Health National Adaptation Plan (HNAP) 2020-2024

i HEALTH NATIONAL ADAPTATION PLAN (HNAP) FOR PREVENTING HEALTH RISKS AND DISEASES FROM CLIMATE CHANGE IN MALDIVES 2020 - 2024 ii Endorsement No: Plan/23/-MoH/2020/14 Endorsement numbered by: Strategic Planning Unit/PIH, MoH Date: November 2020 © Ministry of Health 2020 All rights reserved. Publication is available on the Ministry of health website (www.health.gov.mv). Requests for publication or for permission to reproduce or translate the publication can be obtained from Ministry of Health, Maldives. HEALTH NATIONAL ADAPTATION PLAN (HNAP) FOR PREVENTING HEALTH RISKS AND DISEASES FROM CLIMATE CHANGE IN MALDIVES Developed by Dr. Meghnath Dhimal Health Protection Agency WHO Published in 2020 http://www.health.gov.mv/ iii Contents FOREWORD ................................................................................................................................................... v ACKNOWLEDGEMENT .................................................................................................................................. vi ACRONYMS AND ABBREVIATIONS .............................................................................................................. vii CHAPTER ONE ............................................................................................................................................... 1 1.1. INTRODUCTION ............................................................................................................................. 1 1.2. Climate Change in Maldives .......................................................................................................... 2 1.3. Purpose of Health National Adaptation Plan (HNAP) for Climate Change ................................... 4 1.6. Guidance documents ......................................................................................................................... 5 CHAPTER TWO .............................................................................................................................................. 7 2.1. HEALTH IMPACT OF CLIMATE CHANGE ............................................................................................. 7 2.1.1 Communicable Diseases .............................................................................................................. 7 2.1.2. Non communicable Diseases and Mental Health ....................................................................... 9 2.1.3. Water Resources and Water-borne Diseases ............................................................................. 9 2.1.3.1. Water Resources ...................................................................................................................... 9 2.1.4. Air Quality and Airborne Diseases ............................................................................................ 11 2.1.5. Heat Related Illness ............................................................................................................. 12 2.1.6. Food Security and Nutrition Related Illness .............................................................................. 13 2.2. PHYSICAL INFRASTRUCTURE ............................................................................................................ 14 2.2.1. Built Environment ..................................................................................................................... 14 2.2.2. Waste Management ................................................................................................................. 14 2.3. EMERGENCY PREPAREDNESS AND MANAGEMENT ......................................................................... 15 2.4. RESEARCH AND ADVOCACY ............................................................................................................. 15 2.5. CLIMATE AND HEALTH FINANCING .................................................................................................. 16 CHAPTER THREE .......................................................................................................................................... 17 CHAPTER FOUR ........................................................................................................................................... 29 4.2 Cross Sectorial Collaboration ............................................................................................................ 29 5.4 Monitoring and Evaluation of climate change adaptation/ mitigation measure Indicators for M&E ................................................................................................................................................................ 30 References ................................................................................................................................................ 29 iv Figures Figure 2.1 National dengue trend from 2017 to 12 January 2019………………………………………………..……..8 Figure 2.2 Scrub Typhus cases within atolls (2017 to January 2019)……………………………………………..