, further impacting food security. 2.4.4 Socio-Economic and Nutritional Implications Reduced agricultural productivity leads to lower food availability, particularly affecting staple crops like rice and wheat. This can result in increased dependence on imports, which might not always be reliable or affordable. Climate change can lead to increased food prices, making it harder for vulnerable populations to access nutritious food. This economic strain disproportionately affects low-income households, exacerbating malnutrition. Reduced availability of diverse food sources can lead to a decline in dietary diversity. This increases the risk of micronutrient deficiencies and malnutrition, particularly among children and pregnant women. Many Bangladeshi households depend on agriculture, fisheries, and livestock for their livelihoods. Climate-induced disruptions in these sectors can lead to loss of income and increased poverty, further impacting food security. 2.5 Non-Communicable Diseases In Bangladesh, non-communicable diseases (NCDs) are emerging as a major cause of morbidity and mortality, accounting for 61% of deaths in 2013 (Alam, Robinson, Kanungo, Hossain, & Hassan, 2013). Cardiovascular disease, diabetes, and tobacco-related illness are the three most common NCDs in Bangladesh and make up a considerable proportion of mortality, morbidity, and Figure 10: Major causes of death due to NCDs Source NCDC, 2022:

2. Climate-related health risks in Bangladesh 15 | P a g e health system utilization. Figure-14 shows some major causes of death due to NCDs. The effects of climate change have the potential to exacerbate the incidence of some NCDs, including cardiovascular disease, some cancers, respiratory health, mental disorders, injuries, and malnutrition (Friel et al., 2011). Climate change as an additional driver of NCD risk include adverse effects on domestic agriculture, as well as climate change related population displacement leading to increased urbanization and driving unfavorable changes in diet and physical activity, further increasing the burden of NCDs. 2.6 Mental health Climate change also have significant indirect effects on the psycho-social well-being of individuals and communities (Berry, Bowen, & Kjellstrom, 2010). The relationship between climate change and mental health is complex, as it can exacerbate existing mental health conditions and contribute to new ones. Extreme weather events have a profound impact on affected populations in Bangladesh, leading to adverse influences on mental health through various pathways, including declining income from agriculture production, displacement, and post-traumatic circumstances. The 2012 Vulnerability and Adaptation Assessment examined the relationship between mental health and climate change using hospital admissions records for various mental health disorders, meteorological data, and disaster information (CCHPU, 2012). Overall, mental health should be a priority for the health sector, due to impacts of climate change potentially increasing the risk of mental health disorders. Extreme events, such as temperature increase, heat waves, floods, drought, tornadoes, hurricanes, and wildfire consequences are distress symptoms, suicide rates, and clinical disorders (depression, anxiety, sleep disturbances, PTSD, etc.) (Cianconi, Betrò, & Janiri, 2020). Climate change will produce profound changes in the environment and alter lifestyles, while also generating environmentally motivated migration (random asylum seekers and climatic refugees). These groups of people, forced to migrate, already have their own psychological vulnerabilities (Torres & Casey, 2017). The trauma and stress associated with losing homes, livelihoods, and communities to natural disasters contribute significantly to the mental health burden. Furthermore, extreme events can produce various types of psychopathological reactions over time, as they affect mental health acutely, sub acutely, and over a prolonged period. The level of anxiety disorders increases with temperature and humidity. Increase in mean humidity and mean temperature increases the probability of having anxiety by 0.3 percent and 0.8 percent, respectively. More people suffer from depression during winter. Increase in temperature lowers the probability of depression by 1.6 percent. Further, women are at higher risk than men for depression, while men are more susceptible to anxiety. (World Bank, 2021). Figure-15 shows health outcomes related to climate hazards and health determinants. Evidence shows that a 1°C increase in temperature increases the probability of reporting an anxiety disorder by 21%, while exposure to natural disasters such as flooding increases the likelihood of depression by 31%, anxiety by 69%, and co-presence of both these conditions by 87% (Wahid, Raza, Mahmud, & Kohrt, 2023). Climate change-induced natural disasters also displace a substantial number of people in Bangladesh every year. More than seven million people were displaced by these events in 2022 alone, with the number expected to increase to 13 million per year by 2050 (World Bank, 2022). Here are some keyways in which climate change affects mental health: [Source: O'Leary, Dasgupta, & Robinson, 2023]

2. Climate-related health risks in Bangladesh 16 | P a g e Climate Hazards Health Determinants Health Coutcomes Floods & extreme rainfall Food insecurity Mental Health issues Droughts Loss of livelihood Mental Health Heat waves & Droughts Migration Mental Health Tropical storms Displacement & migration Mental Health Wildfires Food insecurity Mental Health Floods Migration Mental Health Sea level rise Figure 11: Mental Health impacts of the six weather-related events, Source: Customized, WEF, Quantifying the Impact of Climate Change on Human Health. Insight Report January 2024. 2.7 Extreme weather events Bangladesh has a long history of extreme weather events, such as flooding (coastal and inland), drought, cyclone, salinity and storm surges, all of which have a significant impact on human health directly and indirectly, through injuries, disease outbreaks, nutritional deficiencies, psychological well-being, and lives lost. Displaced populations as a result of climate-induced extreme weather events, economic distress, or conflict situations are also highly vulnerable to health risk. Coastal regions especially are vulnerable to sea level rise and saline intrusion leading to contamination of drinking water and low levels of freshwater contributes to increase of water-borne disease (e.g-diarreheal disease). Figure-16 shows percentage of water-borne, water-washed and water-related disease occurrences by salinity and non-salinity areas (Coastal Bangladesh). Figure 12: The pie Charts showing the percentages of water-borne, water-washed and water-related disease occurrences by salinity and non-salinity areas (Coastal Bangladesh) Source: Asma & Kotani, 2021 Frequency of drought, flooding and cyclone events are also increasing, exacerbating food and water security issues, as well as risk of disease outbreaks. Additionally, decreased freshwater availability may lead to reduced food production, which in turn may lead to malnutrition.

2. Climate-related health risks in Bangladesh 17 | P a g e Heat impact on health includes heat exhaustion, heat stroke, dehydration, electrolyte disorders, diarrhea, and respiratory illnesses. Due to their long exposure to high temperatures, daily wage workers are most likely to suffer from heat-related illnesses (HRIs). Bangladesh is one of the world’s most climate- sensitive health risk countries and future predictions indicate that both the frequency and intensity of risks (heat-waves) will rise. Additionally, increasingly higher temperatures are linked to AMR because they are associated with increased bacterial growth rates and horizontal gene transfer (Philipsborn et al. 2016). When Temperature rises above 40.5°C hyperthermia results, with clinical manifestations of “sweating, flushing, tachycardia (rapid pulse), light-headedness, headache, muscle cramps, hypotension, confusion, delirium, seizures, and finally, coma” (Cheshire 2016). Dehydration and electrolyte disturbances are common symptoms of heat exhaustion, which can progress to heat stroke. Heat exhaustion related dehydration can result in lower blood volume (and BP) which reduces cardiac filling, and in compensation increasing heart rate. The main cooling mechanism is sweating where salt and water can be lost at up to 2 L/hour. This cutaneous vasodilation dissipates the loss by radiant and convective pathways. A multi-hazards risk map (Figure-17) for Bangladesh illustrates the spatial distribution across the country (CEGIS, 2021). The risk map includes all described hazards and segregates the country into 11 climate stress areas defined as follows under National Adaptation Plan of Bangladesh (2023‐2050). Figure 13: Climate Stress Areas of Bangladesh Source: National Adaptation Plan of Bangladesh (2023‐2050)

2. Climate-related health risks in Bangladesh 18 | P a g e 2.8 Health Impacts of Air Pollution in Bangladesh Bangladesh consistently ranks as one of the worst countries for air pollution, as well as having the highest death rate. Air pollution is high in both rural and urban areas. It increases both morbidity and mortality from respiratory infections, lung cancer and cardiovascular disease – non-communicable diseases, which constitute 67% of all-cause deaths in Bangladesh (WHO, 2021a). As Bangladesh’s climate is warming and air pollution is increasing, their interaction effect will likely have a detrimental effect on health outcomes, especially cardiovascular disease and respiratory disease. In Bangladesh, policies that reduce air pollution while mitigating climate change will have a significant positive impact on health as a co-benefit. Bangladesh initiatives that explicitly address climate change, air pollution and health: First, to address the health and climate impacts of air pollution, (O'Leary, Dasgupta, & Robinson, 2023), Second, the National Adaptation Plan (NAP) 2023–50 and Third, the Bangladesh Climate Change Trust Fund was established in 2010 to support programs and initiatives aimed at reducing the country’s vulnerability to climate change. Furthermore, access and utilizing international climate financing mechanisms such as the Green Climate Fund (GCF), the multilateral development banks (MDBs), Global Environment Facility (GEF), and Climate Investment Funds (CIF) will be essential to address the health impacts of climate change in Bangladesh. The Seventh Five-Year Plan (2016–2020) was commissioned to develop policies and institutions specifically, to build capacity in the area of environmental health through both public and private sector health care providers. 2.9 Plastic Pollution: WBG Report, Bangladesh’s Plastic Challenge, 2021: With rapid internal migration due to climate change and thus unplanned urbanization, Bangladesh faced a sharp increase in both plastic use and pollution. Plastic is a material that degrades slowly and into tiny particles (called micro-plastics), posing a significant risk to humans, marine life, and ecosystems.

3. Climate change and health-related institutional and policy framework Over the last three decades, Bangladesh has made substantial investments to make the country more climate-resilient and less vulnerable to extreme weather events. To guide this process various plans, strategies, and policies have been developed. The following sections highlight key institutional and policy mechanisms for climate change and health. 3.1 National Health Policy, Bangladesh 2011 The number 18th goal of National Health Policy 2011 clearly stated that “Ensure adequate epidemiological tracking of disease patterns and impacts of climate change on health”; Communicable diseases control, non-communicable disease control, Emerging diseases, and Climate change are some of the major/specific challenges to be addressed. The number 34th strategy of the NHP 2011 mentions that “It is imperative that coordinated initiatives needs to be taken to safeguard against the detrimental impacts of climate change. A thorough examination through field surveys and studies must be conducted to identify the short, medium, and

3. Climate change and health-related institutional and policy framework 19 | P a g e long-term effects of climate change on health. To alleviate the burden of diseases caused by climate change, a national action plan should be developed and implemented.” 3.2 4th Health Population and Nutrition Sector Program (HPNSP) 2017- 2022 (+2 years) The 4th Health Population and Nutrition Sector Program (HPNSP) January 2017 – June 2022, Contains 29 Operational Plans (OP): DGHS (14); DGFP (7); MOHFW (5); and other agencies (one each for DGDA, DGNM and NIPORT). Overall, 4th HPNSP addressed several crucial aspects of the health system's adaptability to climate change. But a separate operational plan on climate change adaptability within this sector program and in the future sector programs with separate budget is essential to control climate sensitive health outcomes effectively. Special attention is needed to enhance the surveillance of climate sensitive diseases and manage those cases early. This operational plan can work on public awareness activities, health manpower orientation activities, surveillance, epidemiological research, disaster response etc. Specific public health measures should also be directed to overall systems strengthening and to dealing with particular climate sensitive diseases. 3.3 Health population and nutrition sector development plan, OP (Operational Plan) The 4th Health, Population and Nutrition Sector Programme (4th HPNSP), Operational Plan, Communicable Disease Control (January 2017 - June 2022+2 years), DGHS, MOHFW has addressed climate change and health-related institutional and policy framework as an important activity. Following activities has been undertaken in response to climate change and health hazards: Communicable diseases program with emphasis on vector borne disease due to climate change; Activities on effects of climate changes including rising temperature, changing patterns of rainfall, sea- level rises are contributing a lot in vector bionomics; Disease Surveillance on disease burden due to climate change; continuous advocacy and sensitization of policy and decision makers; Establishment of effective communication network; Training and retraining of health workers on integrated disease surveillance at all levels; Regular monitoring and evaluation of integrated disease surveillance activities at all levels. Major Components of NCDC, OP includes climate change. The activities are Multisectoral National Policies and strategy in Bangladesh about greenhouse gas emissions, energy, transport, agriculture, and land. Climate change adaptation (preparedness) and mitigation (prevention) policies and interventions; Increase community awareness of health consequences of climate change; Mass awareness is to be developed for increased plantation, avoiding carbon emitting vehicles, adopting carbon free transportation like use of bicycle, walking, climate friendly housing & renewable energy; Capacity assessment of infrastructure and clinical capacity to respond to health impacts of climate sensitive conditions; Resilience of existing health systems to increase capacity against climate change; Climate- sensitive injury and disease surveillance; Systematic documentation of climate-sensitive health outcome in certain cyclone and flood prone upazila. 3.4 Health Curriculum Academic institution NIPSOM, DGME, Department of Occupational and Environmental Health course curriculum includes the following topics for MPH students on Climate change: Greenhouse concept; Global warming; Ozone depletion; Major health impacts associated with climate change; Ways in which

3. Climate change and health-related institutional and policy framework 20 | P a g e climate change will affect human health; Adaptation strategy to preserve health in a changing climate; Climate change affects human social structure, effects on socio-economic status, and psycho-social development. Following trainings are also provided on climate change and health: 3 Days Training on Climate Change; 3 Days Training on Climate Sensitive Diseases (CSD); 3 Days Training on Health effect due to Climate Change. At the medical college level, “Handbook on climate Change and Relevant Issues for MBBS Course” has been developed to bridge the gap between fields of medicine and environmental science. The handbook addresses impact of climate change and significant threats to on human health including the spread of infectious diseases, heat -related illnesses, and disruptions to healthcare infrastructure. This handbook aims to provide medical students with a comprehensive overview of climate change and its relevance to their profession. It covers key topics such as the science of climate change, the impacts on public health, and the role of healthcare professionals in mitigating and adapting to these changes. By incorporating this knowledge into their medical practice, students can become advocates for sustainable healthcare and contribute to the global effort to combat climate change. 3.5 Relevant documents addressing climate change and health 3.5.1 Eight Five-Year Plan (2020-2025) The Eighth Five-year plan of Bangladesh is considered as the key document that illustrates the strategy and action plan of the country to achieve its development goals, which is also aligned with the Sustainable Development Goal (SDG) targets. This document addresses the effect of climate change in detail. Regarding the impact of climate change on health, this planning document has prioritized strengthening of all tiers of the health system and better prepare it for emergency response, increasing the capacity of the health sector for coordinated post-disaster management and protecting people's health from climate change The Eighth Five-Year Plan accorded top priority to the push toward achieving water safety and reducing long-term risk from climate change and natural disaster and gained momentum through the adoption of a techno-economic Bangladesh Delta Plan 2100 (Bangladesh Planning Commission, 2018) covering the whole twenty-first century. 3.5.2 Seventh Five-Year Plan (2016-2020) Bangladesh faces environmental challenges due to economic progress and climate change due to greenhouse gas emissions. The Seventh Five-Year Plan acknowledges the health impacts of a degraded environment, including increased risk of diseases, malaria, dengue, cholera, heat stress on vulnerable populations, and food insecurity due to climate change. 3.5.3 Sixth Five-Year Plan (2011–2016) The Sixth Five-Year Plan recognizes the possible health impacts of a degraded environment, including due to climate change, and aims to “build capacity in the area of environmental health through both public and private sectors”. 3.5.4 3rd Health, Population and Nutrition Sector Development Plan [HPNSDP] (2011-2016) The HPNSDP recognizes ‘climate change and health protection’ as one of eight key priority interventions. As a result, one section of the document deals with ‘Environmental Health and Climate

3. Climate change and health-related institutional and policy framework 21 | P a g e Change’. As per the National Health Policy – An update 2008, this document recognizes the impacts that climate change will have on maintaining basic health needs. 3.5.5 Second National Communication (2012) The document focuses on health as a separate issue, with the SNC (Second National Communication) implementing adaptation measures for the health sector. These include raising awareness about climate change's impacts on health and the public, improving water supply infrastructure and sanitation facilities, conducting research on existing diseases' responses to climate change, developing appropriate adaptation measures, and identifying trade-offs with other sectors' adaptation or mitigation measures. 3.5.6 Vulnerability Assessment Aspect 2021 The 2021 vulnerability assessment focused on identifying population vulnerability to climate variability and change by verifying identified climate-sensitive diseases (CSD) and other health risk factors in climate-vulnerable regions for a better policy & plans of health programs for the improvement of health resilience. The assessment recommended establishing a comprehensive program for coordinating climate change-related health activities, improving communication between health professionals, increasing advocacy for climate change adaptation, enhancing community awareness, and ensuring adequate water supply. 3.6 Climate Change and Health Adaptation Strategy Report (2012) The document provides an extensive overview of the current and potential impacts of climate change on health outcomes, including vector-borne disease, water-borne disease, cardiovascular diseases, mental health, and extreme weather events. 3.7 Bangladesh Climate Change Strategy and Action Plan (2008) The Bangladesh Climate Change Action Plan (BCCSAP) is a comprehensive plan based on six pillars, with the first pillar focusing on food security, social protection, and health for the poorest and most vulnerable, including women and children. The remaining pillars include comprehensive disaster management, infrastructure, research and knowledge management, mitigation and low carbon development, and capacity building and institutional strengthening. 3.8 Nationally Determined Contributions 2021 Bangladesh Bangladesh's National Climate Change Plan (NCDP) aims to reduce emissions and contribute to global climate efforts by 2030. The country has made significant progress in reducing GHG emissions through various initiatives, such as the Mujib Climate Prosperity Plan, which seeks international financing for renewable energy and resilience initiatives. Government projects focus on disaster-affected families, tree planting, rainwater harvesting, solar power, and improved cook stoves. The National Solar Energy Roadmap sets long-term targets for solar energy. 3.9 National Adaptation Plan of Bangladesh (2023‐2050) Bangladesh, Geographic location and flat, low-lying topography, high population density, poverty and reliance on climate-sensitive sectors for water and food security, particularly water resources, agriculture, fisheries and livestock, increase its vulnerability to climate change. Climate-induced disasters such as tropical cyclones and storm surges, monsoon floods, flash floods, droughts, sea-level rise, salinity intrusion, ocean acidification, etc. are exacerbating stresses on the country’s otherwise tremendous development trajectory, impeding socioeconomic progress and human well-being. The

3. Climate change and health-related institutional and policy framework 22 | P a g e NAP addresses developing climate resilient infrastructures, improved public health and enhanced urban resilience. The National Adaptation Plan (NAP) 2022 for Bangladesh addresses the intersection of climate change and health comprehensively. Here are some key points related to climate change and health from the NAP 2022: Increased disease burden, including vector-borne diseases like malaria, dengue, and chikungunya, and water-borne diseases such as cholera, diarrhea, and typhoid; Rising temperatures leading to more cases of heat stress and heat-related illnesses, particularly among vulnerable populations, the elderly and outdoor workers. Higher temperatures and air pollution exacerbating respiratory conditions like asthma and chronic obstructive pulmonary disease (COPD); Climate change impacts on agriculture causing food insecurity and malnutrition, especially among children and pregnant women; Changes in temperature and humidity affecting food storage and safety, leading to foodborne illnesses; Strengthening health systems through capacity building and enhancing healthcare system responses to climate-related health issues; Developing and improving disease surveillance systems to monitor and respond to climate-sensitive diseases; Educating communities about the health risks associated with climate change and promoting adaptive behaviors; Implementing early warning systems for extreme weather events and disease outbreaks to reduce health risks; Building and upgrading health facilities to withstand climate impacts, ensuring continuous and safe healthcare services during extreme weather events; Improving access to clean water and sanitation to reduce the spread of water-borne diseases; Integrating health considerations into climate change adaptation planning at national and local levels; Promoting research on climate change and health to inform policy and practice, and improving data collection and analysis; Promoting collaboration between health, environment, agriculture, water, and other sectors to address the health impacts of climate change comprehensively; Engaging with international organizations and partners to leverage resources, expertise, and best practices for climate change adaptation in the health sector; Supporting community-based adaptation initiatives that address local health vulnerabilities and promote sustainable practices; Empowering local health workers and community leaders through training and resource provision to effectively respond to climate-related health challenges.

3. Climate change and health-related institutional and policy framework 23 | P a g e Table 1: Climate stress area coverage and related hazards with potential impacts Climate Climate Signal Districts Prominence of climate hazards Potential Impacts stress area and Hazards • Urban drainage problem resulting in prolonged water logging South- • Work hours reduced Satkhira, Khulna, Bagherhat, Rainfall variability, river floods, sea- • Education hampered western Pirojpur, Barguna, Barisal, level rise, salinity, tropical cyclone, • Vector-borne diseases due to waterlogged coastal area Patuakhali, Jhalokhathi, Bhola, storm surges, drought, extreme heat Excessive rainfall conditions and Shariatpur, Gopalganj, Jashore, waves, extreme cold, riverbank • Road damages and disrupted communications Sundarbans • Recurrent investment losses Sundarbans erosion and lightning (SWM) • Sanitation problems • Waste washouts that pollute the environment • Loss of infrastructure • Heatstroke and increased deaths • Drinking water crisis Rainfall variability, river floods, sea- • Work hours reduced for the marginal people South-east Noakhali, Feni, Lakshmipur, level rise, salinity, tropical cyclone, • Drops in water levels and quality and eastern Chattogram, Cox's Bazar, storm surges, drought, extreme heat Extreme heat • Declines in dissolved oxygen and poor coastal area Chandpur waves, extreme cold, riverbank habitats for aquatic species (SEE) • Roads, flexible pavement cracking, damaged erosion, lightning and landslides • Vector and water-borne disease outbreaks • The heat island effect intensified Chattogram Rainfall variability, flash floods, Hill Tracts Rangamati, Khagrachari, tropical cyclone, storm surges, • Distress and suffering for homeless and Cold spells (CHT) Bandarban drought, extreme heat waves, extreme marginalized people cold, lightning and landslides

3. Climate change and health-related institutional and policy framework 24 | P a g e Nilphamari, Kurigram, Lalmonirhat, Gaibandha, Rangpur, Bogura, Sirajganj, Pabna, Rajshahi, Jamalpur, • Houses, roads and other infrastructure Tangail, Manikganj, Dhaka, inundated and damaged Munshiganj, Mymensingh, • Communications problems Rivers, • Investment losses Sunamganj, Netrokona, Rainfall variability, river floods, floodplains, Frequent river • Outbreaks of diseases Habiganj, Kishorganj, Sylhet, tropical cyclones, tornado, extreme and erosion- floods • Severe water and sanitation problems Brahmanbaria, Narsingdi, heat waves, extreme cold, riverbank prone areas • Education hampered Narayanganj, Madaripur, erosion and lightning • Poverty increases (FPE) Gopalganj, Rajbari, Faridpur, • Loss of crops, poultry, fish and livestock Narail, Sariatpur, Barisal, • The agriculture supply chain disrupted due to Patuakhali, Bhola, Jhalokathi, poor communications Khulna, Chandpur, Cumilla, Noakhali, Lakshmipur, Cox's Bazar • Houses, roads and other infrastructure inundated and damaged • Communications problems Sunamganj, Netrokona, Rainfall variability, flash floods, • Investment losses Haor and • Outbreaks of diseases Habiganj, Kishorganj, Sylhet, tropical cyclone, tornado, extreme Early or frequent flash floods • Severe water and sanitation problems Maulvibazar, heat waves, intense cold, riverbank flash floods areas (HFF) • Education hampered Brahmanbaria erosion, lightning and landslides • Poverty increases • Loss of crops, poultry, fish and livestock • The agriculture supply chain disrupted due to poor communications Naogaon, Chapai Nawabganj, • A drinking water crisis in urban areas Drought- Rajshahi, Bogura, Joypurhat, Rainfall variability, tropical cyclone, Severe • Disease outbreaks in slum areas prone and Rangpur, Dinajpur, Meherpur, tornado drought, extreme heat waves, droughts/water • WASH problems barind areas scarcity Chudanga, Kushtia, Jashore, extreme cold and lightning • Less spring water in the hills (DBA) • Increased workload for women Magura, Jhenaidah

3. Climate change and health-related institutional and policy framework 25 | P a g e Rainfall variability, river floods, flash Northern, Panchagarh, Thakurgaon, floods, tropical cyclone, tornado, • Accidental deaths Frequent lightning north-western Nilphamari, Lalmonirhat, drought, extreme heat waves, extreme • Hearing problems region (NNW) Rangpur, Kurigram, Dinajpur cold, riverbank erosion, lightning and • Electrocution and fire hazards landslides Chalan beel Rainfall variability, river floods, • Damage to settlements and low-lying Pabna, Natore, Sirajganj, tropical cyclone, tornado, extreme Frequent landslides • Human deaths area of the Rajshahi, Naogaon heat waves, extreme cold, riverbank • Communication problems north-western • erosion and lightning Road and infrastructure damages region (CBL) Nilphamari, Lalmonirhat, Rainfall variability, river floods, sea- • Kurigram, Gaibandha, Severe drinking water crisis level rise, salinity, tropical cyclone, • Sanitation problems Sirajganj, Jamalpur, Char and tornado, storm surges, extreme heat Increased • Corrosion of road and bridge materials due to Mymensingh, Manikganj, Islands (CHI) waves, extreme cold, river bank salinity salt Need for recurrent investment Munshiganj, Shariatpur, erosion, lightning, higher sea surface • Human health issues like premature childbirth Chandpur, Bhola, Patuakhali, or death, stroke, high blood pressure, etc. temperature and ocean acidification Feni, Noakhali, Rainfall variability, sea-level Bay of Bengal rise,tropical cyclone, tornado, storm Frequent cyclones Bay of Bengal (maritime • Losses of houses and damages to properties and and ocean surges, extreme heat waves, lightning, • Losses of livelihoods boundary) storm surges (BoB) higher sea surface temperature, • WASH problems hypoxy and ocean acidification Urban areas Rainfall variability, urban floods, sealevel rise, salinity, tropical cyclone, • Infrastructure damages (URB) Sea-level rise • Recurrent loss of investment 43 cities storm surges, drought, extreme urban • Increased drinking water crisis due to salinity heat waves, extreme cold and intrusion lightning

3. Climate change and health-related institutional and policy framework 26 | P a g e National Adaptation Plan of Bangladesh (2023‐2050) highlighted Climate Resilient Infrastructures, Improved Public Health and Urban Resilience as below: The NAP 2023-2050 implementation process will also explore preferred adaptation choices or practices for WASH and health and will implement climate-resilient rural and urban WASH technologies, climate-resilient health-care facilities and boat ambulances. It will encourage extensive research on the climate sensitivity of health as well as vector or water-borne diseases, etc. The NAP 2023-2050 has adaptation strategies that includes climate-resilient and smart clean and healthy cities; climate-resilient WASH and health-care facilities for urban, slum and hard-to-reach areas, the Chattogram Hill Tracts, and coastal and drought prone areas. Alongside climate change-induced vector or waterborne diseases, research on climate sensitivity of diseases and boosting physical and mental health, well-being, etc., are adaptation entry points for the WASH and health sector. 3.10 National Adaptation Plan Road Map (2014) Prepared by the Ministry of Environment, Forest and Climate Change (MOEFCC) the National Adaptation Plan Road Map details steps and modalities, based on the UNEP Guidelines for Least Developed Countries (LDC), so that the country can formulate a NAP involving its own human and technical capabilities. 3.11 National Adaptation Program of Action (2005) The NAPA included fifteen priority activities of which two have a clear focus on health: Providing drinking water to coastal communities to combat enhanced salinity due to sea-level rise; and Mainstreaming adaptation to climate change into policies and programs in different sectors (focusing on disaster management, water, agriculture, health and industry). 3.12 Mujib Climate Prosperity Plan 2022-2041 Bangladesh faces increasing catastrophic impacts of climate change that could result in a 6.8% loss in GDP per year by 2030 if business as usual is pursued globally. Mujib Climate Prosperity Plan (MCPP) includes a number of ambitious new and strengthened adaptation efforts to build resilience in populations and ecosystems through investment this decade to contribute to 2041 outcomes. Minimizing and averting climate-induced losses and damages is also an international financing priority of this Plan. 3.13 Sustainable Development Goals (2030) The United Nations 2030 global agenda for sustainable development contains seventeen goals, most of which are related to health. In addition to Goal 13: Take Urgent Action to Combat Climate Change and its Impacts, other goals are relevant to climate change and health adaptation, including Goal 2: End Hunger, Achieve Food Security and Improved Nutrition and Promote Sustainable Agriculture, Goal 3: Ensure Health Lives and Promote Well-Being for All Ages, Goal 6: Ensure Availability and Sustainable Management of Water and Sanitation for All, as well as others. 3.14 Delta Plan 2100 The BDP 2100 is essentially an adaptive techno-economic plan involving the interaction of water, land use, ecosystem and climate change with development outcomes. Hence, hydrology plays a major role in delineating the planning regions for the preparation of the BDP 2100. The BDP 2100 seeks to integrate the medium to long term aspirations of Bangladesh to achieve upper middle income (UMIC) status and eliminate extreme poverty by 2030, and become a prosperous country by 2041.

3. Climate change and health-related institutional and policy framework 27 | P a g e 3.15 UNFCCC Policy context Over the past few years, global awareness of the connection between climate change and health has increased substantially. For the first time under the climate change negotiations process, the United Kingdom, as President of the 26th Conference of the Parties (COP26) to the United Nations Framework Convention on Climate Change (UNFCCC), promoted a health program, in collaboration with WHO and other relevant partners in November 2021. Furthermore, Bangladesh is co-chair of one of the working groups ATACH (Alliance for Transformative Action on Climate Change and Health). The COP 26 Health program included two initiatives to be implemented by health systems, namely on climate resilience and low carbon sustainability. At the 28th United Nations Climate Change Conference (COP28), countries reached a historic agreement on the Global Stocktake which calls for groundbreaking goals to triple renewable energy, double energy efficiency, and consensus to transition away from fossil fuels in energy systems. The conference also recognizes the urgency of taking action on climate change and the benefits for health from deep, rapid, and sustained reductions in greenhouse gas emissions, including from just transitions, lower air pollution, active mobility, and shifts to sustainable healthy diets (COP28 UAE Declaration on Climate and Health). 3.16 Key policy and implementation gaps for health adaptation A Review of Policies/Strategies, Plans and Programs relating to Health and Climate Change in Bangladesh identified the following gaps in policy for climate change and health adaptation. • Specification of how, where and when the health sector should engage with others • Evaluation of the extent to which past recommendations have been achieved and have reduced vulnerability to climate change; • Clear identification of measurable outputs or outcomes associated with future interventions; and • Clear timelines for action and funding strategies. • Nationwide Development of EWS and response for climate-sensitive health risks • CC&H resilience costs included into domestic and international planned allocations • Conducted valuation of co-benefits of health implications of mitigation policies

3. Climate change and health-related institutional and policy framework 28 | P a g e

4. Building a climate-resilient health system in Bangladesh The World Health Organization (WHO) presents its ‘Operational Framework for Building Climate Resilient and Low Carbon Health Systems 2023’, addressing the dual challenges of climate resilience and greenhouse gas (GHG) reduction in health systems. Climate change significantly threatens human health and universal health coverage, increasing climate-sensitive health outcomes as GHG emissions rise. To mitigate these impacts, transformative actions across sectors are essential, focusing on social and environmental determinants of health and the root causes of climate change. Health systems must adapt to provide safe, quality care, playing a leading role in this transformation through a sustainable, equitable approach supported by strong governance and political commitment tailored to national circumstances. 4.1 Introduction to Operational framework for building climate resilient and low carbon health systems, 2023 The framework is built on WHO’s 2015 version, incorporating low-carbon sustainability while maintaining its foundational approach. It serves as a resource for health sector managers, public health professionals, and decision-makers, guiding comprehensive planning, project proposals, and interventions on climate change and health. WHO’s framework, 2023 integrates climate considerations into the six building blocks of health systems: leadership, workforce, information systems, medical products, service delivery, and financing. By implementing the 10 key components of the six building blocks, health organizations can better manage climate-related health risks, promote environmental sustainability, and contribute to universal health coverage and the Sustainable Development Goals. The framework’s goal is to increase the climate resilience of health systems to protect and improve the health of communities in an unstable and changing climate, while optimizing the use of resources and implementing strategies to reduce GHG emissions. Implementing low carbon health practices would contribute to climate change mitigation while also improving health outcomes. Achieving these aims is an important contribution to universal health coverage (UHC), global health security, and specific targets within the Sustainable Development Goals (SDGs). WHO has identified six building blocks that are common and relevant to all health systems, and are needed to support the delivery of UHC and improve health outcomes. These are: (i) leadership and governance; (ii) health workforce; (iii) health information systems; (iv) essential medical products and technologies; (v) service delivery; and (vi) financing. For the whole health system to become climate- resilient and have low carbon pathways, each of its six independent building blocks must integrate climate change considerations. To provide a comprehensive health response to climate change risks and protect people’s health and health systems, this new framework proposes 10 components (detailed below) or functions linked to the six building blocks that when implemented by health systems would get translated into increased climate resilience and reduced GHG emissions.

4. Building a climate-resilient health system in Bangladesh 29 | P a g e 4.2 Operational framework for building climate resilient and low carbon health systems Goal: To increase the climate resilience of health systems to protect and improve the health of communities in an unstable and changing climate, while optimizing the use of resources and reducing GHG emissions. Objectives: The framework’s objectives are to: o Guide health sector professionals, including through their collaborations with officials in health determining sectors to understand and effectively prepare for the additional health risks posed by climate change, through climate resilient and low carbon approaches; o Present the main health system functions that need to be strengthened to build climate resilience and low carbon health systems, and use these as the basis for developing comprehensive and practical strategies (e.g. national climate change and health strategy) and plans (e.g. health component of National Adaptation Plan (HNAP) and healthy long-term low emission development strategies (LT-LEDS); o Support the development of specific interventions that can be implemented by health systems that address both the increased risks posed by climate change and progressive reduction of carbon emissions, and the synergies among these actions; and o Support health decision-makers to identify roles and responsibilities to develop and implement action plans for resilience, and low carbon pathways, engaging actors within and outside the health sector. Figure 14: The framework as a tool for building climate resilience and low carbon interventions in health facilities, Source: WHO, 2023b Figure 15: Organogram for HNAP implementationFigure 16: The framework as a tool for building climate resilience and low carbon interventions in health facilities, Source: WHO, 2023b

4. Building a climate-resilient health system in Bangladesh 30 | P a g e 4.3 Framework components for building climate resilient and low carbon health systems The overall purpose of HNAP 2024 is to support for building climate resilient and low carbon health systems, as well as mainstream climate risks into health policies, planning and programs. To accomplish this, the following section outlines the 10-components of the WHO Operational framework, 2023, highlighting long-term strategic objectives, as well as medium to long term adaptation actions appropriate for Bangladesh. The resulting HNAP Action Plan 2024-2029 aims to prioritize these adaptation options and layout plans and actions, and related indicators to be implemented in the next five-years. 4.3.1 Component 1: Climate-transformative leadership and governance A strong political leadership and willingness at the highest levels within the government to address the health risks of climate change and ensuring climate change considerations are included in all health programs. This component aims to establish specific responsibility and accountability mechanisms for climate change and health within the Ministry of Health and its departments, strengthened coordination and cross-sectoral collaboration across different ministries with its departments, such as water, agriculture, environment, and energy with Ministry of Health are required to promote and protect health. The strengthening includes collaboration across all relevant health programs, such as environmental health; epidemiological surveillance; vector and zoonotic control; water, sanitation and hygiene; mental health and NCDs; maternal and newborn health; health care waste management; air quality surveillance; chemical surveillance; preparedness and management of disasters; health information systems; health workforce and human resources; pharmaceuticals, technologies, infrastructure and the supply chain; and operation and delivery of health services, in addition effective response to climate change assessment, monitoring, regulation, and management of climate-related health risks that originate in other sectors. Accountability: Accountability is an integral part of health governance and of effective and efficient health system functioning. It requires engagement with, and accountability to the wider communities that are affected by the decisions taken on their behalf, on the provision of affordable health services for all, ensuring equity, quality and efficient people-centered care and healthy communities in a changing climate. Objectives for the implementation: o Governance – Specific responsibility and accountability mechanisms on climate change and health established within the Ministry of Health; o Policy development – Climate change considerations, both for resilience and low carbon sustainability, reflected in main health policies and programs. o Cross-sectoral collaboration – Cross-sectoral collaboration strengthened, and synergies maximized to ensure that decisions taken in other sectors protect and promote human health. Present status: The Climate Change and Health Promotion Unit (CCHPU) of the Ministry of Health and Family Welfare has been working on climate change and health issues under since 2010 (cchpu-mohfw.gov.bd) under the Ministry of Health and Family Welfare. The CCHPU lacks an appropriate country-specific

4. Building a climate-resilient health system in Bangladesh 31 | P a g e monitoring framework to guide the integration of climate change and health into various policies and plan, as well as provide feedback for decision-makers on key climate-related health risks. Measurable outputs and indicators for climate-transformative leadership and governance Component 1: Climate-transformative leadership and governance Objective 1: Governance Outputs Indicator Official documentation Designated climate change and health focal points Designation of Focal detailing the roles and within the Ministry of Health with specific Program Points responsibilities of the focal of action points. Health sector commitment to achieve climate Climate Resilience Policy Policy Adoption and resilience in the health system and strategy developed Implementation Health sector commitment to transition the health Documentation of Policy Low-Carbon or Net-Zero system (including health care facilities and supply Adoption and Integration in Emission Policy developed chains) to low carbon or net-zero emissions the health system Climate change and health focal points or units, climate change and health working in collaboration with relevant climate- focal points or units Designated number of sensitive health programs (e.g., vector-borne established and functional climate change and health diseases, nutrition, infectious diseases, disaster and SOP developed focal points or units risk reduction) to build climate resilient and low carbon programs Integration of gender considerations into Gender-sensitive approach adopted in the regulations regulations, and strategies Official endorsements and and strategies on climate change and health (e.g- climate change and formal adoption document gender action plan, GoB 2024) Meaningful participation of the health sector in main climate change processes at national, regional, and global levels with UNFCCC global negotiations, Establishment of formal Meetings & Workshops. National Adaptation Plan, National Communications participation network at all Participation document (NCs), Nationally Determined Contributions levels /report (NDCs), and long-term low-emission development strategies (LT-LEDS) promoted Objective 2: Policy development Outputs Indicator Develop National strategy on health and climate National strategy document Official endorsement and change (covering both resilience and low carbon developed publication of the national sustainability approaches) strategy Develop and integrate, Health component of HNAP document Published NAP, Bangladesh National Adaptation Plan (HNAP) as a chapter in the integrated in the NAP, with chapter on H-NAP with overall NAP Bangladesh endorsement Health is integrated into the Nationally Determined Updated NDC Document Presence of health-related Contributions (NDCs) sections and commitments in the NDC document. Establish mechanism to estimate GHG emissions in Mechanism to estimate Number of reports on GHG the health system GHG emissions developed Emissions incorporated in Policy document the national policy developed Develop roadmap or action plan in collaboration with The roadmap (action plan) The roadmap (action plan) health-determining sectors and community actors for for climate resilience in for climate resilience in implementation of HNAP to build climate resilience health systems developed health systems approved health system Develop roadmap or transition plan for reducing The roadmap (transition The roadmap (transition GHG emissions in the health system in collaboration plan) for reducing GHG plan) for reducing GHG with health-determining sectors, including emissions in health systems emissions in health systems decarbonization targets developed report / document Establish coordinated strategies within the health Coordinated strategies Coordinated strategies sector and in health-determining sectors to develop established endorsed and integration in policies for building a climate-resilient and low the NAP carbon health system, maximizing health co-benefits Objective 3: Cross-sectoral collaboration Outputs Indicator

4. Building a climate-resilient health system in Bangladesh 32 | P a g e Component 1: Climate-transformative leadership and governance Establish Agreements (e.g. MoU) between the Ministry of Health and key stakeholders at national Signed multisectoral level (e.g. meteorological and hydrological services, agreements and documents MoE, food and agriculture, energy, transport, Number of Agreements and on climate change and/or planning), including specific roles and Number of key stakeholders GHG emissions of health responsibilities in relation to protecting health from sector operations climate change and/or reducing the GHG emissions of health sector operations Establish Multisectoral governance and coordination Multisectoral governance (involving people, communities, civil society, private Multisectoral governance and coordination sector, and all other engaged stakeholders) and coordination mechanisms established, mechanisms to support climate resilience and mechanisms established document and meeting decarbonization in the health system by the support minutes of MOEFCC Main policies and strategies from health-determining Policies and strategies from sectors reflect climate change and health Number of health- health-determining sectors considerations both in relation to adaptation and determining sector policies incorporated mitigation Inter-ministerial group on climate change and health Inter-ministerial group on Number of Inter-ministerial established and promoting health in all adaptation climate change and health group meetings and meeting and mitigation policies of key health-determining established minute sectors Conduct Health impact assessments for new Health impact assessments mitigation and adaptation policies and programs in Number of Health impact are conducted by relevant all health-determining sectors, in accordance with assessments Reports sectors article 4.1.f. of the UNFCCC Adaptation Options: o To relocate and strengthening of the CCHPU at DGHS for better coordination and sectoral collaboration of climate change and health activities and issues with designated focal point and resources. o Develop a reporting tool to assist ministries and directorates in reporting CC&H activities to strengthen interagency coordinating platforms and climate-sensitive programs and health- determining sectors (water, environment, agriculture, energy) o Establish a HNAP TWG with agreed TORs for updating, monitoring, and evaluating progress of HNAP implementation 4.3.2 Component 2: Climate-smart health workforce The health workforce is key to building climate resilience and environmental sustainability of health systems. Strengthening the technical and professional capacity of health personnel, strengthening the organizational capacity of health systems, and promoting collaboration between the health sector and other sectors are the main objectives of this component. Health workforce competencies can be developed through pre-service education, lifelong learning, and mentoring. Skills required include understanding and using climate information for health interventions and decision-making; engaging in cross-sectoral action; conducting research, assessments, and interventions; and effectively managing climate change risks to health and health system performance. Objectives for the implementation o Health workforce capacity – Sufficient number of health workers with the required technical capacity to deal with the health risks posed by climate variability and change and to lead reductions in GHG emissions.

4. Building a climate-resilient health system in Bangladesh 33 | P a g e o Organizational capacity development – Resources, information, knowledge, and processes employed by health organizations used in an efficient and targeted manner to promote climate resilience and reduce their own GHG emissions and environmental impacts. o Information, awareness and communication – Improved information, awareness and communication on health impacts from climate change and opportunities for reducing emissions targeted among different target audiences (e.g. policymakers, health facility managers, media and communities). Present status: Distribution of workforce (sanctioned post) among different directorates and offices under MOHFW. There are about 233,339 sanctioned posts at the Ministry of Health and Family Welfare and its agencies, for Directorate General of Health Services (DGHS), Directorate General of Family Planning (DGFP) and Directorate General of Nursing and Midwifery (DGNM) (Source: HRH Data Sheet 2022, MOHFW, 2022). At the medical college level, Handbook on climate Change and Relevant Issues for MBBS Course” has been developed to bridge the gap between fields of medicine and environmental science. A regional training package consisting of 16 stand-alone modules on climate change and health was launched in 2015 for WHO SEARO and climate change and health has been included in school health programs in Bangladesh. Many health professionals received training in CC and health at national and grass root level by different organization after 2015. Climate change impacts a wide range of program areas, including communicable diseases, maternal and child health, and nutrition, but the non- communicable diseases control program unit is responsible for addressing climate change in all health programs. Measurable outputs and indicators for a climate-smart health workforce Component 2: Climate-smart health workforce Objective 1: Health workforce capacity Outputs Indicator Report on Number Health health workers received training on climate Health workers trained on workers trained and type of resilience in the past two years climate resilience training Report on Number Health health workers received training on low carbon Health workers trained on workers trained and type of sustainability in the past two years low carbon sustainability training Health workers in specific programs have Health workers in specific Percentage of health workers information and training on the interlinkages programs have received trained on climate and health between specific health outcomes and climate information and training. interlinkages variability and change Develop Health workforce capacity on Number of health workers decarbonization opportunities in health systems Health workforce capacity trained on decarbonization and health care facility operations, the supply developed practices. chain and in-service delivery No. of trainings Coverage of key topics in the Develop and impart ‘Curricula On Climate Curricula on climate curricula. Change and Health’ covering both resilience and change and health, Number of educational low carbon sustainability issues in secondary resilience and low carbon institutions incorporated and/or tertiary levels sustainability developed curriculum Objective 2: Organizational capacity Outputs Indicator development Develop contingency plans for the deployment of Contingency plans for the Approved Contingency plan sufficient health personnel for acute shocks (e.g. deployment of health Number of health personnel extreme weather events and outbreaks) at the personnel developed deployed at the relevant level relevant level Innovative approaches to reducing GHG Number of health facilities Innovative approaches to emissions at health system or health care facility adopted innovative approaches reducing GHG emissions at level (e.g. teams sharing best practices across to reduce GHG

4. Building a climate-resilient health system in Bangladesh 34 | P a g e Component 2: Climate-smart health workforce different domains, and a system of rewards) health care facility level promoted are promoted. Health workforce Health workforce participating in decision- Percentage of Health workforce participated in decision- making, planning and management of climate participating in decision- making, planning change risks making, meeting minutes management meetings Number of capacity building initiatives Capacity building Number of capacity building integrating climate change and health at early initiatives established initiatives stages of professional health training Develop innovative capacity building plans Innovative capacity Number of innovative capacity responding to identified human resources and building plans developed building plans developed institutional capacity gaps Objective 3: Information, awareness and Outputs Indicator communication Health professionals, the media and community Health professionals, the Number of Health professionals, leaders trained on climate change risk media and community the media and community communication, including communication of leaders trained leaders trained uncertainty Establish stakeholder forum on climate change Stakeholder forum on Number of Stakeholder forum and health as a way to engage health determining climate change and health meetings (meeting minutes) sectors, the media and community groups established Number of Stakeholder forum members Develop ‘Internal and external health Internal and external health Number of communication plans communication plans’ with focus on raising communication plans with developed awareness of climate change risks and health focus on raising awareness Implantation strategies outcomes and implementing efficient strategies to of climate change risks and build climate-resilient health system health outcomes plans are developed Internal and external health communication plans Internal and external health Number of communication plans with focus on measuring GHG emissions and communication plans with developed implementing strategies to reduce health system focus on measuring GHG Implantation strategies emissions emissions are developed Health workers and communities understand Health workers and Number of health workers who potential future health risks related to climate communities understand can identify climate-related change and the actions they can take potential future health risks health risks. and the actions Number of community members aware of climate-related health risks. Raise awareness among decision-makers, health Awareness among Number of decision-makers. workers, the media and community leaders on decision-makers, health Number of health workers. climate change and health workers, the media and Number of media and community leaders raised community leaders. Establish initiatives with focus on climate change Initiatives with focus on Number of climate change risk risk communication among different target climate change risk communication initiatives audiences, and develop health action plan communication developed. established. & action plan Endorsed health action plan developed Adaptation options: o Ensure new and in-service training of existing healthcare workforce to deal with emerging and reemerging diseases particularly focusing on CSDs. o Review and update enhanced climate focused health education programs for medical students o Conduct mass media and communication campaigns. 4.3.3 Component 3: Assessments of Climate and Health Risks and GHG emissions This component includes a range of assessments that can be used to generate policy-relevant evidence on the scale and nature of climate-related risks to health and health systems, and the impact of health