…….9 Figure 2.3 National AGE trend from 2016 to 12 January 2019……………………………………………………………11 Figure 2.4 National ARI trend from 2016 to 12 January 2019…………………………………………………………….12 Figure 2.5 National Conjunctivitis cases from 2015 to 12th January 2019…………………………………………..12 Figure 2.6 Viral Fever cases from 2016 to 12th January 2019……………………………………………………………..13 Figure 4.3 Implementation Framework………………………………………………………………………………………………33 Tables Table 2.1 Health Impact of Climate Change…………………………………………………………………………………… 7 Table 3.1 Implementation strategies for strategic areas………………………………………………………………..18 -32 Table 5.5 Indicators for Monitoring and Evaluation………………………………………………………………………………35 - 39 v FOREWORD Direct and indirect effects of climate change play a key role in determining human health in vulnerable populations all around the world. Global warming and sea level rise are a threat especially to countries like Maldives that are just one meter above sea level. Without proper adaptation and mitigation measures, Maldives face great health and environmental risks. Extreme weather events, changes in water quality and ecosystems put communities at risk of communicable diseases, non-communicable diseases, water borne and airborne diseases, heat related illnesses and nutrition related illnesses to name a few. We must take human health into consideration whilst developing policies and plans for adaptation to climate change. Health National Adaptation Plan (NHAP) integrates climate change into health care systems in Maldives. This plan is a stepping stone in accepting environmental health as a pressing issue and initiating sustainable and climate resilient adaptation measures. HNAP will provide opportunities for intersectional collaboration, fund mobilization and holistic approach for sustainable development. I convey my sincere gratitude to Dr.Meghnath Dhimal (WHO consultant for HNAP) for his contributions in the development of this document. And I thank all stakeholders and relevant staff at Health Protection Agency and Ministry of Health for their dedicated efforts in the compilation of this important plan. It is my belief that with the implementation of this plan, the existing gaps in the health care system will be addressed, further strengthening the nation’s resilience to climate change. With inter sectorial collaboration and support, I am confident in ensuring safer, more prepared communities for all. Abdulla Ameen Minister of Health vi ACKNOWLEDGEMENT The development of the National Health Adaptation Plan (HNAP) was an initiation from the Environmental and Occupational Health and Safety Division of Health Protection Agency, Ministry of Health, Maldives. The action plan was developed with technical and financial assistance from World Health Organization. We are grateful for the continuous support given by WHO throughout the development of the action plan. The Ministry is also grateful to Dr.Meghnath Dhimal (WHO consultant for HNAP) in providing technical assistance and guidance in the development of the action plan. The Ministry greatly appreciates the active participation of and valuable contributions of the members from relevant stakeholders which made the development of the action plan possible vii ACRONYMS AND ABBREVIATIONS ARI: Acute Respiratory Illness COP: Conference of Parties EPA: Environment Protection Agency GCF: Green Climate Fund GEF: Global Environmental Facility HNAP: Health National Adaptation Plan HPA: Health Protection Agency IPCC: Inter-governmental Panel on Climate Change IWRM: Integrated Water Resource Management LDCS: Least Developed Countries LECReD: Low Emission Climate Resilient Development Programme LGA: Local Government Authority LRA: Labour Relations Authority, MACI: Maldives Association of Construction Industry MFDA: Maldives Food and Drug Authority MGDs: Millennium Development Goals MHA: Mental Health Association MMS: Maldives Meteorological Services MNDF: Maldives National Defense Force MNU: Maldives National University viii MoE: Ministry of Education MoE: Ministry of Environment MoFA: Ministry of Fisheries and Agriculture, MoFT: Ministry of Finance and Treasure MoH: Ministry of Health MoHI: Ministry of Housing and Infrastructure MoT: Ministry of Tourism MoYS: Ministry of Youths and Sports, MPS: Maldives Police Services, MRC: Maldivian Red Crescent MTA: Maldives Transport Authority MWSC: Male’ Water and Sewerage Company (MWSC) NAP: National Adaptation Plan NAPA: National Adaptation Programme of Action NCDs: Non-communicable diseases NDMC: National Disaster Management Centre NDP: National Development Programme SIDS: Small Island Developing States UN: United Nations UNFCCC: United Nations Framework Convention on Climate Change 1 CHAPTER ONE 1.1. INTRODUCTION Human health is considered as one of the most vulnerable sectors to climate change. Climate change is an emerging threat to global public health as population is sensitive to shifts in weather patterns and other aspects of climate change. Exposure to climate change is directly through extreme weather events such as frequent and intense storms, heat waves; and indirectly through changes in water, air, food quality and quantity, ecosystems, agriculture, and economy. Maldives is among the most vulnerable Small Island Developing State (SIDS) to the predicted impacts of climate change. Thus timely adaptation plan is of utmost importance for the country. Sea-level rise, even by 1 meter, could be a threat to many of the islands in the country. The Maldives consists of about 1190 islands and the population is distributed