4. Building a climate-resilient health system in Bangladesh 35 | P a g e systems operations and GHGs emissions on the environment. It also includes generation of information on health-promoting mitigation actions and policies in sectors responsible for most of the GHG emissions. Vulnerability and Adaptation (V&A) assessments, help to identify populations and geographical areas that are most vulnerable to climate hazards; baseline conditions can be established and future climate change health impacts assessed; changes in disease risks can be assessed; protective measures need to be defined; and health systems' capacity to manage risks can be determined. the V&A assessment process include: Vulnerability and risk mapping, Modelling, Scenario development, Health system capacity and performance assessment, Economic assessments, Health impact assessments of decisions in other sectors, Specific risk, events, and hazard assessments. It is common for healthcare facilities to be exposed to climate-related hazards, such as cyclones, thunderstorms, droughts, floods, sea-level rise, extreme heat, and increased outbreaks of weather climate-sensitive diseases. As health systems are responsible for approximately 5.2% of global carbon emissions (Romanello et al., 2022) approaches and tools to understand key hotspots of these emissions are needed. New assessment tools for estimating GHG emissions from health systems and health care facilities are being developed (e.g. The Aga Khan Development Network’s Carbon Management Tool, 2021). Health systems and health care facilities measurement of emissions per bed will inform the development of targeted decarbonization and environmental sustainability actions and plans. By developing a dedicated carbon analytics capability in health systems, it will be possible to calculate emissions more accurately, fill evidence gaps, prioritize data-driven high impact projects, and monitor and verify emissions reductions. Objectives for the implementation o Health risks – A sound understanding of the main hazards, exposures, current and future health risks, vulnerabilities of different population groups, geographical areas, and health systems available in the country or region. o Perform detailed assessments of GHG emissions across the health sector to identify key emission hotspots at the national and facility levels. o . o Progress tracking – A process and system established to track progress in overall climate resilience and GHG emission in health systems as well as to assess health risks in an iterative manner. Present status: A climate change and health Vulnerability and Adaptation (V&A) assessment was conducted by the Climate Change and Health Promotion Unit in Bangladesh in 2011, which examined relationships between climatic variables and diarrheal disease, vector-borne disease (Kala-azar, dengue, and malaria), mental health, and impacts from extreme weather events; the V&A could not be mainstreamed into regular health programs due to lack of awareness and motivation. In addition, WHO conducted a vulnerability and adaptation to climate change study focused on health and WASH. Although extensive, the assessment was limited to nine communities located in coastal and drought prone areas and only focused on WASH-related impacts. World Bank supported climate change and health assessment conducted in 2014 attempted to measure health adaptation capacity. Using the 2011 Bangladesh Health Facility Survey and 2011 census data,

4. Building a climate-resilient health system in Bangladesh 36 | P a g e the study measured and mapped quality of health service delivery based four core indicators, covering equipment availability, essential drug availability, staffing quality, and patient satisfaction. The exercise summarized that there was strong evidence of poor geographic targeting of public resources in the health sector, as well as basic environmental infrastructure in Bangladesh (Mani & Wang, 2014). Furthermore, Health Vulnerability and Adaptation Assessment of Climate Change Impact in Bangladesh was conducted in 2021. This study was conducted under the WHO and MOHFW project titled “Building resilience of health and health system from the impact of climate change” with financial assistance from GEF. The project sought to achieve the outcome of updating HNAP through effectively revising and integrating health risks from climate variability and adaptation options. (Detailed about this study is already mentioned in 2.1.c). Measurable outputs and indicators for assessments of climate and health risks and GHG emissions Component 3: Assessment of climate and health risks and GHG emissions Objective 1: Health risks Outputs Indicator Conduct climate change and health vulnerability and Climate change and health Number of Climate adaptation assessments, providing evidence on vulnerability and adaptation change and health current and future health risks from climate assessments conducted vulnerability and variability and change adaptation assessments conducted and report produced Assess baseline rates and climate sensitivity of health Monitoring of changing risk Monitoring report of conditions, allowing the selection of priority risks, conditions and health changing risk conditions and continuous monitoring of changing risk outcomes assessed and health outcomes conditions and health outcomes Gathere information on health system’s capacity (for Information on health Report on health system’s each of the ten components included in this system’s capacity health risks capacity to address health framework) to address the increased health risks from from climate change risks from climate change climate change as part of the V&A assessments collected Results of V&A assessments integrated into health V&A assessments integrated V&A assessments system planning and into key climate change into health system planning integration report. processes (e.g. HNAP) and into key climate change processes Identification and mapping of vulnerable populations Vulnerable populations Report on identified and areas prone to high current and future climate- identified and areas mapped vulnerable populations related health risks Assessment of health trends in climate-sensitive Climate-sensitive diseases Assessment report on diseases health trends assessed climate-sensitive diseases Objective 2: GHG emissions Outputs Indicator Conduct assessment of GHG health sector emissions Assessment on GHG Number of facilities with emissions conducted GHG emissions inventories completed Publicly report a GHG inventory for a base year of Publicly the GHG emission GHG emission reported emissions. reported Information on the environmental impact, including Information on environmental Report of environmental GHG emissions, of products and services used or impact and GHG emissions and GHG emissions delivered by the health system developed impact Information on key GHG emissions in health systems Information on GHG Report of GHG emissions and/or health care facilities available and used to emissions in health systems in health systems and/or inform interventions aiming to reduce emissions and/or health care facilities health care facilities gathered Low regret interventions for reduction in GHG Interventions for reduction in Report on Interventions emissions identified for each of the key GHG GHG emissions identified for reduction in GHG emission hotspots (e.g. access to renewable energy, emissions energy efficiency, greener waste management practices, transition to low carbon transport, reducing Adoption rate of emissions from anaesthetic gases and inhalers) renewable energy

4. Building a climate-resilient health system in Bangladesh 37 | P a g e Component 3: Assessment of climate and health risks and GHG emissions solutions in healthcare facilities. Interventions to reduce supply chain emissions Interventions to reduce Report on interventions to identified, including through: more efficient use of supply chain emissions reduce supply chain resources; low carbon substitutions and product identified emissions innovation; and requirements for health system suppliers to reduce GHG emissions Agreements with health system suppliers to reduce Agreements to reduce GHG Number of agreements GHG emissions in the supply chain emissions achieved and partnerships for emission reduction in supply chains Number of health facilities with GHG emissions Health facilities with GHG Report of health facilities assessed emissions assessed with GHG emissions Objective 3: Progress tracking Outputs Indicator Assessments’ results used to identify a set of key Key indicators for health indicators to be tracked over time both for health systems’ climate resilience Key indicators systems’ climate resilience and reductions in GHG and reductions in GHG assessments report emissions emissions identified Establish a dedicated climate change team responsible for coordinating implementation of the Dedicated climate change Document of dedicated climate strategy and monitoring progress across the team established climate change team system Assessments’ results used to prioritize allocation of Assessments’ report to resources and effective climate change and health Assessments to prioritize prioritize allocation of interventions both for resilience and low carbon allocation of resources done resources sustainability Plan defined and establish mechanism for iterative Mechanism established for Iterative assessments assessments of health risks from climate variability iterative assessments Mechanism Report and change Adaptation options: o Update V&A assessments (2012, 2015 & 2021) every three/five year and include climate-related health risks, as well as vulnerable populations and refined scope o Coordination among different actors and relevant sectors o Incorporate details about HNAP in the NAP 2022, Bangladesh. 4.3.4 Component 4: Integrated Risks, Monitoring, Early Warning and GHG Emissions Tracking Integrated risk monitoring refers to the use of tools and epidemiological surveillance for early detection in conjunction with direct and remote sensing technologies for surveillance of the environmental determinants of health (e.g., water and air quality, variability in ambient temperature and humidity or incidence of extreme weather events); integrated monitoring and progress tracking including GHG emissions and other environmental impacts; and communication to inform timely action. Building climate resilience to respond to these challenges entails: (i) developing adequate capacity and flexibility to understand how climate conditions influence health outcomes; (ii) being able to anticipate changing health risks; (iii) informing preparedness, surveillance, and response in a timely manner; and (iv)monitoring health outcomes. Monitoring a broad range of signals around a health risk can allow changing conditions to be identified more quickly in order to anticipate detection of outbreaks and emergencies related to weather and climatic conditions and the core elements of climate informed EWS are to: “(i) monitor environmental

4. Building a climate-resilient health system in Bangladesh 38 | P a g e conditions; (ii) forecast high-risk conditions and initiate active surveillance; (iii) send alerts and communication; and (iv) establish a mechanism for early response.” (WHO, 2021b). Information sources on climate-risks may originate from local community knowledge, as well as multiple fields of scientific and practice-based knowledge (such as epidemiology, meteorology and climate, environment, agriculture, water resource management, environmental health surveillance). Relevant information may be qualitative or quantitative, as well as observational or modelled. Environmental impacts from health systems are related to land use, air pollution and GHG emissions through energy consumption (transport, electricity, heating, and cooling) as well as product manufacturing, procurement, use and disposal.

1. Integrated Disease Surveillance and Early Warning: o Collect, analyze, and interpret data on climate-sensitive environmental risks, hazards, and epidemiological trends to enable timely responses to health risks.

2. Monitoring and Progress Tracking: o Monitor and report on climate change impacts, health risks, vulnerabilities, health system capacity, and GHG emissions from health sector operations over time.

3. Communication: o Deliver timely warnings to health decision-makers, media, and communities, ensuring effective actions are taken to prevent adverse health outcomes. Objectives for the implementation Integrated disease surveillance and early warning – Data on climate-sensitive environmental risks, hazards, and epidemiological trends collected, analyzed and interpreted on a continual basis, and timely response to risks promoted. o Monitoring and progress tracking – Information on climate change, health risks, impacts, vulnerability, health systems capacity, environmental impacts and GHG emissions of health sector operations monitored and reported over time. o Communication – Timely warnings communicated to health decision-makers, the media and communities and translated into effective action to prevent negative health outcomes. Present status: EWARS: EWARS plays a vital role in tracking and predicting the emergence and transmission patterns of climate sensitive diseases by integrating climate data, disease surveillance, and early warning systems. EWARS guideline has been developed through extensive analysis, and collaboration with World Health Organization, Bangladesh, Institute of Epidemiology, Disease Control & Research (IEDCR), DGHS & Public Health experts. It provides comprehensive information on the setup, operation, and management of the surveillance system, along with detailed protocols for data collection, analysis, and reporting. This guideline will serve as a vital resource for healthcare professionals, epidemiologists, and disease control personnel at central and filed levels. The IEDCR in collaboration with WHO HQ, developed climate informed disease surveillance early warning and alert response system. EWARS is currently on trial basis at central (IEDCR) level and hopefully is going to be piloted in three sentinel sites in near future.

4. Building a climate-resilient health system in Bangladesh 39 | P a g e Carbon Emission: (GHG) 'Carbon footprint assessment of the healthcare facilities in Bangladesh-2023' is a pioneering initiative taken by the Institute of Epidemiology Disease Control and Research (IEDCR) under MoHFW with the technical assistance of World Health Organization to estimate the emissions generated from the healthcare sector in Bangladesh. The assessment aimed to evaluate and reduce carbon emissions from healthcare facilities in Bangladesh. The Carbon Management Tool developed by the Aga Khan Development Network was used for the assessment of carbon emissions from 9 hospitals of different categories over the period of 3 months. The annual emissions were projected from 3 months assessment. The carbon mitigation plan was developed for each of the hospitals considering carbon sequestration from tree species (existing and new plantation), and carbon trading mechanism. The mitigation plan indicates that significant profits could be achieved through waste management. Hospitals could also generate revenue by supplying solar energy to the national grid. Hospitals could improve their database management system to improve the record-keeping and make the data digitally accessible. Additionally, hospitals could foster behavioral changes to reduce carbon emissions, such as promoting carbon-neutral travel methods through staff recognition and tracking energy consumption to encourage competition in reducing emissions. By adopting the proposed mitigation strategies, hospitals could potentially achieve carbon neutrality or even negative emissions. Measurable outputs and indicators for integrated risks monitoring and early warning, and GHG emissions tracking Component 4: Integrated risks monitoring and early warning, and GHG emissions tracking Objective 1: Integrated disease surveillance Outputs Indicator and early warning Implement an integrated climate and health An integrated climate and Report on integrated climate and surveillance system for specific climate health surveillance health surveillance sensitive diseases implemented Identify early detection tools (e.g. rapid Documentation on early detection diagnostics, Syndromic surveillance) and Early detection tools tools used to identify changing incidence and early developed Implementation Report action for implementation Develop, Climate-informed health early Climate-informed health early Climate-informed health warning systems that predict the risk of warning systems development early warning systems outbreaks of priority infectious diseases (e.g. and implementation developed and implemented malaria, dengue, cholera) and implement documentation Use climate and weather data to predict risk Assessment tool for climate Assessment tool for using climate of outbreaks of climate-sensitive diseases (i.e. and weather information and weather data in disease risk integrated health and climate surveillance developed prediction developed systems) Number of participatory sessions MOH and cross-sectoral Participation of the Ministry of Health in conducted groups participatory sessions cross-sectoral groups receiving warnings on Number of participants attending on extreme-weather events extreme-weather events cross-sectoral discussions. held Geographic and seasonal distribution of Health risks and outcomes Reports on ‘Risk Mapping health risks and outcomes (e.g. risk mapping) mapping done ‘completed. tracked for priority climate-sensitive diseases Objective 2: Monitoring and progress Outputs Indicator tracking Monitoring process Establish, Monitoring process with a clearly Monitoring process established with established defined mechanism for the tracking system to clear mechanisms Record GHG emission/bed as measure progress in GHG emissions Number of GHG tracking reports per Guide to the Aga Khan reduction completed using established tools Development

4. Building a climate-resilient health system in Bangladesh 40 | P a g e Component 4: Integrated risks monitoring and early warning, and GHG emissions tracking Network’s Carbon Management Tool, 2021 Impacts from main climate-related Monitoring system to track Number and frequency of water, air, determinants of health (e.g. water availability the impacts of main climate- and food quality testing and reporting and quality, air quality, food) monitored by related determinants of health the health sector established Indicators on climate change risks, impacts, vulnerability, capacity of health systems, and Number of reviews conducted Relevant indicators identified emergency preparedness capacity, as well as annually and regular reporting done. climate and environmental variables included Improvements or deteriorations in relevant monitoring systems at the national identified and documented. level and reported over time Number of periodic reviews conducted annually. Periodic reviews for improvement or Periodic capacities reviews Number of assessment reports deterioration of capacities identified in V&A done through V&A produced & published assessments assessment Number of improvements or deteriorations identified Objective 3: Communication Outputs Indicator Develop and implement a communication Approved and published Comprehensive strategy on climate risks to health, targeting communication plan / strategy. communication plan or diverse audiences (e.g., media, public, health strategy developed and workers, and other sectors) with clear roles Number of designated implemented. and communication methods for acute shocks communicators identified and (on climate risks to health) and long-term stresses. trained Develop a communication plan or strategy on Comprehensive Approved and published health system decarbonization – outlining the communication plan or communication plan. scope of information for diverse audiences strategy developed and (e.g., media, public, health personnel and implemented. Number of designated other sectors) and events, including who (on health system communicators identified and should communicate, and the means of decarbonization) trained communication –and implement Number of reports on carbon Dissemination of relevant emissions produced and Information on the health system’s carbon information data and published annually. emissions and best reduction practices and actionable insights with Number of best practices opportunities shared with relevant stakeholders and documents created and updated. stakeholders and communities communities done. Number of stakeholders and community members reached. Number of community Community engagement and feedback engagement platforms or forums mechanisms established to empower affected Community engagement and established. populations to respond to warnings, and to feedback mechanisms Number of training sessions guide future development of monitoring and established conducted. warning systems including with regards to Number of community members environmental impacts of health care trained Adaptation options: o Incorporate the climate informed disease surveillance early warning and alert response system with the health system's MIS o Identify mechanism and conduct baseline assessment of GHG emission from health care facilities and health system o Develop risk communication strategy for vector-borne diseases, water-borne diseases, and nutrition/food security o Strengthen the inter-ministerial and departmental coordination and cooperation by developing mechanism

4. Building a climate-resilient health system in Bangladesh 41 | P a g e 4.3.5 Component 5: Health and Climate Research Research should build from existing knowledge management platforms, be effectively and clearly communicated to communities and healthcare personnel and adapted for practical purposes when possible. Long-term effects depend on current measures to reduce the emission of GHGs. Scientific research allows us to estimate increases in morbidity, injuries and mortality caused by global warming. Implementing strategies for sustainable low carbon health systems also need research support and development of assessment methods to support countries in measuring the total health system resilience and carbon footprint. Research from global to local level can be used in the following ways: to gather knowledge on climate risks to health and health systems’ impacts on the environment; the modulating effect of social and environmental determinants of health; climate-sensitivity of diseases and risks; how communities and health systems currently understand and cope with climate risks and GHG emission reductions; local conditions and vulnerabilities are connected to broader social and environmental determinants; and the degree to which communities and local health services are prepared to reduce carbon emissions and environmental impacts while responding to climate-related stress and shocks. Objectives for the implementation  Develop and Implement a Multidisciplinary Research Agenda: Define, endorse, and implement a national research agenda on climate change and health in collaboration with decision-makers and key stakeholders, ensuring alignment with national priorities and policies.  Strengthen Research Capacity: Build multidisciplinary research capacity on climate change and health by supporting collaborative networks, allocating financial resources, and providing targeted training opportunities. Focus areas include climate resilience, low-carbon sustainability, and evidence generation for adaptation and mitigation strategies.  Translate Research into Policy and Practice: Integrate and apply research findings on climate change and health into policies and decision-making processes. Strengthen evidence- based approaches to improve adaptation and mitigation strategies across sectors, transforming practices and contributing to measurable policy outcomes. Present status: Several globally recognized research institutes (and renowned experts) exist in Bangladesh that focus on climate-related health risks; however, research on climate change and health is still limited. The Climate Change Strategy and Action Plan (2009) and NAP 2022, Bangladesh, highlighted the need to establish a centre for adaptation research and training to help facilitate knowledge management and capacity building on climate change issues. However, there is need for more coordination effort between various sectors, for access to climate- related information with regard to scientific evidence, health risks of climate change, treatment technology, policies and interventions that can minimize the adverse impacts. There is a need for a clear ‘research agenda for climate change and health’ to provide guidance for future research activities. Measurable outputs and indicators under health and climate research

4. Building a climate-resilient health system in Bangladesh 42 | P a g e Component 5: Health and climate research Objective 1: Research agenda Outputs Indicator development and implementation National priority research areas, Approval of the research agenda. Develop national research agenda on and funding strategies Number of stakeholder meetings or climate change and health developed consultations held. Approval of the research agenda National research agenda on climate National research agenda with with de-carbonization. change and health incorporates health incorporation of health system Number of stakeholder meetings or system de-carbonization de-carbonization developed consultations held. The health system has a budget Approved and available dedicated dedicated to climate and health research Dedicated budget allotted budget agenda Results of a V&A assessment are used to V&A assessment incorporated Approved Research agenda with inform a national research agenda on in the Research agenda incorporation of V&A assessment climate change and health Research agenda incorporating the need Research agenda with Approval of the documents. to identify technologies for climate identification of technologies to Number of stakeholder meetings or resilience with GHG emission reduction reduce greenhouse gas (GHG) consultations. potential in priority areas emissions developed Objective 2: Research capacity Outputs Indicator Develop multidisciplinary research Multidisciplinary research Number of members of partnerships, rosters of national experts, partnerships, networks multidisciplinary research and knowledge management networks established partnerships. established to support research agenda Number of experts listed in the and implement knowledge management networks. Provide incentives for tertiary Research programs incentive Approval of document. educational institutions to offer research mechanism established Number of Institutes provided programs on climate change and health funding (Incentives) Establish data-sharing agreements within Data-sharing agreements Approved Agreement document. and outside the health sector established established Number and name of the Sectors for supporting research on GHG involved emissions and low carbon technologies Establish data-sharing agreements within Data-sharing agreements Approved Agreement document and outside the health sector for established Number and name of the Sectors supporting research on climate-sensitive involved disease surveillance and monitoring Establish data-sharing agreements within Data-sharing agreements Approved Agreement document and outside the health sector for established Number and name of the Sectors supporting research on climate resilience involved Establish financial investment Research program financial Approved Agreement document. mechanisms to support research investment mechanisms Module for the postgraduate programs and postgraduate research established research training programs are in training programs place Objective 3: Research into policy Outputs Indicator Establish mechanism for researchers to Mechanism to inform for Approved document. inform planning, policy, and stakeholder researchers, stakeholders group Number of Stakeholders group groups established involved. Establish mechanisms to support, spread Approved document. and scale innovation across the health Mechanisms to support, spread, Number of innovation support system that supports climate resilience and scale innovation established mechanisms established. and/or health care decarbonization Document of allocation of funding Dissemination of research findings on climate change and health and used to Report on Research findings develop key health (e.g. health sector Research findings dissemination program. strategic plans, strategies of priority Dissemination program, done Number of Dissemination programs. vertical programs) and climate change Number of stakeholders. (e.g. NAP, NDCs, LT-LEDs) plans, policies and strategies

4. Building a climate-resilient health system in Bangladesh 43 | P a g e Component 5: Health and climate research Develop evidence-based capacity for decision-making within and outside the Evidence-based policy Report on Policy outcomes health sector to contribute to policy outcomes developed outcomes Orientation program-oriented Report of Orientation program. Health services-oriented climate and climate and health research Number of Orientation programs. health research promoted done. Number of relevant stakeholders Number of Research conducted Conduct research on climate change and Research Data to policy Number of Research data to policy health and translated into health policy developed done. Number of policy documents, strategies, or action plans that Adaptation and mitigation decision- Integration of research findings reference research findings. making based on the results of the into the decision-making done Number of adaptation and research agenda implementation mitigation strategies developed and implemented. Number of consultations with Research agenda that aligns policymakers to identify research Research on climate change and health with the specific needs and needs. responds to needs by policy makers priorities of policymakers Number of policy briefs or reports developed produced Adaptation options:  Knowledge Sharing and Dissemination Platform o Develop a dedicated knowledge-sharing platform or hub to disseminate climate change and health (CC&H) research findings to key stakeholders and policymakers, fostering collaboration and informed decision-making.  Multidisciplinary National Research Agenda o Define, endorse, and implement a multidisciplinary national research agenda on climate change and health in partnership with decision-makers, health stakeholders, and relevant sectors to align research efforts with national priorities.  Data Sharing and Collaboration Framework o Establish a Memorandum of Understanding (MOU) among the Ministry of Health and Family Welfare (MoH&FW), Bangladesh Institute of Development Studies (BIDS), universities, research centers, meteorology services, and other relevant sectors to facilitate data sharing and establish baseline data for prioritized climate-related health risks.  Policy-Oriented Dissemination of Research Findings o Initiate a regular dissemination program to share research findings with policymakers, ensuring the evidence is accessible and actionable.  Incorporation of Research into Policy Development o Ensure that research findings are systematically incorporated into the policy formulation process, emphasizing the need to revise and adapt policies based on emerging evidence and trends in CC&H.

4. Building a climate-resilient health system in Bangladesh 44 | P a g e 4.3.6 Component 6: Climate Resilience and Low Carbon Infrastructures, Technologies and Supply Chain Strengthening adaptation of current infrastructures, technologies, and supply chains; introducing new low carbon technologies; and promoting environmental sustainability of health operations. A climate- resilient health system including provision of essential preventive and curative health products, from vaccines for climate sensitive diseases to surgical equipment, special allocation for climate change affected area in specific technologies both within and outside the health sector can enhance health service delivery and reduce disruptions during extreme weather events. Additionally, it takes into account the importance of environmental services to health facilities, such as safe water, sanitation facilities, reliable cold chains, enforced building codes, and dependable information communication technologies. The energy sources and waste management & drainage system all that contributes to a climate resilient health system, may be compromised by extreme winds, flooding, sea level rise, or drought, as well as electricity supplies. Further, reducing the carbon footprint of healthcare facilities through “greening” exercises, such as solar energy and water recycling pumps, contributes to climate resilience and long-term sustainability. Innovative interventions of climate resilience, health systems and health care facilities can also significantly reduce to GHG emissions. Opportunities needs to be promoted for reducing consumption, reusing and/or recycling; reducing food waste; and establishing sustainable procurement guidelines. By choosing technologies that consume less energy, medical and food supply chains that are more environmentally friendly, and decentralized renewable energy sources, such as solar photovoltaics, can contribute to both climate resilience and long-term environmental sustainability. Objectives for the implementation o Adaptation of current infrastructures, technologies, and supply chain – Current and future climate risks systematically considered in the context of revising and upgrading of infrastructures, technologies, products, and processes for climate resilient and low carbon sustainable health service delivery. o Promotion of new technologies – Innovative climate resilient and low environmental impact technologies, including low carbon measures, promoted and deployed by the health sector through transformative health service delivery. o Environmental sustainability of health operations – Low environmental impact technologies procured and promoted by the health sector to enhance resilience to climate change and contribute to long term sustainability. Present status: Health care facilities, especially in remote areas, are vulnerable to extreme weather events and become inoperable during the events, when they are most needed. Remote facilities often lack access to safe emergency electric supply, running water and sanitation facilities, which are preventive for many climate-sensitive diseases. Orientation of the Policy makers is required for better understanding for the necessary fund allocation to the climate-resilient health care infrastructure. As a part of conserving nature and preventing air pollution, Bangladesh Medical Students’ Society (BMSS) organized “Project: Green Hospital” collaborating with 22 medical colleges & hospitals throughout Bangladesh (Green Time news, May, 2024). The concept of the “Green Hospital” is introduced as a paradigm shift in healthcare, focusing on optimizing resource efficiency and minimizing environmental impact. This concept encompasses renewable energy integration, natural lighting, sustainable materials, green roofs, and smart building management systems.

4. Building a climate-resilient health system in Bangladesh 45 | P a g e In water scarce, salinity prone southern Bangladesh, models like Rain Water Harvesting system and Pond Sand Filtration System in healthcare, school and communities may help meet the safe water needs with low-cost, low-carbon and climate resilient approaches (Ref: Mukherjee S, Hyde KR. Promoting urban rainwater harvesting in Dhaka, Bangladesh.). Measurable outputs and indicators under climate resilient and low carbon infrastructure, technologies, and supply chain Component 6: Climate resilient and low carbon infrastructure, technologies, and supply chain Objective 1: Adaptation of current Outputs Indicator infrastructure, technologies, and supply chain Climate resilience Implementation Document. Implement climate resilience interventions at interventions Number of facilities implemented the health system and/or facility level implemented climate resilient interventions Guidelines and Completion and approval of initial standards for the specifications. Review specifications for siting and construction siting and Number of climate risk projection of health facilities iteratively and revise in line construction of updates incorporated. with projected climate risks health facilities Number of stakeholder consultations developed or meetings Updated guidelines Number of review meetings or Review specifications for technologies and & standards based workshops. selection of products and processes of services, on climate risk Frequency of reviews and updates to iteratively and revise in line with projected climate assessments and best the specifications. risks practices developed Approved specification Guidelines. Number of health facilities identified Number of health facilities retrofitted according to Health facilities and prioritized. climate resilient and low carbon standards Identified Number of retrofitting plans developed. Review specifications for siting and construction Iterative review and Number of review meetings or of health facilities, and energy, water, waste revision of workshops. management and sanitation provisions iteratively specifications for Number of stakeholder consultations and revise in line with (i) projected climate risks, siting and or meetings. and (ii) the latest standards for low or zero carbon construction of Approval of the review and revision and environmentally sustainable buildings health facilities done document. Training and recommendations for prescription of Revised document Approved Document. pharmaceuticals during extreme heat revised developed Number of trainings. Improvement plan for ensuring health service delivery during extreme weather events and Improvement plan Approved plan document. outbreaks of climate-sensitive diseases developed developed Number of trainings. based on results of vulnerability assessments of health care facilities Objective 2: Promotion of new technologies Outputs Indicator Access to renewable energy and Number of renewable energy projects Promote access to renewable energy in health care adaptation to low initiated and completed. facilities as an adaptation and low carbon carbon measures in Types of renewable energy sources sustainable measure the health facilities implemented are promoted Number of Environmental and Environmental and WASH technologies projects initiated Adopt environmentally sustainable technologies WASH related and completed. suitable for harsh conditions (e.g. green cooling) technologies adopted Type of Environmental and WASH sustainable technologies sources implemented

4. Building a climate-resilient health system in Bangladesh 46 | P a g e Component 6: Climate resilient and low carbon infrastructure, technologies, and supply chain Use new technologies such as e-Health, telemedicine or satellite imagery to strengthen New technologies Approved Document. climate resilience and reduce carbon emissions, adopted to improve Number & type of New technologies while contributing to improving health systems health systems implemented performance and UHC Objective 3: Environmental sustainability of Outputs Indicator health operations Conduct assessments of health sector impacts on Impact Assessments Assessment report. the environment, including GHG emissions, conducted Number of Health sectors assessed. Implement decarbonization actions at health Decarbonization Implementation Plan Document. system and/or facility level actions implemented Number of Health facilities Interventions implemented to reduce emissions Implemented the from high carbon medicines at the ‘point of use’, Implementation plan report. interventions to e.g. reducing emissions from inhalers and Number of Health facilities reduce emissions anesthetic gases Promote active transport (e.g. cycling and Active transportation Active transportation plan. walking) and the use of public transportation for to health care centers Number of Promotion activities. patients, visitors, and health workers promoted Number & type of clients oriented. Transportation Transportation systems to low GHG Health sector transportation systems transitioned to systems to low GHG emissions plan. low GHG emissions emissions promoted Number of Promotion activities. Integrate GHG emissions and environmental GHG emissions and sustainability considerations within health sector environmental GHG emissions Policy / Plan. procurement policies and practices, with suppliers, sustainability Number of health sector teams. procurement teams and other stakeholders considerations Number of other Stakeholders engagement to support implementation integrated Prioritize purchases from companies with Purchase from Reduced GHG emissions products transparent sustainability standards and science- reduced GHG and services purchase Policy / plan. based targets (near- and long-term) for reducing emissions products GHG emissions for products and services and services adopted Number of companies oriented Cross-sectoral collaboration Mobilizing practices Policy /Plan. Mobilize cross-sectoral collaboration for Cross-sectoral Number of collaborative frameworks improving practices on environment and health collaboration established. protection mobilized Number of joint initiatives implemented Low carbon diets Promote environmentally sustainable, low carbon Low carbon diets and food and food diets and procurement of locally produced food, procurement Policy / Plan. procurement and interventions implemented to minimize food Number of health facilities plan promoted, and waste in health care facilities executed implemented. Number of health facilities incorporating climate Guidelines and protocols developed variability and change in decisions related to Development of and implemented. siting, construction, technologies, procurement, climate variability Percentage of health facilities and procedures to ensure provision of basic guidelines and adopting these guidelines and services (including energy, water and sanitation, protocols protocols waste management) Adaptation options: o Develop guidelines and SOPs for low carbon climate resilient and low carbon infrastructures, technologies, and supply chain involving private sectors.

4. Building a climate-resilient health system in Bangladesh 47 | P a g e o Promote “Green hospital” initiatives and incorporate all necessary components climate resilient and low carbon infrastructures, technologies, and supply chain. o Provision of Health sector transportation systems transitioned to low GHG emissions o Promotion of low carbon, climate resilient WASH technology e.g. Rainwater Harvesting System, and Pond Sand Filtration System. 4.3.7 Component 7: Management of environmental determinants of health Climate change will likely impact other determinants of health, such as water quality and quantity, air quality, nutrition and food security, waste management, and housing. Respond to environmental risks to health by strengthening monitoring and management of environmental determinants of health; developing and implementing regulatory instruments and mechanisms; and promoting coordinated intersectoral management. Raising awareness, support monitoring of environmental exposures, and define regulatory standards, both at policy and programmatic levels and some of the most effective actions that can be taken by health systems are in collaboration with other sectors. Even though the health sector does not have substantial direct control over environmental determinants, it still plays an important role on both a policy and programmatic level in: (i) providing evidence of the link between risk factors and diseases; (ii) implementing effective preventive measures; (iii) raising awareness; (iv) monitoring environmental exposures and health outcomes; (v) defining regulatory standards and managing health risks. Objectives for the implementation • Monitoring – Joint monitoring of climate-sensitive environmental risks based on evidence-based standards strengthened. • Regulatory mechanisms – Regulatory policies protecting populations from climate-sensitive environmental risks defined, revised, and enforced. • Coordinated cross-sectoral management – Environmental determinants of health jointly managed, with clear roles and responsibilities defined across sectors. Present status: Water, Sanitation, and Hygiene Water, sanitation, and hygiene (WASH) issues are led by the Department of Health and Engineering within the Ministry of Local Government, Rural Development and Cooperatives in Bangladesh. Groundwater is the major source of drinking water in Bangladesh with an estimated 6–11 million tube wells (BGS, 2001), serving an average of 20 people each in country. Although, the coverage of the population with access to improved water sources has increased to 80%, difficulties still exist. Notably, arsenic contamination is becoming a problem with 25% of existing wells being exposed to arsenic (WHO, 2015c). Bacteria contamination, due poor maintenance is also a concern. Cyclones, storm surges, and sea-level rise also affect water quality due to disruptions in supplies, damaged WASH facilities, and reduced freshwater availability. Although some WASH strategies (e.g. Water Safety Plans) have worked to combat communicable diseases and helped increase resilience to extreme weather events, more focus and resources are needed to prepare and management current and future climate-related risks.

4. Building a climate-resilient health system in Bangladesh 48 | P a g e Air Quality Bangladeshi cities have extremely poor air quality compared to other cities in Asian and South Asian countries, posing serious health and economic concern for the citizens. Air pollution is a major health risk in the world and the death tolls in Bangladesh are rising as diseases are being aggravated by polluted air. Outdoor air pollution can have direct and sometime severe consequences for health, leading to increased risk of respiratory infections, lung cancer, and cardiovascular disease (WHO, 2015a). Household air pollution is also a growing health concern in Bangladesh, especially in rural areas that primarily rely on solid fuel for cooking. It is estimated that Nearly 88,000 deaths (44% of deaths from stroke, cardiovascular disease, lung cancer etc.) are attributable to indoor air pollution which accounts for 10% of all death in Bangladesh in 2012 (WHO, 2015a). Exposure to poor and contaminated air triggers adverse health risks, creating various symptoms and diseases. Both long-term and short-term exposure to poor air have detrimental health risks which may contribute to diseases such as lower respiratory infection, pulmonary diseases, ischemic, cardiovascular diseases, and chronic obstructive pulmonary diseases (Boogaard, Walker, & Cohen, 2019). Children between the age 1 year to 4 years, and the elderly between the age of 60 years to more than 95 years, are the most vulnerable groups, as their mortality increases when exposed to ozone, particulate matter, and dust pollution (HEI, 2020). Vehicular emission, coal fired power plants, brick kilns, industrial emissions, road dust, and construction activities are major emission sources of PM in urban cities (Hossain, Majumder, Islam, & Nayeem, 2019) (Majumder, Nayeem, Patoary, & Carter, 2020). According to the annual Air Quality Life Index (AQLI) report of 2022, Bangladesh’s average concentration of PM2.5 increased by 13.1 per cent to 75 μg/m3 from 2019 to 2020 (Greenstone & Hasenkopf, 2023). In a study by the World Bank, it was found that loss of welfare due to air pollution accounted for about 6.14 per cent of the total GDP of Bangladesh in 2013 (World Bank & IHME, 2016). Due to pollution and environmental degradation in urban areas, the annual loss of productivity was estimated to be USD 1.44 billion for Dhaka city, and approximately USD 6.52 billion, or 3.4 per cent of GDP for Bangladesh in 2015 (World Bank, 2018). Despite increasing evidence of the health impacts of poor air quality (Shahid, 2009) (WHO, 2015a) policy and programmatic interventions are limited in Bangladesh. Achieving a greener environment with cleaner air has become a necessity for the citizens of the country. Measurable outputs and indicators under management of environmental determinants of health Component 7: Management of environmental determinants of health Objective 1: Monitoring Outputs Indicator Integrated Integrated monitoring systems strategy Integrated monitoring systems collect data on monitoring systems report. environmental hazards (e.g. water quality, developed and Frequency of water quality data collection. water availability, air quality) operational Frequency of air quality data collection Number of health facilities with Health facilities uninterrupted access to reliable energy. have access to Proportion of health facilities with access to Number of health facilities with access to energy, safe water, energy, safe water, and sanitation services safe drinking water. and sanitation Number of health facilities with access to services sanitation services. Establish integrated monitoring systems Integrated Number of integrated monitoring systems allowing collection and analysis of data on monitoring systems developed and operational. environmental hazards, socioeconomic factors established Types of Data collection form and health outcomes Objective 2: Regulatory mechanisms Outputs Indicator

4. Building a climate-resilient health system in Bangladesh 49 | P a g e Component 7: Management of environmental determinants of health Regulations on key environmental Regulation on key Number of new or revised regulations determinants of health (air quality, water environmental developed and enacted. quality, food quality, waste management) determinants of Document on Types of environmental designed to reflect broader ranges of expected health developed determinants of health considered climatic conditions and the health sector’s own contribution to GHG emissions and environmental impacts Promote regulations for clean energy systems Regulation for clean Number of new or revised regulations as a means to improve local air quality and energy systems developed. reduce the number of premature deaths from promoted Types of clean energy systems are in place exposure to air pollution Implement risk assessment and management Risk assessment Number of risk assessments conducted approaches aiming to minimize the health management focusing on climate change impacts on impacts from climate change via water, approaches WASH systems sanitation and hygiene (WASH) (e.g. climate Implemented Implementation report. resilient water and sanitation safety plans) Objective 3: Coordinated cross-sectoral Outputs Indicator management Environmental health impact assessments for Environmental Environmental health impact assessment policy and programs in sectors such as health impact report for policy and programs transport, water, food and agriculture, and assessments done Numbers of sectors covered WASH implemented in coordination with the Ministry of Health Implement joint multisectoral risk Joint multisectoral Multisectoral Risk Management Plan. management approaches to health risks risk management Number of sectors involved in the related to climate related emergencies and plan implemented development and implementation of these disasters, water, waste, food, and air pollution plans Integrate low carbon sustainability approach Low-carbon Development of Low-Carbon in managing the environmental determinants sustainability Sustainability Policies. of health approach integrated Types of environmental determinants addressed Proportion of population with primary Increase in Percentage increase in the proportion of reliance on clean fuels and technologies Adoption of Clean the population compared to a baseline. increased Fuels and Number of new clean fuel and technology Technologies installations Adaptation options: • Collaboration and development of strategy for jointly managing Environmental determinants of health, with clear roles and responsibilities defined across sectors • Strengthen and develop Joint monitoring of climate-sensitive environmental risks based on evidence-based standards strengthened monitoring system for ambient air quality and link with disease surveillance • Implement/scale up pilot project for climate-resilient water safety plans, WASH models, and WASH FIT programs • Conduct health assessment to reduce household air pollution (identified in NCD plans) and develop strategy to pilot climate-proofing housing for vulnerable communities • Promote, awareness and advocacy to ensure clean, drinkable water everywhere. Additionally, WASH awareness needs to be raised among the vulnerable and marginalized population. 4.3.8 Component 8: Climate informed health programs This component aims to ensure that health policies, programs, and operations are aware of and take into account both current and future climate change risks. The health sector has to take lead, in coordination with other sectors, for programs that address climate-sensitive health risks (such as vector- and water-

4. Building a climate-resilient health system in Bangladesh 50 | P a g e borne diseases, mental health, cardiovascular and respiratory diseases, maternal and newborn health, nutrition), preparedness and response to extreme weather and environmental events, as well as other crises. Multi-sectoral issues should be in collaboration with climate change and health focal points or units in the ministries of health and other sectors, e.g., Emergencies and disaster risk management, public health preparedness, early warnings, food security and nutrition, occupational health, infectious disease monitoring, climate-sensitive disease surveillance, and several vertical programs for communicable and NCDs and injury prevention. Objectives for the implementation o Health programming – Information on current and projected (future) climatic conditions integrated into strategic planning of health programs for climate-sensitive diseases. o Delivery of interventions – Public health programs revise their standard operating procedures to integrate climate change considerations both in relation to resilience and low carbon sustainability in the delivery of interventions Present status: There is inconsistent incorporation of climate change considerations into public health strategies, plans and policies. The 4th Health Population and Nutrition Sector Program (HPNSP) and Operational Plan of DGHS not only identifies the likely impacts of climate change on health, but also sets out priority interventions. The strategies and actions of this HNAP will contribute significantly to the mainstreaming of climate change in health. The current programs needs to address disability-inclusive, gender-responsive national initiatives in mental health, including crisis preparedness, trauma counseling, educational support, and general well- being programs. Measurable outputs and indicators under climate-informed health programs Component 8: Climate-informed health programs Objective 1: Health programming Outputs Indicator Use information and evidence to gathered in Evidence based Evidence generated document. components 3–5 (i.e. addressing research, action on priority Number of Health programs used to assessments, and integrated surveillance) to inform climate-sensitive inform action action on priority climate-sensitive health health programs programs developed Proportion of health programs informed by a V&A V&A assessment is Assessment Report and assessment in integrating climate change and integrated in climate Integration Policy/Plan. health adaptation and resilience actions within change and health Number of health programs V&A their own programs adaptation assessment in integrated Proportion of health programs integrating climate Climate change Programs integrating Report and change mitigation actions mitigation actions Integration Policy/Plan integrated Number of health programs climate change mitigation actions integrated. Procurement processes and mechanisms of specific Procurement Assessment Report Procurement health programs are assessed and improved based mechanisms mechanisms. on climate resilience and low carbon sustainability developed Number of health programs assessed. considerations Investment plans to address identified capacity Investment plans Investment plans document. gaps in health programs to deal with the increased developed Number of capacity gaps identified in health risks from climate variability and change health programs developed

4. Building a climate-resilient health system in Bangladesh 51 | P a g e Component 8: Climate-informed health programs Information on current and projected climate Current and The strategic health plans and change risks integrated into strategic health projected climate policies. programs change risk data into Number of health programs that the health programs include climate risk data in their incorporated planning processes. Number of health programs with standard Focused and revised The revised SOPs document. operating procedures to respond to environmental SOPs developed Number of health programs included risks revised for integration of climate information revised SOPs Service delivery informed by a sound Identification of Detailed reports of these assessments. understanding of the different exposure pathways exposure pathways Number of assessments conducted to from climate related hazards, and targeted to those from climate-related identify exposure pathways. most at-risk, considering gender differences and hazards to those diverse vulnerability factors most at-risk done Objective 2: Delivery of interventions Outputs Indicator Health sector Health sector response plan. Implement health sector response plan for key response plan climate-sensitive health risks Implementation report developed Detailed assessment reports Public health programs are targeted to those most Identification and produced. at-risk of health impacts from climate change (e.g. assessment of maternal, newborn and children, older people, populations most at Number of targeted public health migrants, people with pre-existing conditions) risk done programs developed and implemented. Program Program on GHG emission reduction Number of health sector program areas implemented on implementation report. implementing GHG emission reduction GHG emission Number of health sectors GHG interventions reduction emission reduction program done. Identification of Prioritization of number of short- and long-term Approved short- and long-term short- and long-term climate resilience interventions defined and on key climate resilience climate resilience programs health programs interventions done Sustainable low Approved intervention programs. Number of sustainable low carbon interventions carbon interventions Number of low carbon interventions defined and prioritized on key health programs health programs Identified identified for each health program Risk maps and analysis of seasonal Risk maps and analysis of seasonal trends in Risk maps that trends report diseases used to target resources and preventive identify high-risk Geographic coverage and resolution measures for those most at-risk areas developed of risk map Adaptation options: o Mainstream climate change risks into relevant policies and operational plans for VBD, WBD, and nutrition. o Develop risk maps for VBD, WBD, and nutrition/food security using GIS (strengthen CBNP in hot spot areas) o Develop and implement health adaptation prevention and control interventions based on risk maps. 4.3.9 Component 9: Climate-related emergency preparedness and management Holistic management of overall public health risks with an emphasis on preparedness, as well as emergency response is key for building climate-resilient health systems, through climate-smart policies and protocols; establishing climate-informed health emergency and disaster risk management; and supporting community empowerment. Climate-informed preparedness plans, emergency response systems, and community-based disaster and emergency management are essential for building climate

4. Building a climate-resilient health system in Bangladesh 52 | P a g e resilience in health systems and communities, which are vulnerable to a wide range of hazardous events. National emergency operation policies, plans and programs that apply an all-hazards strategy, comprehensive emergency management principles and whole-of-society approaches are necessary. Community-based actions are at the forefront of protecting health in emergencies and disasters, including those related to extreme weather events. Policies, programs, and strategies related to reducing health risks from climate change and related emergencies and disasters require multisectoral action with community participation (such as health workforce, various community groups, women groups, private sectors, key health-determining sectors, and private sector) in health decision making (WHO, 2019). Objectives for the implementation o Policies and protocols – Climate sensitive health risks and low-carbon operations included within national disaster reduction strategies, plans and protocols and wider development processes. o Risk management – Strengthen health system capacity to manage risks so that overall vulnerability and exposure to climate hazards are reduced and residual risks and uncertainties effectively managed. o Community empowerment – Empower communities to effectively prevent and respond to health risks from extreme weather events. Present status: The Directorate General of Health Services is responsible for providing preventive and curative health services during disasters following extreme weather events by coordinating and funding medical teams on an emergency basis. The Directorate General of Health Services works in all four phases of disaster management: normal, alert and warning stage, disaster stage and rehabilitation stage. Additionally, the Ministry of Disaster Management and Relief is responsible for reducing the risk of people from hazards and ensuring that there is an efficient emergency response management system in place. For data collection and disaster early-warning systems, the Bangladesh Meteorology Department (BMD) collects real-time meteorological information from 35 observatories and the Bangladesh Water Development Board (BWDB) collects ground and surface water information, as well as monitors flood and drought situations. Finally, the Disaster Management Information Network, within the Disaster Management Bureau, support 64 districts and 482 sub-district offices, providing information on risks, mapping risk reduction activities, maintaining information databases on disaster management capacity, and operating a national information portal. The National Disaster Management Council (NDMC) and Inter-Ministerial Disaster Management Coordination Committee also play significant roles in facilitating policy-making, planning and implementation of disaster risk reduction and emergency response management in Bangladesh. Bangladesh doesn’t have the Health Emergency and Disaster Risk Management (H-EDRM) framework. WHO Operational framework for building climate resilient and low carbon health systems, 2023 promotes the Health Emergency and Disaster Risk Management (H-EDRM) framework is a rights- based approach to developing national strategies for emergencies and disasters. Addressing climate risks in H-EDRM requires whole-of-society actions. To strengthen their readiness, health system operations including health facilities and public health infrastructure should implement integrated approaches to H-EDRM as part of developing an all-hazards H-EDRM framework that includes climate hazards and the Climate-based H-EDRM must use a comprehensive emergency management (CEM) approach.

4. Building a climate-resilient health system in Bangladesh 53 | P a g e Measurable outputs and indicators under climate related emergency preparedness and management Component 9: Climate-related emergency preparedness and management Objective 1: Policies and protocols Outputs Indicator Policies, protocols, plans, and strategies for Health Emergency and Disaster Risk Policies, protocols, Approved Policies, protocols, plans, Management (H-EDRM) reviewed and plans, and strategies for and strategies for H-EDRM. improved through the integration of climate- H-EDRM developed sensitive health risks and weather and climate information (e.g. El Niño/La Niña conditions) Approved Health sector contingency Develop health sector contingency plans for Health sector contingency plans extreme weather events and implement plans developed Implementation report Include gender sensitivity and equity Gender sensitivity and Approved H-EDRM document with approaches in H-EDRM, considering equity approaches included Gender, equity, vulnerable populations vulnerable populations and regions at risk from in H-EDRM and regions climate related hazards Health sector contingency plans for extreme weather events, including risk reduction, Aligned health sector Aligned health sector contingency preparedness, and response, are aligned with contingency plans plans document the WHO H-EDRM or a local health developed emergency and disaster risk management framework Protocols for H-EDRM integrate low carbon and environmentally sustainable practices Sustainable Approved H-EDRM protocols. including for logistics, supply change, H-EDRM protocols procurement and storage of medicines and developed equipment, and transport Objective 2: Risk management Outputs Indicator Risk assessments for current and projected Risk assessments for Risk assessments Report. future exposure to extreme weather events current and projected Number of risk assessments conducted routinely used to inform health sector strategic future exposure done annually. development plans Approved emergency and disaster Climate change related Develop climate change related emergency and response plans. emergency and disaster disaster response plans for individual health Implementation report. response plans facilities and implement Number of health facilities developed implemented the plans. Geographical and Approved health risks response plans. Geographical and seasonal distribution of seasonal distribution of Number of data collection initiatives climate health risks and outcomes used to climate health risks on climate health risks conducted inform emergency and disaster response plans response plans annually. developed Use EWS for extreme weather events and EWS for extreme EWS use operationalized. climate-sensitive diseases to inform roles and weather events and Roles and responsibilities of different responsibilities of different actors for H- climate-sensitive actors defined. EDRM planning diseases practiced Objective 3: Community empowerment Outputs Indicator Implement capacity development programs to Capacity Development Approved Capacity Development support the roles of local communities to Programs implemented Programs. identify risks, prevent exposure to hazards, and Operational Capacity Development take action to save lives in extreme weather Programs events Establish stakeholder mechanism to support Mechanism to support Number of meetings and dialogue participation, dialogue and information stakeholder sessions conducted annually.