over approximately 197 inhabited islands. The challenges Maldives faces in the context of climate change and development include, but are not limited to, the low-lying nature of the islands, frequent soil erosion, high population density, and a dispersed geography. Vulnerability of Maldives to impacts of climate change and associated extreme weather events and disasters are significantly higher due to limited ecological, socio-economic, and technological capacities. Despite continuous efforts being undertaken to increase the adaptation actions and opportunities, and to undertake low emission development, limited financial resources, capacity and technology remain major challenges in addressing the impacts of climate change in the country. Although Maldives is the country hard- hit by the effect of global warming and climate change, it has a track record of leadership in climate change mitigation. According to the World Economic Forum’s Global Risks Report 2018, extreme weather events and natural disasters, failure of climate change mitigation and adaptation, water crises, biodiversity loss, and air and soil pollution are the most pressing threats that are perceived as having the biggest impact in next 10 years1. Climate change and climate-induced extreme events will continue to accelerate the loss of lives and property and increase the burden of 2 diseases if adaptive actions are not taken timely. The 21st UN Climate Change Conference of the Parties (COP21) held in Paris in December 2015 came up with the Paris Agreement which framed a bold ambition to keep warming “well below” the 2°C point regarded as untenably dangerous by the scientists, and “pursuing efforts to limit the temperature increase to 1.5° C.” The agreement includes a strong commitment to climate change mitigation and adaptation actions, recognizing the principle of loss and damage due to climate change and the protection of those most vulnerable populations. The United Nations Climate Change Conference of Parties (COP23), WHO, in collaboration with the UN Climate Change secretariat and in partnership with the Fijian Presidency of the twenty- third Conference of the Parties (COP23), launched a special initiative to protect people living in Small Island Developing States from the health impacts of climate change. The vision of this initiative is that, by 2030, all Small Island Developing States will have health systems that are resilient to climate change and countries around the world will be reducing their carbon emissions both to protect the most vulnerable from climate risks and deliver large health benefits in carbon-emitting countries2. Increases in sea surface temperature and ocean acidification threaten both biodiversity and livelihoods of people. Primary health care facilities are available at each inhabited island, however in extreme weather events such as floods and storms, access to higher tiered health care facilities becomes a challenge due to the isolated nature of the islands. 1.2. Climate Change in Maldives The Maldives’ has a tropical climate which is warm and humid. The weather is dominated by two monsoon periods, the southwest monsoon (wet, May to November) and the northeast monsoon (dry, January to March). Annual average rainfall is 2,124 mm and average relative humidity is 80% 3. The mean annual temperature is 28°C, with little variation throughout the year. 3 According to Second Communication Report of Maldives to UNFCCC, following is the situation of current and projected trends of climate change in Maldives4: 1. Current trends:  An overall decreasing trend is observed for annual rainfall over the 3 regions (9.5mm, 0.02 mm and 2.21 mm per year over Hanimaadhoo, Malé and Gan respectively).  Number of rainfall days per year is decreasing  Mean average temperature increases for Malé (0.267 °C/decade) and Gan (0.168 °C/decade) while a decrease is observed in the northern station in Hanimaadhoo (0.086°C/decade)  Maximum temperature shows an increase in the northern part of the country (0.21°C per decade) and a decrease (-0.06 °C/decade) in the southern part of the country.  Rising sea level trend with 3.753 and 2.933mm per year in Malé and Gan respectively  An increasing trend, of 0.11 to 0.15 °C/decade, in SST throughout the country 2. Future climate projections from the downscaled models are  increase in rainfall over northern and central regions and a decrease in the southern region for the years 2021-2050, while an overall increase in rainfall is shown from 2082- 2100 years  temperature projected to increase over different zones for the different time periods.  