4. Building a climate-resilient health system in Bangladesh 54 | P a g e Component 9: Climate-related emergency preparedness and management exchange, to empower civil society and participation, dialogue, Attendance and participation rates of community groups as primary actors in and information civil society and community groups. emergency preparedness and response exchange established Mechanisms in place to ensure information Mechanism for Number of communication channels related to health risks from extreme weather information exchange (e.g., radio, SMS, social media, events reaches communities in a way that on health risks from community meetings) operational. preventive action by them is triggered extreme weather events Frequency and consistency of established information dissemination during extreme weather events Adaptation options: o Develop climate-smart policies and protocols for emergency and disaster risk management strategies o Integrate climate-sensitive health risks and climate data into national disaster risk reduction strategy o Incorporate climate-related health risks into emergency preparedness and response plans for health facilities o Strengthen procurement system to access and manage medical and disaster response supplies during emergencies. o Develop Health Emergency and Disaster Risk Management (H-EDRM) framework in health systems – considering climate change risks and low-carbon operations – contributes to building climate resilience and to protecting population health. 4.3.10 Component 10: Sustainable climate and health financing Additional funds will be required to enhance the climate-resilience of health systems. For example, resources to expand the geographic or seasonal range or population coverage of surveillance and control programmes for climate-sensitive infectious diseases, or to retrofit health facilities to withstand more extreme weather events. A comprehensive approach to financing health protection from climate change will first build on core investments in the health sector, such as investments to ensure adequate numbers of trained health personnel, and basic health infrastructure and services, which also help to address climate change risks. To mobilize and implement resources, assessments should be conducted to determine requirements, available finance, finance gaps and opportunities to acquire funds (from national funds or external donors) (WHO 2024). At the international level, the main multilateral funding mechanisms are mandated under the United Nations Framework Convention on Climate Change (UNFCCC) and the Kyoto Protocol, promoting financial assistance from more developed parties to those countries deemed more vulnerable and with fewer resources available to adapt to climate change. Parties to the UNFCCC have mandated the Global Environmental Facility (GEF) to manage the Special Climate Change Fund and the Least Developed Countries Fund, established the Adaptation Fund under the Kyoto Protocol and recently the Green Climate Fund. The key international climate change funding streams are included in Box. Green Climate Fund (GCF): At the 16th session of the UNFCCC Conference of Parties (COP) in 2010, the Parties established the GCF to assist in mobilizing funding for low-emission and climate-resilient development. The GCF was designated as an operating entity of the financial mechanism accountable to the COP in 2011, and remains involved in decision-making regarding policies, program priorities and eligibility criteria for funding. The WHO has been approved as a GCF Readiness Delivery Partner, enabling WHO to support countries in accessing GCF Readiness funds, undertaking adaptation planning and developing strategic frameworks to build their programming with the GCF.

4. Building a climate-resilient health system in Bangladesh 55 | P a g e Global Environment Facility (GEF): was established in 1992, is an international partnership with a large network of countries, international institutions, private sector, and civil society organizations. It serves as an operating entity of the financial mechanism of the UNFCCC to provide financial resources to developing country Parties. Parties also founded the Special Climate Change Fund (SCCF) and the Least Developed Countries Fund (LDCF), which are both managed by the GEF. The SCCF was established to finance initiatives relating to adaptation; technology transfer and capacity building; energy, transport, industry, agriculture, forestry and waste management; and economic diversification. The LDCF was established to support least developed countries in preparing and implementing National Adaptation Programs of Action (NAPAs). Adaptation Fund (AF): was established under the Kyoto Protocol in 2001, also supports environmental initiatives by financing concrete adaptation projects and programs in developing countries that are particularly vulnerable to the adverse effects of climate change. The AF is managed by the Adaptation Fund Board. Source: Finance for health and climate change The main international climate change specific financing mechanisms, funding is also available through bilateral and regional channels. The ATACH Finance Working Group aims to support countries aiming to access finance and funding for climate change and health by reducing barriers to funding and by maximizing investments in health (WHO, 2023) Objectives for the implementation o Health specific funding and financing mechanisms – Climate change considerations for both resilience and low carbon sustainability included in relevant proposals submitted to and funded by health funding mechanisms. o Climate change funding streams – Climate change finance accessed by the health sector. o Funding and financing for health-determining sectors – Health and climate change considerations incorporated in projects and programs supported through funding for health-determining sectors. Current status: The Bangladesh Government has incorporated climate change into national planning. In the existing development planning process, all projects worth more than US$ 6.37 million go to the Executive Committee of the National Economic Council of the Ministry of Planning for review and approval. Now, projects related to climate change and costing less than US$ 250 million will not need to go to the Executive Committee. The Monitoring and Evaluation wing of the Ministry of Planning monitors and evaluates Bangladeshi Government-funded projects. A cost-effectiveness analysis was conducted in 2014 to estimate the cost and health benefits of three adaptation interventions focused on WASH, nutrition, and early-warning/risk reduction systems (CCHPU, 2014). In summary, the study identified several key gaps, including lack of cost data on projects and programs related to access safe WASH, investment in early-warning systems, and risk management measures, as well as absence of rigorous impact evaluations for health adaptation interventions. In addition, a small amount of funding, distributed through the Climate Change Trust Fund, has been disbursed to the CCHPU Unit for climate change and health projects. Further, a GEF proposal for building climate resilient health systems in Bangladesh has been approved with funds set to be disbursed in 2018.

4. Building a climate-resilient health system in Bangladesh 56 | P a g e Measurable outputs and indicators under sustainable climate and health financing Component 10: Sustainable climate and health financing Objective 1: Health specific funding and Outputs Indicator financing mechanisms Scale-up public financing to build the Public financing to Public financing to climate-resilient and foundations of climate resilient and low climate-resilient and low-carbon health system document. carbon health system low-carbon health Total amount of public financing allocated system developed to climate-related health initiatives Access to domestic or international funding Domestic and international Number of funding sources accessed. to strengthen climate resilience of health funds to support health Breakdown of funding types secured (e.g., systems systems accessed grants, loans, equity). Resources for climate change and health National or Approved National or subnational health interventions, both for resilience and low subnational health investment plans carbon sustainability, included in national or investment plans subnational health investment plans developed Access domestic or international funding to Domestic and Number of funding sources accessed. strengthen low carbon sustainability of international funds to health systems support low carbon Breakdown of funding types secured (e.g., sustainability health grants, loans, equity). systems accessed Percentage of the national health budget Climate variability Portion of the national health budget addresses risks posed by climate variability and change addressed specifically address risks posed by climate and change including at health care facility in national health variability and change level budget Use decadal and longer-term forecasts to Integration of Number of health investment projects that inform health investments (e.g. construction Forecasts into have utilized climate forecasts in their of new health care facilities) Planning done planning stages. Number of decisions or investments made based on climate forecast data Use results of V&A assessment and HNAP Funding Access on Funding Access Based on Assessments to access health funding and financing Results of V&A documents. mechanisms assessment and HNAP Percentage of funding requests that used incorporate findings from V&A assessments and HNAP Objective 2: Climate change funding Outputs Indicator streams Submit climate change and health projects Climate change & and programs to and granted by the main health projects and international climate change funding Number of project proposals submitted. programs submitted to mechanisms (e.g. Green Climate Fund Number of projects and programs major international (GCF), the Global Environment Facility approved and funded climate change for (GEF), the Adaptation Fund (AF) and funding bilateral donors) Investment cases for Development of investment cases for Number of comprehensive investment climate-resilient and climate resilient and low carbon sustainable cases developed. low-carbon health systems by relevant actors (e.g. List of relevant sectors sustainable health multilateral development banks) and used to Quality and completeness of investment systems by relevant facilitate access to funding and financing cases actors developed Objective 3: Funding and financing for Outputs Indicator health-determining sectors Monitor health impacts of climate change in Health impact Health impact monitoring report. programs funded through financial monitoring Number of funded programs with mechanisms specific to health-determining operational established monitored sectors

4. Building a climate-resilient health system in Bangladesh 57 | P a g e Component 10: Sustainable climate and health financing Number of climate intervention projects Funding of climate interventions across Climate interventions funded. sectors with a focus on health, including with a specific focus Number of low-carbon health facilities sustainable low carbon health facilities on health, funded funded. Submission of Climate change adaptation Climate change adaptation and mitigation Climate change and mitigation projects and programs and projects and programs submission report. adaptation and granted to key health-determining sectors mitigation projects integrate costed activities related to Number of approved of climate change and programs assessing and monitoring potential positive adaptation and mitigation projects and Submitted and negative health impacts programs Screening for climate variability and change, and related health risks included as criteria Climate variability Screening report of climate variability and for selecting investments in key health and change, and change, and related health risks. determining sectors, (such as water, related health risks Criteria for selecting investments in key sanitation, food and agriculture, energy, screening done health determining sectors developed transport, and urban planning) Adaptation options: o Develop a resource mobilization plan that identifies funding mechanisms for health (e.g. Climate Change Trust Fund) as well as resource gaps o Develop and submit proposals for building climate-resilient health systems to international climate change and health funding sources (e.g. GEF, GCF, bi-lateral donors) o Develop and submit proposal for building climate resilient health system in perspective of Bangladeshi climate variability.

5. HNAP HNAP Implementation Strategy The Health National Adaptation Plan (HNAP) 2024 for Bangladesh is a comprehensive strategy aimed at addressing the impacts of climate change on the health sector. This plan will guide the integration of climate resilience into health policies, programs, and systems to safeguard public health in the face of changing environmental conditions. 5.1 Key Components of Implementation 5.1.1 Policy and Governance o Integrate HNAP into National Health Policies: Ensure that the HNAP is incorporated into existing and future health policies, plans, and frameworks. o To relocate and strengthening of the CCHPU at DGHS for better coordination and sectoral collaboration of climate change and health activities and issues with designated focal point and resources. o The IEDCR will coordinate the “Climate Change Project” activities for implementation of the HNAP. o Legislation and Regulation: Develop and enforce regulations that support climate-resilient health systems.

5. HNAP HNAP Implementation Strategy 58 | P a g e 5.1.2 Health System Strengthening o Infrastructure Development: Upgrade/retrofit health facilities to withstand climate impacts, such as extreme weather events, and ensure uninterrupted service delivery. o Supply Chain Management: Ensure the availability of essential medicines, vaccines, and medical supplies in the face of climate-related disruptions. o Human Resources for Health: Recruit, train, and retain health workers with expertise in climate change and health. 5.1.3 Surveillance, Monitoring, and Evaluation o Climate-Health Data Systems: Develop integrated data systems to monitor climate-sensitive diseases and health outcomes. o Early Warning Systems: Strengthen early warning systems to predict and respond to climate-related health emergencies. o Monitoring and Evaluation Framework: Establish a robust M&E framework to track progress and effectiveness of the HNAP implementation. 5.1.4 Community Engagement and Public Awareness o Community-Based Adaptation Programs: Support community-driven health adaptation initiatives, particularly in vulnerable areas. o Public Awareness Campaigns: Implement targeted campaigns to raise awareness about the health impacts of climate change and promote adaptive behaviors. o Behavioral Change Communication: Design and implement programs that encourage health- promoting behaviors in the context of climate change. 5.1.5 Capacity Building and Training o Professional Development Programs: Provide continuous education and training for health professionals on climate change and health and emergency preparedness. o Curriculum Development: Periodic review and update climate change and health into the curricula of medical and public health schools. o Community Training: Develop training programs for community health workers and volunteers on climate-related health risks. 5.1.6 GHG Emission Reduction in Health Sector  Energy Efficiency: Implement energy-efficient technologies in healthcare facilities, such as LED lighting, efficient HVAC systems, and energy management practices.  Renewable Energy Use: Transition to solar, wind, or other renewable energy sources in hospitals and clinics, reducing reliance on fossil fuels.  Sustainable Transportation: Promote the use of electric or low-emission vehicles for health-related transportation and patient services.  Waste Management: Improve waste segregation, recycling, and safe disposal of medical waste to minimize environmental impact. 5.1.7 Research and Innovation o Climate and Health Research: Promote interdisciplinary research to generate evidence on the health impacts of climate change in Bangladesh. o Innovation in Health Technologies: Support the development and deployment of innovative technologies for climate-resilient healthcare delivery.

5. HNAP HNAP Implementation Strategy 59 | P a g e o Knowledge Sharing Platforms: Establish platforms for sharing best practices and lessons learned in climate change adaptation in the health sector. 5.1.8 Intersectoral Collaboration o Cross-Sector Partnerships: Foster partnerships between the health sector and other sectors such as agriculture, water, environment, and disaster management. o Integrated Health and Climate Policy: Promote policies that integrate health considerations into climate change adaptation and mitigation strategies. o International Collaboration: Engage with international organizations and donors to leverage support for HNAP implementation. 5.1.9 Resource Mobilization o Domestic Financing: Secure funding from national budgets and allocate resources specifically for the implementation of HNAP. o International Funding: Access international climate finance mechanisms, such as the Green Climate Fund, to support HNAP activities. o Public-Private Partnerships: Encourage private sector investment in climate-resilient health infrastructure and technologies. 5.1.10 Implementation Timeline o Short-Term (2024-2025): Initiate policy integration, establish coordinating bodies, and begin capacity-building activities. o Medium-Term (2025-2028): Scale up health system strengthening, surveillance, and community- based interventions. o Long-Term (2028-2030): Achieve full integration of climate resilience into the health sector and ensure sustainability of adaptation efforts. 5.1.11 Monitoring and Evaluation o Regular Progress Reviews: Conduct annual reviews to assess progress against targets and adjust strategies as needed. Intra-sectoral and multisectoral ‘Regular Progress Reviews’ o Vulnerability assessment: Undertake periodic vulnerability assessments to evaluate and identify vulnerabilities and recommend for remediation or mitigation steps where required. o Impact Assessment: Undertake periodic impact assessments to evaluate the effectiveness of HNAP interventions. o Reporting Mechanisms: Establish clear reporting mechanisms to communicate progress to stakeholders and the public. 5.2 Coordination Mechanism The Climate change and health project, “Building Resilience of Health Systems in Asian LDC to Climate Change of Bangladesh” at MOHFW will provide the necessary technical guidance and oversight for all climate change and health (CC&H) activities. The coordination of HNAP implementation activities will be led by the Director General of Health Services, HSD, Ministry of Health and Family Welfare and Institute of Epidemiology, Disease Control and Research (IEDCR). This “Climate Change & Health Project” Project Director and Program Manager will also link with the focal point of the ‘National Adaptation Plan, Bangladesh (2023-2050), Bangladesh for the alignment of the HNAP activities. Figure 19 provides a simplified diagram of the organizational structure for HNAP

5. HNAP HNAP Implementation Strategy 60 | P a g e implementation. The coordination mechanism for implementation of the HNAP will be based on existing institutional arrangements and structures within the health sector (DGHS) to ensure alignment with national priorities. The MOHFW will also contribute to ensure effective coordination between MOHFW, DGHS, and other relevant stakeholders across ministries (e.g. MoLGRD, MoEFCC and MoF), departments, and institutions that will lead the updating, monitoring, and evaluating progress. Ministry of Health and Family Welfare Health Service Division Director General of Health Services Lead Lead Lead Lead Lead Organization for Organization for Organization for Organization for Organization for component 1,2 component 3,4,5 component 6 component 7, 8,9 component 10 Non Government Stakeholders Figure 17: Organogram for HNAP implementation Figure 18: Organogram for HNAP implementation 5.3 HNAP Action Plan 2024-2029 The HNAP Action Plan outlines key short-and-medium term health adaptation activities to be carried out over a five-year period (2024-2029). The prioritized actions build from the strategic objectives presented in Part 4, with the aim of building a climate-resilient and low carbon health system in Bangladesh. The action plan in Table-2 also provides intended deliverables for each action, as well as the responsible institution. Implementation Timeline o Short-Term (2024-2025): Initiate policy integration, establish coordinating bodies, and begin capacity-building activities. o Medium-Term (2024-2027): Scale up health system strengthening, surveillance, and community- based interventions. o Long-Term (2024-2029): Achieve full integration of climate resilience into the health sector and ensure sustainability of adaptation efforts.

5. HNAP HNAP Implementation Strategy 61 | P a g e Table 2: HNAP 2024-2029 Action Plan Outline Time Responsible Actions Deliverable frame institutions COMPONENT 1: Climate-transformative leadership and governance Objective 1: Governance “Climate change related health issues” incorporated in the Climate change and health focal points designated within the Ministry OP of DGHS of Health with specific Program of action and budget allocation Competent and functional CCHPU with adequate human and financial resources Health sector commitment to achieve climate resilience in the health Develop and implementing health policies that integrate system climate risks and adaptation strategies. Health sector commitment to transition the health system (including Develop low carbon or net-zero emissions health care facilities and supply chains) to low carbon or net-zero implementation strategy emissions Climate change and health focal points or units, working in collaboration with relevant climate sensitive health programs (e.g., Health Focal Points identified from the relevant climate Lead: MOHFW; vector-borne diseases, nutrition, infectious diseases, disaster risk sensitive health programs Other: IEDCR, 2024-2027 reduction) to build climate resilient and low carbon Programs CCHPU, NCDC, CDC Gender-sensitive approach adopted in the regulations and strategies on climate change and health Gender-inclusive strategies and policy developed Meaningful participation of the health sector in main climate change processes at national, regional, and global levels with UNFCCC global negotiations, National Adaptation Plan, National Focal/Responsible person identified Cross Communications (NCs), Nationally Determined Contributions sectoral/departmental members, with established TOR, (NDCs), and promote long-term low-emission development strategies and regular meetings. (LT-LEDS) Develop long-term low-emission strategies (LT-LEDS)

5. HNAP HNAP Implementation Strategy 62 | P a g e Objective 2: Policy development HNAP Updated Develop National strategy on health and climate change (covering National Strategy for implementation of H-NAP both resilience and low carbon sustainability approaches) developed Health component of National Adaptation Plan ( HNAP ) developed Health component ( HNAP ) incorporated as section in and integrated as a chapter in the overall NAP National Adaptation Plan (NAP), Bangladesh Health is integrated into the Nationally Determined Contributions Inclusion of Health-Specific Targets and Indicators Lead: MOHFW; (NDCs) Other: IEDCR, Develop a roadmap or action plan for building climate resilience in Comprehensive vulnerabilities assessment in the health CCHPU, BFD, health systems in collaboration with health-determining sectors and system related to climate change for the Multisectoral 2024-2025 DDM, BMD, DoE, community actors to support HNAP implementation approach action plan developed Other key Establish coordinated strategies within the health sector and in health- stakeholders determining sectors to develop policies for building a climate-resilient Coordinated strategies established and low carbon health system, maximizing health co-benefits Develop a roadmap or transition plan for reducing GHG emissions in A roadmap or transition plan for reducing GHG emissions the health system in collaboration with health-determining sectors, in the health system developed including decarbonization targets Established mechanism to estimate GHG emissions in the health Mechanism to estimate GHG emissions in the health system system established Objective 3: Cross-sectoral collaboration Agreements (e.g. Memoranda of Understanding) established between the Ministry of Health and key stakeholders at national level (e.g. Establishing formal collaboration mechanisms, such as meteorological and hydrological services, ministries of environment, inter-sectoral committees or working groups, to facilitate food and agriculture, energy, transport, planning), including specific communication and joint planning between the health Lead: MOHFW; roles and responsibilities in relation to protecting health from climate sector and related sectors. Other: IEDCR, change and/or reducing the GHG emissions of health sector operations NCDC, CCHPU, 2024-2025 Multisectoral governance and coordination (involving people, DPHE, BFD, communities, civil society, private sector, and all other engaged Multisectoral Engagement Framework Governance Body Municipalities, DDM, stakeholders) mechanisms established to support climate resilience Formed BMD, DoE, Other and decarbonization in the health system key stakeholders Main policies and strategies from health-determining sectors reflect Inclusion of Health and Climate change considerations in climate change and health considerations both in relation to adaptation Policy Frameworks

5. HNAP HNAP Implementation Strategy 63 | P a g e (e.g. climate-resilient water and sanitation safety plans) and mitigation (e.g. promotion of policies maximizing health co-benefits in the transport sector) Inter-ministerial group on climate change and health established and promoting health in all adaptation and mitigation policies of key Formation of the Inter-Ministerial Group health-determining sectors Health impact assessments (HIA) conducted for new mitigation and A comprehensive HIA done and guidelines tailored to the adaptation policies and Programs in all health-determining sectors, in specific needs of different health-determining sectors accordance with article 4.1.f. of the UNFCCC (minimize adverse developed effects on public health) COMPONENT 2: Climate-smart health workforce Objective 1: Health workforce capacity Develop a training course on climate resilience of health systems and Percentage of health workers having received training on integrate it in health workforce annual training program climate resilience in the past two years Lead: IEDCR (DGHS) Other: DGME, Percentage of health workers having received training on Develop training course on low carbon sustainability NCDC, PHC, low carbon sustainability in the past two years MOEFCC, icddr,b, NIPSOM Develop training course for health workers in specific Programs have information and training on the interlinkages between specific health Percentage of Programs specific ‘Trained workforce’ 2024-2026 outcomes and climate variability and change Lead: PHC (DGHS) Percentage of Health professionals with better awareness Other: CDC, IEDCR, Develop training course on Health workforce capacity developed on and understanding of CC&H issues and in-service NCDC, MOEFCC, decarbonization opportunities in health systems and health care delivery BHE, IPH, NIPSOM, facility operations, the supply chain and in-service delivery NGOs Develop training Curricula on climate change and health covering Percentage of Communities with better awareness and both resilience and low carbon sustainability issues developed understanding of CC&H issues Objective 2: Organizational capacity development

5. HNAP HNAP Implementation Strategy 64 | P a g e Contingency plans for the deployment of sufficient health personnel for acute shocks (e.g., extreme weather events and outbreaks) Assessment based Contingency Plans developed developed at the relevant level (i.e., national, provincial, local) Innovative approaches to reducing GHG emissions at health system or Lead: Hospital and Case studies of successful innovative approaches health care facility level (e.g., teams sharing best practices across clinics Unit, DGHS documented and disseminated different domains, and a system of rewards) promoted Other: CDC, IEDCR, Health workforce participating in decision-making, planning and Total number of health workers involved in decision- 2024-2027 NCDC, PHC, BHE, management of climate change risks making, planning, and management IPH, NIPSOM, NGOs Documentation of initiatives health topics integrated in MOEFCC Capacity building initiatives integrating climate change and health at Training Materials early stages of professional health training Innovative capacity building plans responding to identified human Innovative Capacity Building Plans after assessment resources and institutional capacity gaps developed Objective 3: Information, awareness and communication Training programs of health professionals, the media and community Training Program/plan developed for Health leaders on climate change risk communication, including professionals, the media and community leaders communication of uncertainty Establishment of stakeholder forum on climate change and health as a Stakeholder forum on climate change and health way to engage health determining sectors, the media and community Lead: MOHFW established groups Other: IEDCR, CDC, Development of internal and external health communication plans NCDC, PHC, with focus on raising awareness of climate change risks and health CCHPU, outcomes and implementing efficient strategies to build climate- Communication material developed with focus on raising BHE, IPH, MOEFCC, resilient health system awareness of climate change risks, health and GHG Ministry of 2024-2027 Development of internal and external health communication plans emissions information, NGOs, with focus on measuring GHG emissions and implementing strategies and other relevant to reduce health system emissions stakeholders Comprehensive guides, educational materials and Health workers and communities understand potential future health resources developed risks related to climate change and the actions Training Programs conducted and Risk Communication Campaigns executed