Mean temperature increases by 1.8°C from baseline (1981-2000) by mid- (2021-2050)  maximum sea surface height is projected to increase between 0.40 to 0.48m by 2100  sea surface temperature (SST) has a rising trend in all four geographic zones in all selected special report on emissions scenarios (SRES) 4 1.3. Purpose of Health National Adaptation Plan (HNAP) for Climate Change The 70th regional committee meeting of WHO SEARO held in Male' in 2017 passed Male' Declaration signed by health ministers which will be implemented through a regional framework for action. One of the activities outlined in the framework is for all countries to have an HNAP. Also Maldives Climate Change Policy Framework highlighted the importance for developing sectoral plans to adapt and mitigate the impact of climate change. Maldives is currently strengthening its NAP process in accordance with its climate change policy framework and thereby developing a National Adaption Plan (NAP). Hence, sectoral Adaptation Plans are required to strengthen this process and increase adaptive capacity of vulnerable sectors. Taking into consideration of future health risks of climate change, HNAP is developed to ensure that the management of health risk of climate change is integrated into the overall NAP process including assessing risks, identifying, prioritizing and implementation of adaptation options. Therefore, key purpose of HNAP is to holistically address environmental health risk of climate change and to strengthen intersectoral approach in understanding and addressing the key environment and climate change key issues including social issues. HNAP will also provide better opportunities for fund mobilization for health adaptation process. 1.3.1. GOAL Protect and promote the health and well-being of the present and future generations through sustainable and climate resilient adaptation measures 1.3.2. STRATEGIC OBJECTIVES ● Ensure the management of health risk of climate change is integrated into the overall NAP process ● Ensure health system is climate resilient ● To reduce the morbidity and mortality attributed to climate change ● Generate evidences on health effects of climate change ● Enhance health co-benefits of climate change mitigation and adaptation measures 5 ● Build health workforce capacity on climate change adaptation and to raise public awareness about climate change and its effects on health ● Ensure financing for sustainable implementation of the HNAP for climate change ● Protect human health from climate change through multi-sectoral response ensuing health in all policies. 1.6. Guidance documents 1.6.1. National Guidance Documents National Adaptation Programme of Action (2007) Climate Change Policy Framework (2015) Maldives’ Intended Nationally Determined Contribution (2015) Health Master Plan (2016–2025) National Environmental Health Action Plan (2017–2021) Second National Communication of Maldives to UNFCCC (2016) Seventh National Development Plan (7NDP) National Mental Health Policy 2015-2025 National Mental Health Strategic Plan 2016-2021 National Food Safety Policy (2017 - 2026) National Healthcare Waste Management Policy 2016 National Healthcare Waste Management Strategic Plan (2016-2021) National Water and Sewerage Policy 2017 Constitution of the Republic of Maldives (2008) 6 1.6.2. International Guidance documents Initial National Communication to UNFCCC (2001) WHO Country Cooperative Strategy Maldives (2018-2022) Malé Declaration 2017 and Framework for Action for Building Health Systems Resilience to Climate Change in South-East Asia Region (2017- 2022) Regional Plan of Action for SIDS in the African and South East Asian Regions (2019- 2023) 7 CHAPTER TWO 2.1. HEALTH IMPACT OF CLIMATE CHANGE 2.1.1 Climate Sensitive Diseases 2.1.1.1. Vector Borne Diseases Climate factors, primarily high and low temperatures and precipitation patterns influence the prevalence of vector borne diseases. Climate change is likely to have both short term and long term effects on vector borne disease transmission. Dengue is one of the prominent climate sensitive vector borne disease in Maldives. Dengue is expressed as a huge public health concern with the highest prevalence of dengue cases recorded in the year 2018 with total cases of 3404 (HPA). Serology confirms that Dengue Virus type 1, 2 and 3 is circulating in the Maldives with DEN 3 being the most common serotype5. Figure 2.1: National dengue trend from 2017 to 12 January 2019 The available data in Maldives strongly suggest that the epidemic dynamics of dengue fever is strongly influenced by climate variability5. It is reported that dengue incidence is positively associated with the rainfall and mean relative humidity and inversely associated with increase in temperature5. Therefore, it is imperative to strengthen public health surveillance and conduct rigorous scientific research in this area. It is also important that the Ministry of Health, Maldives integrate these findings into the decision making process in order to improve 8 management of dengue, in combination with clinical laboratory (e.g. serotype determination), and entomological surveillance data. The first recorded Chikungunya outbreak in the Maldives was in December 2006 and after that no outbreaks have been recorded so far. However, cases are apparent in different parts of the country. There are no studies conducted to assess the relationship between Chikungunya cases and climate change. Scrub typhus cases have been emerging since 1941 in the country. The prevalence of scrub typhus cases has decreased in the year 2018 with preventive measures and efforts in raising awareness. Figure 2.2: Scrub Typhus cases within atolls (2017 to January 2019) Maldives is a Malaria free nation since 1984 and after 1990 the malaria vector has not been detected. In December 2015 World Health Organization certified Maldives as the first malaria free country in the South East Asia Region6. However, there is constant threat of re- introduction of malaria vector via sea transportation and air transportation, especially considering the fact that all of its neighboring countries are endemic of Malaria5. Maldives is the first country in the WHO South East Asia Region to officially eliminate Lymphatic Filariasis. Transmission of Filariasis has been controlled in the country for almost 7 years, however the vector for this disease is found in the country and few imported cases are 9 detected5. Hence, there is need of reassessment and preparedness for the risk of re-emergence of malaria and filarial in the Maldives. 