5. HNAP HNAP Implementation Strategy 65 | P a g e Raising awareness among decision-makers, health workers, the media Comprehensive awareness campaigns done with and community leaders on climate change and health decision-makers and other relevant stakeholders Establishment of initiatives with focus on climate change risk communication among different target audiences in the health action Comprehensive risk communication strategy developed plan COMPONENT 3: Assessments of climate and health risks and GHG emissions Objective 1: Health risks Climate change and health vulnerability and adaptation Conduction of Climate change and health vulnerability and adaptation assessments conducted, and a report prepared and assessments, providing evidence on current and future health risks communicated with health ministry and ministry of forest from climate variability and change environment and climate change Assessment of baseline rates and climate sensitivity of health Baseline assessment detailing the current baseline rates of conditions, allowing the selection of priority risks, and continuous Lead: Hospital and various health conditions and statistics, done monitoring of changing risk conditions and health outcomes clinics Unit, DGHS Assessment of information on health system’s capacity to address the Other: CDC, IEDCR, Information on health system’s capacity assessment done increased health risks from climate change 2024-2027 NCDC, PHC, IPH, Results of V&A assessments integrated into health system planning Updated HNAP and other programs as per V&A DDM, DoE, DPHE, and into key climate change processes (e.g. HNAP ) assessments into key climate change processes BUET, NGOs, and Mapping of vulnerable populations and areas prone to high current other relevant Vulnerable populations and areas mapped stakeholders and future climate-related health risks Assessment of health trends in climate-sensitive diseases Trends in climate-sensitive diseases assessment done Objective 2: GHG emissions Assessment of GHG health sector emissions conducted Health sector GHG emissions assessment report done GHG Inventory Report (website, newspaper publication, Publicly report a GHG inventory for a base year of emissions. scientific journal etc.) published 2024-2027 Lead: IEDCR (DGHS) Information on the environmental impact, including GHG emissions, Other: Environmental Impact information report prepared of products and services used or delivered by the health system

5. HNAP HNAP Implementation Strategy 66 | P a g e Information on key GHG emissions in health systems and/or health Hospital and clinics GHG emissions in health systems and/or health care care facilities available and used to inform interventions aiming to Unit, IPH, DDM, facilities information use information report reduce emissions DPHE, BUET, icddr,b, Identification of low regret interventions for reduction in GHG NGOs, academic emissions for each of the key GHG emission hotspots (e.g. access to A comprehensive report that identifies and analyzes the institutions and other renewable energy, energy efficiency, greener waste management key GHG emission hotspots within the health system, relevant stakeholders practices, transition to low carbon transport, reducing emissions from developed anesthetic gases and inhalers) Identification of interventions to reduce supply chain emissions including through more efficient use of resources; low carbon Interventions identified to reduce supply chain emissions substitutions and product innovation; and requirements for health system suppliers to reduce GHG emissions Agreements with health system suppliers to reduce GHG emissions in The Agreements reached the supply chain Number of health facilities with GHG emissions assessment The health facilities with GHG emissions assessed Objective 3: Progress tracking Usages of assessments’ results to identify a set of key indicators to be tracked over time both for health systems’ climate resilience and ‘Key indicators’ for progress tracking identified reductions in GHG emissions Lead: Hospital and Identification of coordinating agencies for implementation of the Clinics Unit (DGHS) Coordinating climate change agencies identified climate strategy and monitoring progress Other: Usage of assessments’ results to prioritize allocation of resources and 2024-2027 IEDCR, CCHPU, Report on resource allocation as per assessment priorities effective climate change and health interventions both for resilience DoE, IPH, DPHE, (Public and NGOs/Academic) and low carbon sustainability DDM, icddr,b, NGOs, A comprehensive plan with ‘Risk Assessment and other relevant Establishment of plan and mechanism for iterative assessments of Methodology’ and ‘Stakeholder Engagement Strategy’ stakeholders health risks from climate variability and change developed COMPONENT 4: Integrated risks monitoring, early warning, and GHG emissions tracking Objective 1: Integrated disease surveillance and early warning

5. HNAP HNAP Implementation Strategy 67 | P a g e Implementation of an integrated climate and health surveillance Health integrated surveillance system developed system for specific climate sensitive diseases Development and implementation of Early detection tools (e.g., rapid diagnostics, Syndromic surveillance) to identify changing incidence Early detection tools developed and early action Development and implementation of climate-informed health early warning systems that predict the risk of outbreaks of priority Climate-Informed Early Warning System developed infectious diseases (e.g., malaria, dengue, cholera) Lead: IEDCR Usage of climate and weather information to assess risk of outbreaks Other: Hospital and of climate-sensitive diseases (i.e., integrated health and climate Integrated Surveillance System developed Clinics Unit, CDC, 2024-2027 surveillance systems) DPHE, BMD, DoE, Participation of the Ministry of Health in cross-sectoral groups Ministry of Health participation with cross-sectoral DDM, icddr,b, and receiving warnings on extreme weather events working group, operational academic institutions Tracking of geographic and seasonal distribution of health risks and Risk Mapping and Geospatial Analysis Tools developed outcomes (e.g. risk mapping) for priority climate-sensitive diseases Objective 2: Monitoring and progress tracking Establishment of Monitoring process with a clearly defined Monitoring Framework Document and Action Plan for mechanism for the tracking system to measure progress in GHG identifying and addressing Gaps, developed emissions reduction Lead: IEDCR (DGHS) Monitoring of impacts from main climate-related determinants of Monitoring of impacts from main climate-related Other: health (e.g. water availability and quality, air quality, food) by the determinants, documented Hospital and Clinics health sector 2024-2029 Unit, NCDC, CDC, Inclusion of indicators on climate change risks, impacts, vulnerability, IPH, BMD, DoE, capacity of health systems, and emergency preparedness capacity, as Developed, Indicator based Monitoring Systems DDM, and other well as climate and environmental variables in relevant monitoring relevant stakeholders systems at the national level and reported over time Periodic reviews for identification and improvement or deterioration Periodic reviews assessments report for identification and in capacities through V&A assessments improvement or deterioration Objective 3: Communication

5. HNAP HNAP Implementation Strategy 68 | P a g e A communication plan or strategy on climate risks to health (both for acute shocks and stresses) developed and implemented, outlining the scope of information for diverse audiences (e.g. media, public, health A communication plan or strategy on climate risks to personnel and other sectors) and events, including who should health developed communicate, and the means of communications – developed and implemented Lead: IEDCR A communication plan or strategy on health system de-carbonization – Other: BHE, CDC, outlining the scope of information for diverse audiences (e.g. media, A communication plan or strategy on health system de- NCDC, PHC, IPH, public, health personnel and other sectors) and events, including who carbonization developed NIPSOM, ICMH, should communicate, and the means of communication – developed 2024-2026 MOEFCC, City and implemented Corporation, icddr,b, Information on the health system’s carbon emissions and best Health based NGOs reduction practices and opportunities shared with relevant Health System Carbon Footprint report shared stakeholders and communities Community engagement and feedback mechanisms established to empower affected populations to respond to warnings, and to guide Community Engagement Strategy and Feedback future development of monitoring and warning systems including with Mechanism regards to environmental impacts of health care COMPONENT 5: Health and climate Research Objective 1: Research agenda development and implementation Development of national research agenda on climate change and National Research Agenda on climate change and health health developed Lead: PMR (DGHS) Development of National research agenda on climate change and National research agenda on climate change and health Other: CCHPU, health incorporates health system decarbonization incorporates health system decarbonization developed IEDCR, NCDC, Dedicate a budget for climate and health research agenda Climate and Health Research Budget allocated PHC, Usage of results of a V&A assessment to inform a national research NNS, IPHN, BNNC, V&A Assessment Report utilized for Research Agenda 2024-2029 NIPSOM, ICMH, agenda on climate change and health MOEFCC, Research agenda incorporating the need to identify technologies for icddr,b, climate resilience with GHG emission reduction potential in priority Research Agenda document on Climate-Resilient Health based NGOs areas Technologies developed

5. HNAP HNAP Implementation Strategy 69 | P a g e Objective 2: Research capacity Establishment of multidisciplinary research partnerships, rosters of national experts, and knowledge management networks to support Multidisciplinary Research Partnership developed research agenda development and implementation Provide incentives for tertiary educational institutions to offer Plan developed for tertiary educational institutions to Lead: PMR (DGHS) research Programs on climate change and health offer research Programs on climate change and health Other: IEDCR, Establishment of data-sharing agreements within and outside the CCHPU, health sector for supporting research on GHG emissions and low Data-sharing mechanism and agreements established NCDC, PHC, carbon technologies NIPSOM, MOEFCC, Establishment of data-sharing agreements within and outside the BMD, icddrb, health sector for supporting research on climate sensitive disease 2024-2027 academic institutions, surveillance and monitoring Health based NGOs Research data-sharing agreements for surveillance, Establishment of data-sharing agreements within and outside the monitoring developed health sector for supporting research on climate resilience Establishment of financial investment mechanisms to support research Programs and postgraduate research training programs Objective 3: Research into policy Establishment of Mechanism for researchers to inform planning, Research data-to-Policy translation mechanism Lead: IEDCR policy, and stakeholder groups established Other: CCHPU, Establishment of mechanisms to support, spread and scale innovation Innovative Support system and Funding Programs NCDC, CDC, PHC, across the health system that supports climate resilience and/or health developed PMR, IPHN, care de-carbonization 2025-2029 NIPSOM, ICMH, Dissemination of Research findings on climate change and health and DDM, MOEFCC, develop key health (e.g. health sector strategic plans, strategies of Report on research findings on climate change and health icddr,b, priority vertical Programs) and climate change (e.g. NAP, NDCs, LT- dissemination program Health based NGOs LEDs) plans, policies and strategies

5. HNAP HNAP Implementation Strategy 70 | P a g e Development of evidence-based capacity for decision-making within Evidence-Based Decision-Making policy developed and outside the health sector to contribute to policy outcomes Promotion programs on climate and health research Promotion of health services-oriented climate and health research established Conduction of research on climate change and health and translation Research on climate change and health and translation into health policy into health policy document Implementation of adaptation and mitigation decision-making based Action Plans for ‘Adaptation and Mitigation’ developed on the results of the research agenda Conduction of research on climate change and health responds to Policy makers need based research report on climate needs by policy makers change & health, document COMPONENT 6: Climate resilient and low carbon infrastructures, technologies, and supply chain Objective 1: Adaptation of current infrastructure, technologies, and supply chain Implementation of climate resilience interventions at health system Climate Resilience interventions Action Plan and/or facility level Regularly review and revise specifications for siting and construction Health facilities ‘Construction Guidelines’ in line with of health facilities in line with projected climate risks projected climate risks developed Regularly review and revise specifications for technologies and Specifications for technologies and selection of products selection of products and processes of services in line with projected in line with projected climate risks, guidelines developed Lead: MOHFW climate risks Other: Hospital and Retrofit health facilities to meet climate-resilient and low-carbon List health facilities for retrofit developed clinics unit, CCHPU, standards IEDCR,CDC, Regularly review and revise specifications for siting and construction NCDC, PHC, DPHE, of health facilities, and energy, water, waste management and Revised, specifications for siting and construction of HEU (Health sanitation provisions in line with (i) projected climate risks, and (ii) health facilities as per the Climate Risk and 2025-2029 Engineering Unit), the latest standards for low or zero carbon and environmentally Sustainability Assessment Reports MOEFCC, sustainable buildings DDM, BUET and Revision of training and recommendations for prescription of Guidelines for Pharmaceuticals prescription during other relevant pharmaceuticals during extreme heat ‘Extreme Heat’ stakeholders Development of improvement plan for ensuring health service 2026-2029 delivery during extreme weather events and outbreaks of climate- Improvement Plan for ensuring health service delivery sensitive diseases based on results of vulnerability assessments of during extreme weather events are in place, developed health care facilities

5. HNAP HNAP Implementation Strategy 71 | P a g e Objective 2: Promotion of new technologies Access to renewable energy in health care facilities promoted as an Lead: MOHFW adaptation and low carbon sustainable measure Other: Hospital and Adoption of environmentally sustainable technologies suitable for clinics unit, CCHPU, harsh conditions (e.g. green cooling) IEDCR,CDC, NCDC, PHC, DPHE, HED (Health Feasibility Studies and low carbon Energy Assessments 2024-2029 Engineering Usage of New technologies such as e-Health, telemedicine or satellite and Renewable Energy Implementation Plan Department), imagery to strengthen climate resilience and reduce carbon emissions, MOEFCC, while contributing to improving health systems performance and UHC DDM, BUET and other relevant stakeholders Objective 3: Environmental sustainability of health operations Assessments of health sector impacts on the environment, including Health sector impacts on the environment assessment Lead: MOHFW & GHG emissions, done Co-lead: MOEFCC Implementation of decarbonization actions at health system and/or Other: CCHPU, A mitigation plan for decarbonization developed facility level IEDCR, CDC, Implementation of interventions to reduce emissions from high carbon NCDC, PHC, MOE, Emission Reduction Strategy Document and intervention medicines at the ‘point of use’, e.g. reducing emissions from inhalers DDM, NIPSOM, Report. and an aesthetic gas Health based NGOs Promotion of active transport (e.g. cycling and walking) and the use of public transportation for patients, visitors, and health workers 2024-2027 Policies that encourage the use of active transport and Transition of health sector transportation systems to low GHG public transportation established Lead: MOHFW; emissions Other: Hospital and Integration of GHG emissions and environmental sustainability clinics unit, CCHPU; considerations within health sector procurement policies and Health sector climate friendly procurement policies and IEDCR, practices, with suppliers, procurement teams and other stakeholders practices operational DPHE; DDM, DoE engagement to support implementation and other relevant Purchases from companies with transparent sustainability standards Sustainable Procurement Policy of reducing GHG stakeholders and science-based targets (near- and long-term) for reducing GHG emissions emissions for products and services prioritization

5. HNAP HNAP Implementation Strategy 72 | P a g e Mobilization of cross-sectoral collaboration for improving practices Cross-sectoral collaboration agreements on environment and health protection Promotion of environmentally sustainable, low carbon diets and procurement of locally produced food and implementation of Sustainable Food Procurement Policy developed interventions to minimize food waste in health care facilities Incorporate climate variability and change into siting, construction, List of the health facilities incorporating climate technologies, procurement, and operational procedures (including variability change in procedures energy, water and sanitation, waste management) COMPONENT 7: Management of environmental determinants of health Objective 1: Monitoring Lead: MOHFW Co-Lead: LGED Integration of monitoring systems, collect data on environmental Monitoring systems that continuously collect data on key Other: DoE, HED, hazards (e.g. water quality, water availability, air quality) environmental hazards developed Municipalities, IEDCR, NCDC Lead: Hospitals and Proportion of health facilities with access to energy, safe water, and Baseline assessment report, to determine the proportion of clinics unit, 2024-2025 sanitation services health facilities Other: CBHC, NCDC, IEDCR, HED Lead: IEDCR Integration of monitoring systems allowing collection and analysis of Integrated Monitoring Systems designed for collection Other: Hospitals and data on environmental hazards, socioeconomic factors and health and analysis of data from various sources clinics unit, NIPSOM, outcomes established HED, DoE, Objective 2: Regulatory mechanisms Lead: MOHFW Designing of regulations on key environmental determinants of health Other: DPHE, (air quality, water quality, food quality, waste management) to reflect Regulatory framework on key environmental DoE, HED, IPH, broader ranges of expected climatic conditions and the health sector’s determinants of health, designed 2024-2029 IEDCR own contribution to GHG emissions and environmental impacts

5. HNAP HNAP Implementation Strategy 73 | P a g e Promotion of regulations for clean energy systems as a means to improve local air quality and reduce the number of premature deaths Regulations for Clean Energy Systems promoted, report Lead: MOHFW from exposure to air pollution Other: IEDCR, Implementation of risk assessment and management approaches DPHE, DoE, HED, aiming to minimize the health impacts from climate change via water, Development of Climate-Resilient WASH Risk sanitation and hygiene (WASH) (e.g. climate resilient water and Assessment implementation report sanitation safety plans) Objective 3: Coordinated cross-sectoral management Lead: IEDCR Implementation of environmental health impact assessments for Other: CCPHU, DoE, Development of environmental health impact assessments policy and Programs in sectors such as transport, water, food and HED, IPHN, BRTA, (EHIAs) implementation Guidelines agriculture, and WASH in coordination with the Ministry of Health DAE, IPH, DDM, LGED, DPHE Lead: MOHFW Implementation of joint multisectoral risk management approaches to Other: CCPHU, Joint Multisectoral Risk Management implementation health risks related to climate related emergencies and disasters, water, 2024-2027 IEDCR, DoE, HED, Guidelines waste, food, and air pollution IPHN, BRTA, DAE, IPH, DDM, CDC Integration of low carbon sustainability approach in managing the Development of Low-Carbon sustainability integration Lead: MOHFW environmental determinants of health plan Other: CCPHU, IEDCR, DoE, IPH, Increase the proportion of the population relying on clean fuels and Tools developed for data collection to track proportion of CDC, DPHE and technologies the population relying on clean fuels and technologies academic institution COMPONENT 8: Climate-informed health programs Objective 1: Health programming Usage of information and evidence gathered in components 3–5 (i.e. Evidence-based climate risks included in planning and addressing research, assessments, and integrated surveillance) to Lead: MOHFW implementation of climate-sensitive diseases programs inform action on priority climate-sensitive health programs Other: IEDCR, Integration of health Programs informed by a V&A assessment in 2024-2028 CCPHU, DoE, IPH, climate change and health adaptation and resilience actions within V&A Assessment integrated for Health Programs CDC, DPHE, DGME, their own Programs DDM, IPHN,

5. HNAP HNAP Implementation Strategy 74 | P a g e Expand the proportion of health programs integrating climate change Development of Climate Change Mitigation Frameworks identified Health mitigation actions for Health Programs Programs, academic Assessment of and improvement of procurement processes and institution and other Development of Climate-Resilient and Low-Carbon mechanisms of specific health Programs based on climate resilience relevant stakeholders Procurement Guidelines and low carbon sustainability considerations Development of investment plans to address identified capacity gaps Developed, Investment Plans after analysis of identified in health Programs to deal with the increased health risks from climate capacity gaps in health programs variability and change Integration of information on current and projected climate change Information integrated in the strategic health Programs risks into strategic health Programs Revise standard operating procedures of health programs to integrate Standard operating procedures related to environmental climate information risks within health programs, revised Service delivery informed by a sound understanding of the different Reports detailing the different exposure pathways from exposure pathways from climate related hazards, and targeted to those climate-related hazards identifying populations most at most at-risk, considering gender differences and diverse vulnerability risk factors Objective 2: Delivery of interventions Implementation of Health sector response plan for key climate- sensitive health risks Targeted Public health Programs to those most at-risk of health Development of the Health Sector Response Plan impacts from climate change (e.g. maternal, newborn and children, Lead: MOHFW older people, migrants, people with pre-existing conditions) Other: IEDCR, Increase health sector Program areas implementing GHG emission List of health sector Program areas implementing GHG CCPHU, DoE, IPH, reduction interventions emission reduction interventions 2024-2029 CDC, DPHE, DDM, Prioritization of short- and long-term climate resilience interventions Climate Resilience Interventions on key health Programs IPHN, identified on key health Programs prioritized Health programs, Number of sustainable low carbon interventions defined and Sustainable low carbon interventions of key health academic institution prioritized on key health Programs programs prioritized. Usage of risk maps and analysis of seasonal trends in diseases to Identification of regions with high incidences of climate- target resources and preventive measures for those most at-risk sensitive diseases COMPONENT 9: Climate-related emergency preparedness and management

5. HNAP HNAP Implementation Strategy 75 | P a g e Objective 1: Policies and protocol Policies, protocols, plans, and strategies for Health Emergency and Review and Assessment report of Existing H-EDRM Disaster Risk Management (H-EDRM) reviewed and improved Documents and integration of Climate of climate- through the integration of climate-sensitive health risks and weather sensitive health risks and weather and climate information and climate information (e.g. El Niño/La Niña conditions) Lead: MOHFW Health sector contingency plans for extreme weather events developed Other: IEDCR, Health sector contingency plans developed and implemented CCPHU, DoE, IPH, Gender sensitivity and equity approaches included in H-EDRM, CDC, DPHE, DDM, Integration of Gender Sensitivity and Equity included in considering vulnerable populations and regions at risk from climate IPHN, identified H-EDRM related hazards Health Programs and 2024-2029 Health sector contingency plans for extreme weather events, including other relevant Health sector contingency plans (for extreme weather risk reduction, preparedness, and response, are aligned with the WHO stakeholders events, including risk reduction, preparedness, and H-EDRM or a local health emergency and disaster risk management response) developed framework Lead: DGHS, Protocols for H-EDRM integrate low carbon and environmentally H-EDRM protocols developed to integrate low-carbon Other: HED, DDM, sustainable practices including for logistics, supply change, and environmentally sustainable practices in all CMSD, academic procurement and storage of medicines and equipment, and transport components. institution Objective 2: Risk management Risk assessments for current and projected future exposure to extreme Comprehensive risk assessment to inform health sector weather events routinely used to inform health sector strategic strategic development plans done development plans 2024-2029 Lead: MOHFW Climate change related emergency and disaster response plans for Other: CCPHU, Climate Change-Related Response Plans developed individual health facilities developed and implemented IEDCR, DoE, IPH, Geographical and seasonal distribution of climate health risks and Geographical and Seasonal emergency and disaster CDC, DPHE, DDM, outcomes used to inform emergency and disaster response plans response plans developed BDRCS, NGOs and 2024-2029 Development of a matrix that defines the roles and other relevant EWS for extreme weather events and climate-sensitive diseases used responsibilities of different actors in the context of EWS stakeholders to inform roles and responsibilities of different actors for H-EDRM alerts. planning Objective 3: Community empowerment

5. HNAP HNAP Implementation Strategy 76 | P a g e Capacity development Programs implemented to support the roles of Need based assessment report for specific capacity local communities to identify risks, prevent exposure to hazards, and Lead: MOHFW development of local communities take action to save lives in extreme weather events Other: CCPHU, Stakeholder mechanism to support participation, dialogue and IEDCR, DoE, IPH, information exchange, to empower civil society and community Identification and mapping of relevant stakeholders in CDC, DPHE, DDM, 2024-2027 groups as primary actors in emergency preparedness and response emergency preparedness and response document BHE, LGED, BDRCS, established NGOs identified Mechanisms in place to ensure information related to health risks Health programs Mechanism developed for information related to health from extreme weather events reaches communities in a way that risks from extreme weather events reaches communities preventive action by them is triggered COMPONENT 10: Sustainable climate and health financing Objective 1: Health specific funding and financing mechanisms Scale-up public financing to build the foundations of climate resilient and low carbon health system Domestic or international funding accessed to strengthen climate resilience of health systems Financing Strategy and Framework for a climate-resilient Lead: MOHFW Resources for climate change and health interventions, both for and low-carbon health system developed Other: PMR, DGHS, resilience and low carbon sustainability, included in national or CCHPU, HEU, DAE, subnational health investment plans DPHE, DDM, Domestic or international funding to strengthen low carbon 2024-2029 MOEFCC, ERD, MoP, sustainability of health systems accessed MoF, development Percentage of the national health budget addresses risks posed by Budget Analysis and Allocation Framework developed partners and other climate variability and change including at health care facility level identified Health Decadal and longer-term forecasts used to inform health investments Health investment planning for decadal and longer-term programs (e.g. construction of new health care facilities) climate challenges developed Results of V&A assessment and HNAP used to access health funding V&A assessment and HNAP integrated into health and financing mechanisms funding and financing strategies Objective 2: Climate change funding streams Lead: MOHFW Climate change and health projects and programs submitted to and Fund mobilized for adaptation and mitigation measures Other: PMR, DGHS, granted by the main international climate change funding mechanisms 2024-2029 CCHPU, HEU, DAE,