2.1.2. Non communicable Diseases and Mental Health Climate related extreme weather events (heat waves, droughts, storms, floods, etc.) impacts physical, mental and community health and are likely to exacerbate the incidence of some NCDs including cardiovascular disease, cancers, respiratory diseases, mental disorders and injuries12. Changing weather patterns could increase food instability through drought, or spoiled or contaminated crops. Food insecurity leads to increased use of more intensive farming practices, including greater use of carcinogenic pesticides and preservatives13. Manifestations of disaster-related psychiatric trauma include severe anxiety reactions (such as post-traumatic stress) and longer-term impacts such as generalized anxiety, depression, aggression, and complex psychopathology. The National mental health policy was finalized and endorsed in the year 2017. It is important to integrate mental health in primary health care and train mental health workforce to ensure that proper care is provided and more emphasis is given to the cause. 2.1.3. Water Resources and Water-borne Diseases 2.1.3.1. Water Resources Maldives rely on groundwater from fresh water lenses, harvested rainwater stored in tanks and desalinated water. However, groundwater is highly polluted in most densely populated islands4. Groundwater depletion, contamination through poor sewage disposal, and saltwater intrusion threaten the Maldives’ water resources5. Similar to many other SIDS, most of the islands in Maldives are experiencing water scarcity which is bound to aggravate with time with the increasing population, the declining rainfall and incident of drought. 10 Climate projections show that the Maldives would experience issues with adequate availability of rainwater in future5. The northern and central islands are currently more vulnerable to elongated dry periods with the need for emergency water supplied during dry periods. While the availability is an issue of concern, another important consideration is the quality of rainwater collected. It is important that safe methods are used in rainwater harvesting and storage and rooftops are thoroughly cleaned prior to use5. Maldives is currently moving towards an integrated water resource management (IWRM) approach to address cost-effective adaptation measure to water issues5. 2.1.3.2 Water-borne Diseases Climate-sensitive weather events, particularly floods and droughts, are linked to diarrheal diseases and Typhoid fever7. Rates of diarrhea have been associated with high temperatures and continue to cause significant morbidity both in adults and children. Figure 2.3: National AGE trend from 2016 to 12 January 2019 Typhoid fever is a bacterial disease, caused by Salmonella typhi and is transmitted through the ingestion of food or drink contaminated by the feces or urine of infected people. Typhoid was also expressed as a concern during flood events. In the year 2013 a total of 143 cases of typhoid were reported 5 . 11 2.1.4. Air Quality and Airborne Diseases Air quality is strongly dependent on weather and is therefore sensitive to climate change. Both indoors and outdoors air we breathe are affected by changes in the climate. Weather patterns have been modified by the changing climate, which in turn have influenced the levels and location of outdoor air pollution such as ground level ozone and fine particulate matter 8. According to WHO the top five causes of death includes heart diseases, lungs diseases, stroke and cancers and one quarter to one third of deaths from these diseases are due to air pollution9. Climate factors such as absolute humidity have been associated with Lower respiratory tract infection 10. Similarly, In Maldives, Acute Respiratory Infections (ARI), Viral fever and conjunctivitis are likely to be associated with changes in climate5. Though there are no studies undertaken previously to confirm the causal relationship of ARI and allergies, some of the issues reported by qualitative studies include dust, humidity attributed to sea breeze and winds. Figure 2.4: National ARI trend from 2016 to 12 January 2019 12 Figure 2.5: National Conjunctivitis cases from 2015 to 12 th January 2019 Figure 2.6: Viral Fever cases from 2016 to 12 th January 2019 2.1.5. Heat Related Illness Prolonged exposure to extreme temperature can worsen chronic conditions such as cardiovascular disease, respiratory disease, cerebrovascular disease and diabetes related conditions 8. Heat-related morbidity and mortality increases in countries with limited adaptive 13 capacities and large exposed populations. However, there has been no assessment done in Maldives to find the exact relationship between extreme heat and related illness and deaths. Workers that are exposed to extreme heat or works in hot environment may be at risk of heat stress which may result in heat stroke, heat exhaustion, heat cramps or heat rashes 11. Workplace heat exposure is an increasing challenge in Maldives with majority of population working outdoors (Fisheries, Agricultures, construction workers, electricians etc.). To minimize heat related illnesses it is important to build awareness among workers regarding heat stress and how it affects their health and safety. 