5. HNAP HNAP Implementation Strategy 77 | P a g e (e.g. Green Climate Fund (GCF), the Global Environment Facility DPHE, DDM, (GEF), the Adaptation Fund (AF) and bilateral donors) MOEFCC, ERD, MoP, MoF, development partners and other identified Health programs Lead: MOHFW Other: DGHS, Investment cases for climate resilient and low carbon sustainable CCHPU, HEU, health systems developed by relevant actors (e.g. multilateral Fund mobilized for adaptation and mitigation measures MOEFCC, ERD, MoP, development banks) and used to facilitate access to funding and MoF, and other financing 2024-2029 identified Health programs Objective 3: Funding and financing for health-determining sectors Health impacts of climate change monitored in programs funded through financial mechanisms specific to health-determining sectors Lead: MOHFW Climate interventions across sectors with a focus on health, including Other: DGHS, sustainable low carbon health facilities funded Detailed proposals developed for investment projects in CCHPU, HEU, Climate change adaptation and mitigation projects and Programs mobilizing potential funding sources, including DoE, DAE, DPHE, submitted and granted to key health-determining sectors integrate government budgets, international grants, and private 2024-2029 DDM, IPHN, costed activities related to assessing and monitoring potential positive sector investments to support health-determining sectors development partners and negative health impacts and other identified Screening for climate variability and change, and related health risks Health Programs included as criteria for selecting investments in key health determining sectors, such as water, sanitation, food and agriculture, energy, transport, and urban planning

5. HNAP HNAP Implementation Strategy 78 | P a g e 5.4 Costing of HNAP Implementation plan The Costed Implementation Plan in Table-3 outlines key short-and-medium and long term health adaptation activities to be carried out over a five-year period (2024-2029). The prioritized actions build from the strategic objectives presented in Part 4, with the aim of building a climate-resilient and low carbon sustainable health system in Bangladesh. It is estimated that about US$ 1.4 billion will be needed to implement the activities under this action plan in five years. Table 3: Costing of HNAP Implementation Plan SI Total No. Component Objectives Budget in US$ Budget US$

1. Governance Component 1 Total US$46.36 Climate-transformative 1 2. Policy development Total US$37.73 140 m leadership and governance 3. Cross-sectoral collaboration Total US$55.91 Component 2 1. Health workforce capacity Total US$54.21 m Climate-smart health 2. Organizational capacity development Total US$62.26 m 2. 210 m workforce

3. Information, awareness and Total US$93.53 m communication Component 3 1. Health risks Total US$ 6 m Assessments of climate 2. GHG emissions Total US$ 6 m 3. and health risks and GHG 14 m

3. Progress tracking Total US$ 2 m emissions Component 4 1. Integrated disease surveillance and Integrated risks early warning Total US$ 80 monitoring and early 4. 266 m warning, and GHG

2. Monitoring and progress tracking Total US$ 120 emissions tracking

3. Communication Total US$ 66

1. Research agenda development and Component 5 implementation Total US$ 30

5. Health and climate 112 m research 2. Research capacity Total US$ 52

3. Research into policy Total US$ 30

1. Adaptation of current infrastructure, Component 6 Total US$ 155 technologies, and supply chain Climate resilient and low

2. Promotion of new technologies Total US$ 82 6. carbon infrastructure, 350 m

3. Environmental sustainability of technologies, and supply health operations Total US$ 113 chain

1. Monitoring Total US$ 15 Component 7 Management of 2. Regulatory mechanisms Total US$ 5 7 70 m environmental determinants of health 3. Coordinated cross-sectoral Total US$ 50 management Component 8 1. Health programming Total US$ 49 8 Climate- informed health 70 m

2. Delivery of interventions Total US$ 21 programs 9 Component 9 1. Policies and protocols Total US$ 50 98 m

5. HNAP HNAP Implementation Strategy 79 | P a g e Climate-related 2. Risk management Total US$ 25 emergency preparedness and management 3. Community empowerment Total US$ 23

1. Health specific funding and Total US$ 15 financing mechanisms Component 10

2. Climate change funding streams Total US$ 25

10. Sustainable climate and 70 m Total US$ 30 health financing 3. Funding and financing for health- determining sectors GRAND TOTAL USD 1. 4 b This estimated cost USD 1.4 billion will be needed to implement the activities described in Table 3, under this action plan over the period of five-years and it is validated through the workshops conducted during the HNAP updating process, draft HNAP 2018 and climate change & health expert’s opinions. National budget allocation for the health sector was also considered to develop this estimated cost. 5.5 Cost Benefit Analysis of HNAP Implementation plan The Table 3 already identified the sectors for investment and associated cost. The table below (Table- 4) analyses the cost related to those identified sectors and its corresponding benefits. In addition, proper availability of required fund and timely utilization for the relevant events and components for building climate resilient and low carbon health systems will contribute in improved capacity to recover quickly due to climate impact on overall heath events and hazards. This will lead to cost saving in health sector for healthy population and eventually contribution and benefit to national GDP. Table 4: Proposed Cost and Benefit Analysis for climate change in Bangladesh Sectors for Investment Corresponding Benefits

1. Disease Burden: o Waterborne Diseases: Frequent flooding and rising sea levels can contaminate drinking water, leading to an increase in waterborne diseases such as cholera, diarrhea, and Resilient Health System: dysentery. o Vector-Borne Diseases: Climate change is o Increased climate-sensitive health expanding the range of vectors like mosquitoes, initiatives increasing the prevalence of malaria, dengue, o Improved early warning systems and chikungunya. Prolonged monsoon seasons o Developed heat action plans and warmer temperatures provide favorable o Decreased climate sensitive disease conditions for these diseases. burden o Respiratory Issues: Rising air pollution levels, combined with higher temperatures, may exacerbate respiratory diseases like asthma and bronchitis, especially in urban areas.

2. Heat-Related Illnesses: Reduced heat related illness: Bangladesh is experiencing more frequent and intense heat waves, which can lead to dehydration, heat o Cleaner air and decreased temperature exhaustion, and heatstroke among the vulnerable o Reduced respiratory illnesses and populations including the elderly, children and comorbid cardiovascular diseases associated with people and people with outdoor profession. A large pollution.

5. HNAP HNAP Implementation Strategy 80 | P a g e Sectors for Investment Corresponding Benefits portion of Bangladesh’s workforce is employed in o Reduced indoor air pollution- reduce agriculture. Rising temperatures can increase heat stress reliance on biomass for cooking and among farmers. Investment for switching to cleaner energy solutions o Green Belt o Increase use of Solar energy o Reduction of GHG effect o Cleaner energy

3. Food and Nutritional Insecurity: Climate-Adapted food industry and o Crop Failures: Climate change, including Agriculture: erratic rainfall, floods, and droughts, can lead o Increased food availability and different to crop failures. This threatens food security, varieties leading to malnutrition, especially in rural and o Increased production of nutrient-rich crops impoverished communities. e.g- climate-resilient, drought-resistant o Increased Hunger: The rise in food prices due crops. to climate-induced agricultural losses could o Adapted new innovative agricultural lead to increased hunger and undernutrition, approach which disproportionately affects children, o Decreased hunger ensuring climate-smart leading to long-term developmental impacts. agriculture, forestry, and fisheries

4. Mental Health Impact: o Displacement Stress: Bangladesh faces severe Improved Mental Health Services: displacement due to rising sea levels, cyclones, and riverbank erosion. Climate refugees o Increased trained mental health experience heightened stress, anxiety, and workforce depression due to loss of livelihoods and o Increased a number of facilities available homes. for mental health services o Community Disruption: Forced migration can o Available support services to address lead to social instability, disruption of support disruption and livelihoods systems, and additional mental health challenges. o Investment in mental health workforce

5. Health Infrastructure Strain: o Damage to Healthcare Facilities: Floods, cyclones, and storm surges can damage Improved health infrastructure: healthcare infrastructure, disrupting essential services and making it difficult to respond to o Increased number of climate resilient disease outbreaks or provide regular care. infrastructure o Overburdened Health Systems: As more o Increased undisrupted essential health people fall ill due to climate-related factors, services Bangladesh’s healthcare system, which is o Increased logistic support to ensure already under strain, will face even greater essential health services pressure. o Health infrastructure: Resilient healthcare infrastructure.

5. HNAP HNAP Implementation Strategy 81 | P a g e Sectors for Investment Corresponding Benefits

6. Community-Led Adaptation: Ensured Community engagement and o Local Health Solutions: Community-led Participation adaptation strategies, such as building raised platforms for homes and water o Increased number of homes and water systems to withstand floods, could sources and distribution centers improve public health outcomes. These o Increased number of community led grassroots initiatives also help to empower innovative programs (e.g- floating local communities to manage health risks farming) associated with climate change. Trained relevant health care service providers

7. Workforce development o Increased number of trained workforces o Early Response capacity o Disease decreased (mortality, morbidity) o Increased number of treated patients In the context of Bangladesh, the costs of climate change on health are immense, particularly for the poor and vulnerable populations. However, benefits can arise from targeted adaptation strategies, infrastructure improvements, and global cooperation that foster a more resilient and health-conscious future for the country. Addressing these health impacts will require adequate funding, strong policy and international support, and community-based efforts. However, quantitative analysis of the cost-benefits of climate change on health is a complex task due to some challenges such as data unavailability and quality, uncertainty in climate projections, economic costs, dynamic and evolving risk factors etc. Quantifying the costs of mitigating climate-related health impacts is challenging due to the nature of climate change and health dynamics. In addition, a baseline survey is required to have evidence-based cost-benefit analysis. 5.6 HNAP Financing Strategies The HNAP implementation process will strengthen the climate-inclusive public financial management (PFM) system through an updated climate fiscal framework to access, allocate, prioritize and utilize climate funds from public, private and international sources, efficiently and in a transparent way. Also, it will bolster efforts to access climate finance from international climate funds (GEF, Adaptation Fund, GCF, etc.), and bilateral and multilateral sources. Potential options for harnessing climate funds under readiness support or through direct access should be further explored. Potential sources of funding for climate change adaptation There is a wide range of potential funding sources, from national to bilateral to multinational organizations, and from nongovernmental organizations and other sources. The adaptation funds under the UNFCCC are a significant international source of adaptation funding. The four funds (Least Developed Country Fund, Special Climate Change Fund, Adaptation Fund, and Green Climate Fund) have different rules and accessing mechanisms. Many bilateral aid organizations provide adaptation funding, including the UK Department for International Development, US Agency for International Development, and development organizations from high-income countries. Some of their adaptation

5. HNAP HNAP Implementation Strategy 82 | P a g e funding may go through another organization, such as the Climate and Development Knowledge Network etc. National governments and nongovernmental organizations also may have adaptation funding (WHO, 2014). Table 5: Potential sources of funding for climate change adaptation Development Partners New scope for Government Sources/Domestic Fund Global Climate Fund (DPs) funding on Climate change  Use of National Revenue Budget  World Bank, and other  The United Nations  FCDO  Use of fund allocated to MP/Local development banks, Framework Convention  EU Government  Bilateral donors, on Climate  BHA of representative/organisations or multilateral and UN Change(UNFCCC) USAID leaders organizations,  Green Climate Fund  French Govt.  Corporate social responsibility  Asian Development (GCF)  IFRC, fund (Pool fund) e.g. Business Bank(ADB) ,  The Adaptation Fund  Swiss Red enterprises  World Health (AF) Cross  Use of locally available funds e.g. Organization,  The Global Local Elite Person/ Local Society  International Monetary Environment Facility Welfare/ Cooperative Society Fund(IMF), (GEF)  Bangladesh Climate Change Trust  Japan International  The Least Developed Fund (BCCTF) is based on Cooperation Agency( Country Fund (LDCF) revenue from the national budget. JICA),  Special Climate  Government Organization  Korea International Change Fund (SCCF)  NGO/ International organizations Cooperation Agency  The Canadian Climate  Local Elite Person/ Local Society (KOICA), and Nature Fund Welfare/ Cooperative Society  The European  Business enterprises Union (EU),  Others  USAID's Bureau for Humanitarian Assistance (BHA),  The International Federation of Red Cross and Red Crescent Societies (IFRC),  Swiss Red Cross(SRC),  Embassy of Sweden,  The Government of France,  Foreign, Commonwealth and Development Office (FCDO). Source: BBS: Statistics for Disasters and Consultants’ suggestions

5. HNAP HNAP Implementation Strategy 83 | P a g e Resource Mobilization Strategy While HNAP development and implementation activities may be included in national budget allocations, many countries are likely to face funding gaps. For this, a resource mobilization strategy can be used to plan for short-medium- and long-term resourcing requirements, and seek external funding. The HNAP outlines existing funding sources and funding gaps and presents a plan for addressing the gaps and for scaling up adaptation activities into the future. This may include actions to streamline adaptation for health into national budget allocation processes, and planning for access to external funding sources, such as the GCF, GEF or the Adaptation Fund, among others. A robust HNAP is an essential tool for presenting a strong case to donors to support funding proposals. Cost–benefit analyses of action and inaction as well as the return on investment may be useful to assist the investment case (WHO, 2021c). Mobilizing Innovative Finance Mobilizing Innovative Finance require paying special attention to ensure that funds are distributed in an inclusive manner, benefit the most vulnerable and improve the enabling conditions for fostering investments. These include improved transparency and policy coherence to strengthen the bankability of projects. It also requires building capacity to improve know-how of the value of integrated approaches and using this knowledge for scaling of climate financing, especially consider the interdependencies and mutual (financial) benefits among the sectors in investment planning.

5. HNAP HNAP Implementation Strategy 84 | P a g e

6. HNAP Monitoring, Evaluation, and Reporting For the successful implementation of the Health National Adaptation Plan (HNAP), a robust and adaptable monitoring and evaluation (M&E) plan is essential. This M&E framework should be designed to be flexible, practical, and capable of fostering an iterative process that engages a wide array of stakeholders. It should align with existing M&E systems and adhere to both global and regional reporting commitments. The framework should incorporate indicators that are both process and outcome-based, with accountability as a core component. The M&E plan should aim to: • Track the progress of HNAP action plan implementation at the levels of input and output. • Assess the effectiveness and suitability of adaptation actions in meeting the strategic and overall objectives of the HNAP, including the evaluation of allocated resources. • Provide transparent progress updates to beneficiaries, implementing agencies, and financiers on HNAP actions. The Health National Adaptation Plan (HNAP) of Bangladesh is a framework designed to enhance the resilience of the health sector to the impacts of climate change. This plan outlines strategic actions to safeguard public health, ensure robust health systems, and adapt to evolving environmental challenges. Effective monitoring, evaluation, and reporting (MER) are essential components to assess the progress and impact of the HNAP. Effective monitoring, evaluation, and reporting are crucial for the success of the Health National Adaptation Plan in Bangladesh. By systematically assessing progress, evaluating effectiveness, and transparently reporting findings, Bangladesh can strengthen its health sector's resilience to climate change and ensure a healthier future for its population. Continued commitment to these MER activities will be essential in adapting to ongoing and emerging challenges. In addition, the M&E plan and the overall HNAP document should address both demand and supply aspects, ensure the engagement of all stakeholders, and include all relevant ministries. It should promote strong intra- and inter-ministerial coordination and include a five-year review and update plan with a dedicated budget. Finally, the outcome and indicators of HNAP implementation should focus on the 3D framework: Disease, Disability, and Death. 6.1 HNAP review process The HNAP activities will be reviewed once a year by concerned technical group and chaired by the Program Director, “Building Resilience of Health Systems in Asian LDC to Climate Change of Bangladesh”, Climate Change Project, of MOH&FW. The Climate Change Project technical group, will coordinate the review process to ensure all relevant stakeholders are engaged. DPs will also be members of the review committee to provide technical support and guidance. A timeline have to be developed to review and revise the HNAP every 5-years. 6.2 HNAP reporting The HNAP reporting mechanisms will focus on quarterly and annual reports to monitor the progress of implementation of the Action Plan (2024-2029) based on the indicators described in the M&E Plan. The Program Director, of the “Building Resilience of Health Systems in Asian LDC to Climate Change of Bangladesh”, Climate Change Project, of MOH&FW will include this responsibility in the technical group ToR.

6. HNAP Monitoring, Evaluation, and Reporting 85 | P a g e 6.3 M&E Plan (2024-2029) Based on the Action Plan and identified deliverables, the M&E plan outlines indicators, including baseline, means of verification, frequency of reporting, and responsible institutions. Table 6: M&E Plan of HNAP Implementation Indicator Frequency of Objective Baseline Means of Verification Responsible institutions Output reporting Long-term HNAP Strategic Objective To build low carbon, sustainable and climate resilient health system in Bangladesh. COMPONENT 1: Climate-transformative leadership and governance Government order for the Governance – Specific responsibility establishment Technical group and accountability mechanisms on Technical group (TWG) No Technical Lead: MOHFW; (TWG) climate change and health established with approved group (TWG) Other: IEDCR, CCHPU, NCDC, CDC, Approved Meeting minutes established within the Ministry of TORs established Yearly Other key stakeholders written Health. ToRS Policy development – Climate change considerations, both for National Lead: MOHFW; Policy Formulation and Approved Policy Documents and resilience and low carbon Adaptation Plan Approval Rate Records Yearly Other: IEDCR, CCHPU, BFD, DDM, sustainability, reflected in main 2022 BMD, DoE, Other key stakeholders health policies and Programs. Frequency of Inter- Cross-sectoral collaboration – Sectoral Meetings and Meeting minutes Cross-sectoral collaboration Workshops Workshop reports strengthened, and synergies Agreements document Lead: MOHFW; maximized to ensure that decisions Number of Inter-Sectoral Low frequency Multisectoral (GO & NGOs Other: IEDCR, NCDC, CCHPU, taken in other sectors protect and Agreements Private Sectors) Health & Quarterly DPHE, BFD, Municipalities, DDM, promote human health. Climate change Forum formation BMD, DoE, Other key stakeholders Health & Climate change with ToR. Forum COMPONENT 2: Climate-smart health workforce Health workforce capacity – Sufficient number of health workers Professionals possess the Training and Development Lead: IEDCR (DGHS) with the required technical capacity No data-base competencies and skills Records Other: DGME, NCDC, PHC, to deal with the health risks posed document available necessary for climate MOEFCC, icddr,b, by climate variability and change adaptation and resilience. Competency Assessments reports NIPSOM, NGOs and to lead reductions in GHG 6-monthly emissions.

6. HNAP Monitoring, Evaluation, and Reporting 86 | P a g e Indicator Frequency of Objective Baseline Means of Verification Responsible institutions Output reporting Organizational capacity development – Resources, The number and scope of information, knowledge, and organizational capacity- processes employed by health building programs, No assessment Records and documentation of organizations used in an efficient trainings and initiatives document available capacity-building programs and targeted manner to promote focused on enhancing the 6-monthly Lead: Hospital and clinics Unit, DGHS climate resilience and reduce their skills and knowledge of Other: CDC, IEDCR, NCDC, PHC, own GHG emissions and the health workforce BHE, IPH, NIPSOM, NGOs MOEFCC environmental impacts. Information, awareness and communication – Improved Effectiveness of information, awareness and Documentation and evaluation of Awareness Campaigns communication on health impacts CC&H Awareness materials and channels used for Lead: MOHFW from climate change and Campaigns communication and awareness Other: IEDCR, CDC, NCDC, PHC, opportunities for reducing emissions meetings record Reports and records of awareness Quality and Relevance of CCHPU, targeted among different target not available campaigns and their impact on Information BHE, IPH, MOEFCC, Ministry of audiences (e.g. policymakers, health the health workforce Disseminated information, NGOs, and other relevant facility managers, media and 6-monthly stakeholders communities). COMPONENT 3: Assessments of climate and health risks and GHG emissions Health risks – A sound Frequency and Severity understanding of the main hazards, of Climate-Related Lead: Hospital and clinics Unit, DGHS exposures, current and future health Health Events report with V&A assessments Other: CDC, IEDCR, risks, vulnerabilities of different vulnerabilities of conducted in 2011 V&A assessments reports NCDC, PHC, IPH, DDM, DoE, population groups, geographical different population and 2015, 2021 3-yearly DPHE, BUET, NGOs, and other areas, and health systems available groups, geographical relevant stakeholders in the country or region. areas Lead: IEDCR (DGHS) GHG emissions – Information on The total amount of GHG Other: key hotspots of GHG emissions at emissions produced by No information/ GHG emissions assessments Hospital and clinics Unit, IPH, DDM, national health system level and the health sector or report available reports DPHE, BUET, icddr,b, NGOs, facility level available in the country relevant sectors report. 3-yearly academic institutions and other or region. relevant stakeholders Progress tracking – A process and Completion Rate of Lead: Hospital and Clinics Unit system established to track progress Climate and Health Risk (DGHS) in overall climate resilience and Assessments. No Process and Process and system progress track Other: GHG emission in health systems as Process and system system established report IEDCR, CCHPU, DoE, IPH, DPHE, well as to assess health risks in an established to track Annually DDM, icddr,b, NGOs, and other iterative manner progress relevant stakeholders

6. HNAP Monitoring, Evaluation, and Reporting 87 | P a g e Indicator Frequency of Objective Baseline Means of Verification Responsible institutions Output reporting COMPONENT 4: Integrated risks monitoring, early warning, and GHG emissions tracking Integrated disease surveillance and Integrated Disease early warning – Data on climate- surveillance systems in No Integrated Lead: IEDCR sensitive environmental risks, place to monitor climate- Disease Reports of the Integrated Disease Other: Hospital and Clinics Unit, CDC, hazards, and epidemiological trends sensitive diseases across surveillance surveillance systems DPHE, BMD, DoE, DDM, icddr,b, and collected, analyzed and interpreted Annually different regions and systems in place academic institutions on a continual basis, and timely populations in place. response to risks promoted. Monitoring and progress tracking – Information on climate change, Integrated risk health risks, impacts, vulnerability, Integrated risk monitoring and Lead: IEDCR (DGHS) monitoring and GHG health systems capacity, Not in place GHG emissions monitoring Other: emissions tracking environmental impacts and GHG Reports Hospital and Clinics Unit, NCDC, systems plan emissions of health sector operations Annually CDC, IPH, BMD, DoE, DDM, and monitored and reported over time. other relevant stakeholders Risk communication Risk Communication – Timely warnings Lead: IEDCR strategy (for VBD, communication communicated to health decision- No risk Other: BHE, CDC, NCDC, PHC, IPH, WBD, and strategy makers, the media and communities communication NIPSOM, ICMH, MOEFCC, City nutrition/food security) Dissemination of relevant and translated into effective action strategy exists Corporation, icddr,b, Health based developed information to target audiences to prevent negative health outcomes Annually NGOs and approved by report MOHFW COMPONENT 5: Health and climate research Research agenda development and Multi-disciplinary national Lead: PMR (DGHS) implementation – Multidisciplinary The formulation and research agenda on climate Other: CCHPU, IEDCR, NCDC, national research agenda on climate formal adoption of a change and health document. PHC, change and health defined, endorsed comprehensive research Not in place Number and diversity of NNS, IPHN, BNNC, NIPSOM, ICMH, and implemented in collaboration agenda focused on health stakeholders participating in the Annually MOEFCC, with decision-makers and key and climate change agenda-setting process icddr,b, stakeholders. Health based NGOs Research capacity – Research capacity on climate change and Multidisciplinary Number of researchers with Lead: PMR (DGHS) health developed, covering climate Researchers with No CC&H specialized training in health and Other: IEDCR, CCHPU, resilience, low carbon sustainability specialized training in research agenda climate change research NCDC, PHC, NIPSOM, MOEFCC, and built by supporting relevant health and climate change exists Number of multidisciplinary Quarterly BMD, icddrb, academic institutions, multidisciplinary networks, making research. networks research done Health based NGOs available financial resources and creating training opportunities.