2.1.6. Food Security and Nutrition Related Illness Limited cultivable land area, poor quality of the soil and scarce sources of freshwater makes it a challenge for agriculture in Maldives. Heavy import dependency, limitations in storage and challenges in the distribution of food across the nation are major threats to national food security in the Maldives5. Extreme weather events further exacerbate this vulnerability, especially when flooding due to surges or sea swells and high waves. About 90% of the food consumed in the country is imported and any impact on food production in the source countries or regions will directly affect food security in the country. In addition, any disruptions to transportation of food due to extreme weather events would put a halt to food supplies into the country and within the country as food distribution is mainly by sea. Despite improvements in many areas of health, malnutrition among children continues to be an area of public health concern5. However, there are improvements and gains on nutrition as well. According to Maldives Demographic and Health survey 2009, percentage of children under 145years who are underweight has gradually declined from 43% in 1996 to 17.3% in 2009. Similarly, stunting declined from 30% in 1996 to 18.9 % in 2009; wasting declined from 17% in 1996 to 10.6 % in 2009. The extreme climatic events may increase food insecurity and nutrition related health problems16. 14 2.2. PHYSICAL INFRASTRUCTURE 2.2.1. Built Environment The built environment is broadly defined as surroundings that include buildings, public resources, land use patterns, the transportation system, and design features including health care infrastructures. Design and development of built environment can help to mitigate climate change, support adaptation and improve environment. Maldives being a small island nation there is little or no option other than to build critical infrastructure in close proximity to the shoreline making it extremely vulnerable to adverse impacts of climate change. Sea swells, storm surges, and coastal flooding are among the major costal hazards associated with climate change that Maldives experiences4. Critical infrastructures such as transport, utility, communication infrastructures, health care facilities, etc. are more vulnerable to the coastal hazards and are at risk of service disruptions during extreme events. 2.2.2. Waste Management Solid waste management is a bigger environmental threat and a major public health concern in Maldives with limited land area, technology, financial and human resources. The waste management in islands varies depending on the availability of disposal facilities and local custom. Segregation of wastes is not commonly practiced in the country and all types of wastes are mixed and openly burnt in the island waste sites. It is estimated that 312,075 metric tons of solid waste are generated per year throughout the country4. Over the past years waste management is considered as a high priority by the Government of Maldives, and has been working towards establishing a proper waste management system in the country. Hence, Waste Management Regulation was enacted in 2013, National Solid Waste Management Policy developed in 2015 and National Health Care Waste Management Policy 15 and Strategic Plan were endorsed in 2016, and waste management projects in different zones of Maldives are being implanted. 2.3. EMERGENCY PREPAREDNESS AND MANAGEMENT Emergencies or disasters associated with extreme weather events are among the clearest dangers of climate variability and climate change. Health systems should emphasize preparedness, and aim to holistically manage overall public health risks, through climate- informed preparedness plans, emergency systems, and community-based disaster and emergency management. Health operations including healthcare and public health infrastructure should be prepared to address changing population catchments, service demands, increasing emergency events, and to operate under changing environmental conditions14. In the year 2018 Health Emergency Operations Plan was endorsed to ensure efficient and effective response and to strengthen health sector emergency preparedness. To build capacity among the health workforce and relevant organizations Hospital emergency drills was conducted among 13 Islands in Maldives. However, there is a need to focus on the community knowledge of local risks and vulnerabilities as communities are the forefront in protecting health and responding in emergencies. Health- care facilities should increasingly prepare to address changing demand of disasters and extreme weather events. This include infrastructure like water supplies, drainage, waste disposal and sanitation as well as telecommunication, energy supplies and medical transport. 