6. HNAP Monitoring, Evaluation, and Reporting 88 | P a g e Indicator Frequency of Objective Baseline Means of Verification Responsible institutions Output reporting Research into policy – Research on climate change and health integrated and translated into Lead: IEDCR Health and climate policies to build evidence-based No CC&H List and number of health and Other: CCHPU, research data integrated capacity on adaptation and Research into climate policies, strategies, or NCDC, CDC, PHC, PMR, IPHN, into policies, strategies, mitigation options and inform policy document action plans integrated and NIPSOM, ICMH, DDM, MOEFCC, or action plans for decision-making within and outside exists translated into policies. Annually icddr,b, decision-making the health sector to transform Health based NGOs practices and contribute to policy outcomes. COMPONENT 6: Climate resilient and low carbon infrastructures, technologies, and supply chain Adaptation of current infrastructures, technologies, and Number of health facilities or Assessment of supply chain – Current and future infrastructures upgraded with Vulnerability and Risk of Lead: MOHFW climate risks systematically climate-resilient features Existing Infrastructure Other: Hospital and clinics unit, considered in the context of revising No baseline Percentage of health facilities that CCHPU, IEDCR,CDC, and upgrading of infrastructures, information have adopted low-carbon Implementation of NCDC, PHC, DPHE, HEU (Health technologies, products, and technologies Annually Climate-Resilient Engineering Unit), MOEFCC, processes for climate resilient and Green Infrastructure DDM, BUET and other relevant low carbon sustainable health hospital assessment stakeholders service delivery Number of pilot projects or Promotion of new technologies – Lead: MOHFW demonstrations conducted, Innovative climate resilient and low Innovative climate Other: Hospital and clinics unit, including their geographic environmental impact technologies, resilient and low CCHPU, IEDCR,CDC, distribution and scale, tracked including low carbon measures, environmental impact MOHFW through project reports and NCDC, PHC, DPHE, HED (Health promoted and deployed by the technologies, and low Assessment report evaluations Engineering Department), MOEFCC, health sector through carbon measures, Percentage of health facilities or DDM, BUET and other relevant transformative health service promoted supply chains that have integrated stakeholders delivery. Annually new technologies Environmental sustainability of health operations – Low Reduction in GHG Lead: MOHFW & Reduction in GHG emissions environmental impact technologies emissions resulting from Co-lead: MOEFCC report procured and promoted by the technologies and No baseline data Other: CCHPU, IEDCR, CDC, Percentage of total energy use health sector to enhance resilience to practices in health NCDC, PHC, MOE, DDM, NIPSOM, derived from renewable sources climate change and contribute to operations Annually Health based NGOs long term sustainability. COMPONENT 7: Management of environmental determinants of health Monitoring – Joint monitoring of Risk assessment that No baseline Risk assessment reports, Lead: MOHFW climate-sensitive environmental integrate climate- information publications and review records Co-Lead: LGED

6. HNAP Monitoring, Evaluation, and Reporting 89 | P a g e Indicator Frequency of Objective Baseline Means of Verification Responsible institutions Output reporting risks based on evidence-based sensitive environmental Quarterly Other: Hospitals and clinics unit, standards strengthened. risks, reviewed IEDCR, CBHC, DoE, HED, NIPSOM, Municipalities, NCDC Regulatory mechanisms – Regulatory policies protecting Lead: MOHFW Regulatory policies No baseline Regulatory policies populations from climate-sensitive Other: DPHE, developed and enforced document List of places enforced environmental risks defined, Quarterly DoE, HED, IPH, IEDCR revised, and enforced. Coordinated cross-sectoral Initiatives or projects management – Environmental Number of Cross-Sectoral involving multiple sectors determinants of health jointly No baseline Collaboration Initiatives Lead: MOHFW, IEDCR working together with managed, with clear roles and document Frequency of Cross-Sectoral Other: CCPHU, DoE, HED, IPHN, clear roles and responsibilities defined across Meetings and Coordination BRTA, DAE, IPH, DDM, LGED, responsibilities Quarterly sectors. DPHE and academic institution COMPONENT 8: Climate-informed health Programs Health programming – Information Prevalence of Climate-Related on current and projected (future) Climatic conditions Health Conditions report Lead: MOHFW climatic conditions integrated into strategic planning of No baseline Future projected Climate-Related Other: IEDCR, CCPHU, DoE, IPH, strategic planning of health health Programs document Health Conditions report CDC, DPHE, DGME, DDM, IPHN, Programs for climate-sensitive developed The proportion of the population Annually identified Health Programs, academic diseases. with access to health services institution and other relevant stakeholders Proportion of the target Delivery of interventions – Public population receiving specific health Programs revise their climate-related health standard operating procedures to Population receiving Lead: MOHFW interventions integrate climate change services of Climate- No baseline Other: IEDCR, CCPHU, DoE, IPH, considerations both in relation to Related Health information CDC, DPHE, DDM, IPHN, identified Timeliness of Intervention resilience and low carbon Interventions Annually Health programs, academic institution Implementation sustainability in the delivery of interventions. Quality of Service Delivery COMPONENT 9: Climate-related emergency preparedness and management Policies and protocols – Climate National disaster sensitive health risks and low- reduction strategies, plans National disaster reduction carbon operations included within MOHFW and protocols with strategies, Lead: MOHFW national disaster reduction assessment report Climate sensitive health plans and protocols document Other: IEDCR, CCPHU, DoE, IPH, strategies, plans and protocols and risks and low-carbon CDC, DPHE, HED, CMSD, DDM, wider development processes. Annually

6. HNAP Monitoring, Evaluation, and Reporting 90 | P a g e Indicator Frequency of Objective Baseline Means of Verification Responsible institutions Output reporting operations Policies and IPHN, identified Health Programs and protocols other relevant stakeholders Risk management – Strengthen Health system capacity Comparative assessment reports health system capacity to manage Strengthen to manage showing improvements in health Lead: MOHFW risks so that overall vulnerability MOHFW vulnerability and facility infrastructure, equipment, Other: CCPHU, IEDCR, DoE, IPH, and exposure to climate hazards are assessment report exposure to climate and resource availability before CDC, DPHE, DDM, BDRCS, NGOs reduced and residual risks and hazards and after interventions 6-montly and other relevant stakeholders uncertainties effectively managed. Report of community members Lead: MOHFW Community empowerment – Community members trained in emergency Other: CCPHU, IEDCR, DoE, IPH, Empower communities to effectively trained in emergency No baseline preparedness and response. CDC, DPHE, DDM, BHE, LGED, prevent and respond to health risks preparedness and document Meetings minutes from Annually BDRCS, NGOs identified Health from extreme weather events response established community-based programs emergency committees COMPONENT 10: Sustainable climate and health financing Funds secured through Health specific funding and health-specific financing financing mechanisms – Climate Official government or health mechanisms (e.g., change considerations for both Government sector budget documents showing national budgets, Lead: MOHFW resilience and low carbon assessment report the allocation of funds. international donors, Other: PMR, DGHS, CCHPU, HEU, sustainability included in relevant (if available) Signed agreements with domestic public-private DAE, DPHE, DDM, MOEFCC, ERD, proposals submitted to and funded or international funding agencies partnerships) for climate- Annually MoP, MoF, development partners and by health funding mechanisms. related health initiatives. other identified Health programs Funding secured from Funding Agreements and Lead: MOHFW climate change-specific Climate change funding streams – Government Commitments. Other: PMR, DGHS, CCHPU, HEU, funding streams (e.g., Climate change finance accessed by assessment report DAE, DPHE, DDM, MOEFCC, ERD, Green Climate Fund, the health sector. (if available) Official budget documents MoP, MoF, development partners and Adaptation Fund) for Annually allocation other identified Health programs health-related projects. Funding and financing for health- Proportion of the total determining sectors – Health and Official budget allocation of Lead: MOHFW budget of health- climate change considerations Government funds to health-determining Other: DGHS, CCHPU, HEU, determining sectors incorporated in projects and assessment report sectors. DoE, DAE, DPHE, DDM, IPHN, specifically allocated to Programs supported through (if available) development partners and other climate adaptation and funding for health-determining Sector-Specific Financial Reports identified Health Programs health-related initiatives. Annually sectors.

6. HNAP Monitoring, Evaluation, and Reporting 91 | P a g e Annex 1: Proposed Technical Working Group (TWG) Technical Working Group (TWG) for the updating “Health-National Adaptation Plan (H-NAP)” (Not According to seniority) Representative from the MOHFW

1. Joint Secretary (WHO), Chairperson Climate Change Focal Point, Program Director, “Building Resilience of Health Systems in Asian LDC to Climate Change of Bangladesh”, Climate Change Project, MOH&FW Health Services Division, Ministry of Health and Family Welfare. Bangladesh

2. Line Director/ Director Member Non-Communicable Diseases Control (NCDC), Directorate General Health Services (DGHS) HSD, MOHFW

3. Director Member Institute of Epidemiology, Disease Control & Research (IEDCR) Directorate General Health Services (DGHS), HSD, MOHFW

4. Director (Disease Control) & LD CDC, DGHS Member Directorate General Health Services (DGHS), HSD, MOHFW

5. Program Manager Climate Project. Member Secretary Senior Scientific Officer (SSO) Institute of Epidemiology, Disease Control & Research (IEDCR) DGHS, HSD, MOHFW. Mohakhali, Dhaka Program Manager, “Building Resilience of Health Systems in Asian LDC to Climate Change of Bangladesh”, Climate Change Project, MOH&FW

1. Director (Planning & Development) Member Directorate General of Medical Education (DGME) Medical Education and Family Welfare Division, MOHFW, Dhaka Representative from NIPSOM

7. Head of the Department Member Department of Occupational and Environmental Health (OEH) National Institute of Preventive and Social Medicine (NIPSOM) Mohakhali, Dhaka 1212, Bangladesh Representative from the Department of Environment (DoE)

8. Director (Climate change & International Convention) Member Department of Environment Ministry of Environment, Forest and Climate Change Government of the People's Republic of Bangladesh Representative from Bangladesh Meteorological Department (BMD),

9. Meteorologist Scientist Member Bangladesh Meteorological Department (BMD), Dhaka Representative from icddr,b

10. Project Coordinator Member Environmental Health and WASH Health Systems and Population Studies Division, icddr’b. Dhaka

Annex 1: Proposed Technical Working Group (TWG) i|Page Representative from WHO Country Office 11. Focal Person H-NAP Member EHU Technical Unit of WHO WHO-Bangladesh Country Office Dhaka Bangladesh Terms of Reference: 1) The Chairperson will lead the Technical Working Group (TWG) for the Bangladesh ‘Health National Adaptation Plan (HNAP)’ and Member Secretary will work in consultation with the Chairperson. 2) Member Secretary, will plan the necessary coordination-meetings and workshops with members and review the progress of the activities. 3) The committee members will finalize the ‘Action Plan’ for successful implementation of the ‘Health National Adaptation Plan (HNAP) 2024; through necessary stakeholders consultation meeting / Workshop). 4) The committee members will engage in ‘Monitoring & Evaluation” of the H-NAP activities 5) The committee members can Co-opt member(s) or representative as and when necessary Annex 2: List of stakeholders participated in KII The Technical team conduct 7 selective key informant interviews with representative from both Government (5) and non-government sectors (2). i. Additional Director General, DGHS, HSD. MOHFW ii. Director NIPSOM, HSD. MOHFW iii. Director Disease Control DGHS. HSD. MOHFW iv. Director IEDCR, DGHS HSD. MOHFW and v. The Program manager, Climate Change Project and SSO IEDCR, DGHS vi. Country Director, WaterAid Bangladesh vii. Senior Director-Strategic Planning & Head of Climate Action, Friendship Bangladesh

Annex 3: Literature Review 1. National Adaptation Plan (NAP), Bangladesh, 2022 2. Health National Adaptation Plan (H-NAP), 2018 Bangladesh; 3. Vulnerability and Adaptation to Climate Change in Coastal and Drought Prone Areas of Bangladesh: Health and WASH, EHU, WHO, 2015; 4. Health Vulnerability and Adaptation Assessment of Climate Change Impact in Bangladesh, 2021, IEDCR, EHU; 5. Nationally determined contribution (NDC), 2021 of Ministry of Environment Forest and Climate Change 6. Climate Change and WASH Initiatives in Bangladesh EHU, WHO; 7. National Health Policy 8. Health Population Nutrition Sector Development Program (HPNSDP). 9. Climate change adaptation in Bangladesh: Current practices, challenges and the way forward 10. A review of the global climate change impacts, adaptation, and sustainable mitigation measures 11. Climate Change in Bangladesh: Impact on Infectious Diseases and Mental Health 12. Public health emergencies: preparedness and response - Report by the Director-General 13. Public Health Impact and Health System Preparedness within a Changing Climate in Bangladesh: A Scoping Review 14. World Health Organization’s Operational framework for building climate resilient and low carbon health systems, 2023 15. World Health Organization’s Operational framework for building a climate-resilient health system, 2015 16. Climate Change Health Adaptation Strategies and Action Plans of Nepal (2016-2020) 17. National Adaptation Plan for Climate Change Impacts in Sri Lanka 2016 – 2025 18. National Adaptation Plan Pakistan

Annex 2: List of stakeholders participated in KII ii | P a g e 19. Philippines National Climate Change Adaptation in Health (CCAH) Strategic Plan 20. Climate Change Adaptation on Health Sector in Indonesia 21. Health Adaptation and Resilience to Climate Risks India 22. Climate Related Health Adaptation and Resilience in India: Southern Region 23. Framework for action in building health systems resilience to climate change in South East Asia Region 24. The Philippine National Adaptation Priorities 25. Costing Methodology for Fiji’s National Adaptation Plan, 2020 26. Communicating climate change: A practitioner’s guide Insights from Africa, Asia and Latin America, 2019 27. Review Health in National Adaptation Plans, 2021 28. First Biennial Update Report of Bangladesh to the UNFCCC, June 2023 United Nations Framework Convention on Climate Change 29. 8th five-year plan 30. Mujib Climate Prosperity Plan 31. 3rd country investment plan. 32. Climate Change and Gender Action Plan (CCGAP) 33. Poverty Reduction Strategy 34. Standing order on disaster (SOD) 2019 35. Guideline for Participatory water management 36. Current version of One heath strategic plan 37. 5th Health Sectoral Program Annex 4: NGO workshop participants’ list I. CARE Bangladesh II. ActionAid Bangladesh III. GIZ Bangladesh IV. BRAC Bangladesh V. Sajida Foundation VI. Institute of Disaster Management and Vulnerability Studies, Dhaka University VII. Centre for Climate Change and VIII. Bangladesh Resource Centre for Indigenous Environmental Research (C3ER), BRAC Knowledge (BARCIK) University IX. Bangladesh Red Crescent Society (BDRCS) X. UDAYAN Bangladesh XI. Christian Commission for Development in XII. Akota Somaj Kollayan Songstha (ASKS) Bangladesh (CCDB) Annex 5: Financial analysis Health Services Division Ensuring affordable and culturally appropriate healthcare services for all through the development of health, nutrition, and population sectors is mentioned as the mission statement of Health Services Division to establish a healthy, robust, and productive community. With the aim of keeping the population capable and healthy, Health Services Division emphasizes climate resilience, climate change adaptation, and health risks in the context of ensuring health security. To achieve this objective, various activities have been undertaken in this sector to make it climate-responsive, benefiting particularly vulnerable populations, especially impoverished women and children who need these services the most. In combating the adverse effects of climate change, assistance is provided in implementing maternal health voucher programs in 53 vulnerable upazilas to support pregnant and underprivileged women. Community clinics and specialized hospitals provide medical services to the most marginalized population in society who are the most affected by climate change. Measures are being taken to control vector-borne diseases such as dengue, which have seen an increase due to climate change. Training is provided at the grassroots level to ensure competent healthcare delivery enabling effective response to climate-relevant health risks for the poorest and most vulnerable communities (Ministry of Finance, 2023).

Annex 4: NGO workshop participants’ list iii | P a g e Budget allocation for Climate Change ❑ Budget allocation for FY2024-2025 ➢ The climate relevant allocation has increased significantly over times. The cumulative budget allocations for the 25 Ministries/Divisions in FY25 account for BDT 4,18,160.64 crore of which 10.09% (BDT 42206.89 crore) are climate-relevant. ➢ However, the climate-relevant budget allocation for 25 Ministries/Divisions has decreased by 0.72% compared to the revised budget for FY24, where it constituted 10.81% of the total climate-relevant allocation. ➢ Sectoral allocation as a share of total budget and GDP has stagnated over time. Total revised budget for climate relevant allocation as a share of total budget increased from 5.63% in FY23 to 5.81% in FY24. ➢ However, as a share of GDP, the total allocation as % of GDP decreased from 0.84% in FY23 to 0.82% in FY24. ❑ Climate Budget Utilization ➢ 25 Ministries/Divisions performed well in utilizing climate relevant budget in FY22 and FY23 when utilization rates were 93% and 91%, respectively. However, the climate budget utilization decreased from 93% in FY22 to 91% in FY23. ➢ Development budget utilization has remained stagnant around 85% during FY21-FY23. ➢ Given the country’s climate vulnerability, development budget utilization should be increased in the coming years by enhancing designated ministries/divisions’ capacity. ❑ Budget Allocation for the MOEFCC ➢ The allocation for the MOEFCC has increased to 0.27% of total budgetary allocation in FY25 from 0.23% in FY24. ➢ However, the allocation for the ministry as a share of GDP falls behind the targets stated in 8FYP which are 0.10% of GDP by 2025 (actual 0.038% in FY25) and 0.5% of GDP by 2041. ➢ The allocation for strengthening institutional capacity for climate risk management increased by 44.36% from BDT 104.61 crore in RBFY24 to BDT 151.01 crore in FY25. ❑ BCCSAP thematic areas in the budget ➢ Considering the six BCCSAP thematic areas, 13.66% of the climate budget is allocated to mitigation and low- carbon development thematic areas whereas only 6.35% is allocated to comprehensive disaster management. ❑ Allocation for Renewable Energy and Fossil Fuel in ADP ➢ The allocation for renewable energy in ADP shows a fluctuating trend over the years. ➢ Only 4.26% of total allocation for the energy sector was allocated for renewable energy in FY25. ➢ The share of allocation for renewable energy in ADP should be increased in order to achieve the target of 40% power generation from clean energy by 2041. ❑ ADP Allocation for Improving the Capacity of the MOEFCC ➢ The MOEFCC undertakes coordinating functions and plays the lead role in developing and enforcing environmental policies. The 8FYP proposed a significant increase in the ADP allocation for environment and climate change. However, the proposed ADP allocation in the budget for the ministry continues to fall behind the target as stated in 8FYP.

Annex 5: Financial analysis iv | P a g e Annex 6: Climate-related health risks in Bangladesh: Related Climate Climate-Sensitive Projected Future Risk Hazard Health Risk Increased Rising temperatures are projected to exacerbate frequency and heat-related morbidity and mortality, especially Heat-related illnesses intensity of heat among vulnerable groups such as children, the waves elderly, and outdoor workers. Increased Warmer temperatures and altered rainfall temperature, Vector-borne diseases patterns are likely to expand the range and rainfall variability, (e.g., dengue, malaria) transmission season of vector-borne diseases, and humidity increasing outbreaks. More frequent and severe flooding and water Flooding, heavy Waterborne diseases salinity are expected to increase contamination rainfall, and saline (e.g., cholera, diarrhea) of water sources, leading to higher risks of water intrusion waterborne diseases. Climate-induced changes in air quality, coupled Air pollution and Respiratory illnesses with urbanization, may worsen respiratory dust storms illnesses like asthma and bronchitis. Reduced agricultural productivity and food Drought, crop Malnutrition and under insecurity caused by climate-related hazards failures, and rising nutrition will likely increase malnutrition, particularly food prices among children and women. Recurrent cyclones, floods, and sea-level rise Displacement from may lead to forced displacement, increasing the extreme weather Mental health impacts incidence of anxiety, depression, and other events mental health issues. Rising sea levels and stronger storms are Cyclones, storm projected to increase the frequency of natural surges, and Injury and mortality disasters, resulting in higher rates of injuries and extreme flooding deaths. Changes in land use and habitat disruption due Habitat changes to climate change may increase the risk of and migration of Zoonotic diseases zoonotic diseases as human-wildlife interactions wildlife become more frequent. Notes:  Bangladesh's vulnerability stems from its low-lying geography, dense population, and reliance on agriculture.  Projected risks assume current adaptation measures remain inadequate, emphasizing the need for enhanced climate resilience and health system preparedness.

Annex 6: Climate-related health risks in Bangladesh: v|Page References 1. Alam, D., Robinson, H., Kanungo, A., Hossain, M. D., & Hassan, M. (2013). Health system preparedness for responding to the growing burden of non-communicable disease – A case study of Bangladesh. Nossal Institute for Global Health. https://www.researchgate.net/publication/262451665 2. Asma, K. M., & Kotani, K. (2021). Salinity and Water-Related Disease risk in coastal Bangladesh. EcoHealth, 18(1), 61–75. https://doi.org/10.1007/s10393-021-01517-z 3. ATDCP. (2022). Division-wise Dengue case distribution in year 2022. Aedes Transmitted Diseases Control Program, Communicable Disease Control, Directorate General of Health Services. 4. Bangladesh Planning Commission (2018). Delta Plan 2100. Government of the People's Republic of Bangladesh https://bdp2100kp.gov.bd/. https://plancomm.gov.bd/site/files/0adcee77-2db8-41bf-b36b- 657b5ee1efb9/Bangladesh-Delta-Plan-2100. 5. Berry, H. L., Bowen, K., & Kjellstrom, T. (2010). 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World Bank Group & Institute for Health Metrics and Evaluation. https://documents1.worldbank.org/curated/en/781521473177013155/pdf/108141-REVISED-Cost-of- PollutionWebCORRECTEDfile.pdf References ix | P a g e List of Contributors (Not According to Seniority) Name Designation & Institute/Directorate/Office Prof. Dr. Tahmina Shirin PhD Director, IEDCR Dr. Md Zainal Abedin Tito Line Director, Hospital Service Management, DGHS Dr. Moinul Ahsan Director (Hospital), DGHS Dr. Shah Ali Akbar Ashrafi Director (MIS) & LD HIS & E-Health, DGHS Md. Mamunur Rashid Joint Secretary (WH Wing), & PD, Climate Change & Health, Health Services Division, MoHFW Dr. Md. Shibbir Ahmed Osmani Joint Secretary (PH Wing), Health Services Division, MoHFW Dr. Ahmed Nawsher Alam Associate Prof. & PSO, IEDCR Dr. Umme Ruman Siddiqi Asst. Director, P&R, DGHS Dr. Ahsanul Hoque Assistant Director (Hospital), DGHS Dr. Jayanto Kumar Saha Assistant Director (Disaster), CDC, DGHS Dr. Md Golam Abbas PhD Asst. Prof, Head Dept of OEH, NIPSOM Dr. Mahbubur Rahman PhD Asst. Prof. , Epidemiology, IEDCR Dr. Md Sabbir Haider PhD SSO, IEDCR Dr. Mohammad Anisur Rahman Program Manager, Hospital Services, DGHS Syed Ashraf CMS, Health Focal Point, DDM Mr. Md Shamim Anwar Executive Engineer, DPHE Nazim Hossain Sheikh Deputy Director, DoE Shaheda Begum Deputy Director, DoE S.M Quamrul Hassan Deputy Director, BMD Mohammad Abul Kalam Mallik Meteorologist, BMD Dr. Manjur Hossain Khan Asst. Prof, Virology, IEDCR Dr. Shyamol Kumer Das DPM (Malaria & Aedes Transmitted Disease), CDC, DGHS Dr. Nusaer Chowdhury DPM, NCDC, DGHS Dr Nigar Sultana DPM-9, HSM, DGHS Dr. Sajib Roy DPM-4, NCDC, DGHS Mr. Masud Rana Senior Chemist, DoE Dr. Md. Adnan Khan Assistant Chief (Medical), MIS, DGHS Dr. Md Omar Qayum SSO, IEDCR Dr. Mohammad Ferdous Rahman SSO, IEDCR & PM, Climate Change & Health Sarker Dr. Mohammad Rashedul Hassan Medical Officer, IEDCR Dr. Immamul Muntasir SO, IEDCR Dr. Abir Saqran Mahmood Medical Officer, IEDCR Dr. Fariha Masfiqua Malek Medical Officer, IEDCR Dr. Mushtuq Husain Advisor H-NAP Development Team Dr. M Salimuzzaman Consultant, OH, IEDCR Dr. Mohammad Zahuirul Islam PhD Asst. Prof, NSU Dr. Farjana Jahan Associate Scientist, icddr,b Dr. Mizanul Islam Nasim Research Investigator, EWASH, HSPSD Dr. Sabbir Ahmed Sr. Manager-BRAC Health Program, BRAC Dr. Aerangajeb Al Hossain WaterAid Bangladesh References x|Page Dr Priscilla Wobil, Health Specialist, UNICEF Bangladesh Felix Helgesson Second Secretary/Health Officer, Embassy of Sweden Faustina Gomez Technical Officer (Climate Change and Health), WHO Regional Office Amy Savage Technical Officer (Climate Change and Health), WHO HQ Dr. Ahmedul Kabir Program Officer, WHO, Bangladesh Dr. Nargis Akter NPO WASH & Environment, WHO Dr. Anthony O. Eshofonie Team Leader HSE, EHU,WHO References xi | P a g e