2.4. RESEARCH AND ADVOCACY There is growing evidence done globally to support the scientific theory indicating that climate change is adversely affecting human health. However, the impact of climate change on health is quite complex and the same factor may sometimes act as a cause and other times as an effect. The consequences of climate change are expected to increase the demand on health services, which will require implementation of adaptation measures to reduce the incidences of climate- related health issues. The need to identify and prevent adverse health impacts is rising to the 16 forefront of climate change policy debates and is becoming a growing priority of the public health community15. There is limited research done in Maldives to see the association of climate change and health, hence it is essential that an integrated, cross-sectoral and long-term programme of research be initiated to ensure that decisions and planning are evidence-based, and that adaptation measures implemented are the most cost-effective and efficient15. 2.5. CLIMATE AND HEALTH FINANCING Protecting health from climate change will gain financial costs for health systems. Health systems may need to increase investments 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. Additional investment may also be needed in other sectors in order to achieve health goals, such as implementing climate resilient water safety plans, or enhanced food security forecasting and nutritional screening during droughts14. The health sector must ensure to train adequate numbers health personnel, and basic health infrastructure and services, which also help to address climate change risks. Resources can also be mobilized through mainstreaming climate change and health considerations in investments in key health determining sectors. Adding criteria for climate resilience and health promotion to investment strategies can ensure that these investments bring the greatest possible benefit in terms of human health, climate adaptation and social return on investment, over the long term14. The Paris Climate agreement commits to raise US$100 billion a year in climate finance by the year 2020, with the Green Climate Fund, the funds of the Global Environmental Facility and the Adaptation Fund as the main multilateral financing mechanisms, alongside bilateral and regional channels. The development of a clear action agenda will be fundamental to accessing climate finance for health resilience14. 17 CHAPTER THREE Table 3.1. IMPLEMENTATION STRATEGIES FOR STRATEGIC AREAS Expected Result Planned Activities Implementing Agency Collaborating partner Indicator Budget (USD) Total Budget 2020 2021 2022 2023 2024 Goal of the HNAP: Together as a nation to protect and promote the health and well-being of the present and future generations through sustainable and climate resilient interventions Strategic Component 1: Climate sensitive communicable diseases Morbidity and mortality from vector borne, zoonotic and other climate sensitive communicable diseases reduced Objective : - Reduce morbidity and mortality from vector borne and climate sensitive communicable diseases - Strengthen vector control and vector surveillance 1. Conduct vector surveillance and monitoring including risk mapping Lead: HPA Number of surveillance report received 1000 1000 1000 1000 1000 5000 2.Conduct training on climate sensitive vector borne diseases to the communities and carry out advocacy with relevant stakeholders Lead: HPA Number of people trained 3000 2000 3000 2000 3000 13000 3.Develop proper Information management and response capacity Lead: HPA No. of relevant officials trained - 3000 3000 - 6000 4.Develop models for forecasting and predicting Lead: PHPSE No. of outbreak notification - 3000 - - - 3000 18 diseases such as chikungunya and dengue Partners: MNU, Maldives Meteorologic al Services shared/predicted. 6.Update guidelines on diagnosis and treatment of existing and emerging vector borne diseases Lead: Health Protection Agency, MOH Number of guidelines developed Number of guidelines developed updated 1500 - - - 1500 3000 7. Strengthen entomology lab with basic equipment and monitor insecticide resistance. Lead: HPA Partner MoH Number of entomology lab set up Number of monitoring reports on insecticide resistance 3000 - 2000 - - 5000 8. Strengthen the surveillance and control of vectors at port of entry as per international health regulation Lead: PHPSE Partners: HPA Number of outbreak notification shared. Number of collaborative control operation performed. 1000 1000 1000 1000 1000 5000 9.Conduct research on climate change and vector-borne diseases at national and sub- national level Lead: HPA Partners: PHPSE Number of research studied published (1 in 5 years) - - 3000 - - 3000 19 10.Sensitize community on common climate sensitive communicable diseases for their prevention and control HPA Number of Community Action Group formed Number of sensitize programs conducted. 1500 1500 1500 1500 1500 7500 Total for Vector-borne , zoonotic and other climate sensitive communicable diseases control programme 14,000 8,500 19,000 5,500 6,500 50,500 Strategic component 2: Non communicable Diseases and Mental health Objective:  Prevent and control mental health illness  Establish green space for outdoor activities Improved Health through Promotion of healthy living environment 1.Advocate to establish green space Lead: HPA Partners: MHAF, SHE, ICP and MNNU Number of green areas established - - - - - - 2.Conduct Inter-sectoral collaboration and Community engagement programs / sessions on socialization, mental health and well being Lead: HPA (Mental Health Program) Number of people reached 1500 1500 1500 1500 1500 7500 3.Create awareness among farmers and public on safe use of pesticides and fertilizers. Lead: MoFA Partners: HPA Number of People reached 1000 1000 1000 1000 1000 5000 Total budget for Mental Health 2,500 2,500 2,500 2,500 2,500 12,500 Strategic component 3: Water Resources and water borne diseases Morbidity and mortality from Strategic objective - Ensure provision of safe drinking water for all - Reduce morbidity and mortality from water borne diseases 20 water borne and water related diseases reduced 1.Develop/update national standards for quality of drinking water Lead: MFDA Number of standards developed/Updat ed. 1500 - - 1500 - 3000 2.Develop/update standards for water carrier vessels to supply water during disasters Lead: MFDA Number of standards developed/Updat ed. - 1500 - - - 1500 3.Strengthen inter sectoral collaboration Lead: MFDA/HPA Number of meetings conducted with stakeholders 500 - - 500 - 1000 4.Develop a mechanism for testing quality of water at regional level Lead: MoH/ MFDA Water quality testing mechanism established. 3000 3000 3000 3000 3000 15000 5.Create awareness and promote advocacy through media. Lead: MFDA/HPA Number of video spots/Audio spots/Social and mass media materials telecasted or broadcasted or delivered to public 1000 - - 1000 - 2000 Total for Water, Sanitation and Hygiene 6,000 4,500 3,000 6,000 3,000 22,500 Strategic Component 4: Air Quality and Airborne Diseases Morbidity and mortality related to air pollution is reduced Strategic Objective: - Reduce incidence of air quality related morbidity and mortality 1. Strengthen monitoring mechanism for ambient air pollution from vehicular Lead: EPA Partner: MoE Monitoring mechanism established/Stren gthened. - - - 2000 - 2000 21 emission 2. Establish the recycle mechanism at national and regional levels Lead: MoEE/EPA Recycle mechanism established at regional level. Recycle mechanism established at national level. - 5000 - 2000 - 7000 3. Conduct research on air pollution and occurrences of respiratory illness and diseases Lead: HPA Partners: MoEE/MNU/EPA Research conducted within 5 years - - - 3000 - 3000 Total for Air quality and airborne diseases - 5,000 - 7,000 - 12,000 Strategic Component 5: Heat related illnesses UV radiation and Heat related morbidity and mortality reduced. strategic Objective: - Reduce heat related illnesses and occupational hazards - Foster a safe and healthy environment for people at work. - Maintain the physical, mental and social wellbeing of workers 1.Create awareness among the general population on health risk associated with excessive heat Lead: HPA Partner: MoEE, MoE, MoFA, MoT, MoHI, LGA, MNDF, MPS, Higher Education Sector, Fishermen’s Association, MACI etc. Number of awareness program conducted 1000 - - 1000 - 2000 2.Advocate and initiate greening of the work environment by adopting Lead: MoH, Partner: MoEE, MoE, MoHI, LGA, Number of work environment initiated green 1000 1000 1000 1000 1000 5000 22 user friendly technologies and using energy efficient services technology 3.Conduct assessment on heat related illnesses and its effect on vulnerable groups Lead: HPA, Partners: MNU, MoEE Assessment conducted 2000 2000 - - - 4000 4.Increase awareness on heat related illnesses for general public and workers in different occupations Lead: HPA Number of Community action group formed Number of education programs conducted 2000 2000 2000 2000 2000 10000 5.Identify health hazards and reduction risk of occupational related illness by proper infrastructure designs and creating friendly working environments. Lead: MoH/HPA Partner: MoHI, LGA Number of occupational injuries reported, Number of occupational diseases reported 2000 2000 2000 2000 2000 10000 Total for Heat related illnesses 8,000 7,000 5,000 6,000 5,000 31,000 Strategic component 6: Food security & nutrition Improved food and Nutritional security Strategic objective - Ensure access to safe food at all times 1. Strengthen implementation of national guideline/standards on food security and safety Lead: MFDA/HPA Number of standards/guidelin es implemented - 2000 - - - 2000 2. Endorse and implement food Act Lead: MFDA Bills endorsed and 1000 1000 - 1000 - 3000 23 implementation started 3. Establishment of regional food storage facilities Lead: MFDA Partners: HPA and STO No of food storage facilities established 5000 5000 5000 5000 5000 25000 Total for Food security & nutrition related illness 6,000 8,000 5,000 6,000 5,000 30,000 Strategic Component 7:Waste Management Health and wellbeing of the population promoted through proper waste management Strategic Objective : - Manage waste in an environmental friendly way to protect human health and environment 1. Strengthen implementation of Health care waste management strategic plan HPA Number of goals/ Objectives achieved 5000 5000 5000 5000 5000 25000 2. Create awareness among waste handlers and the general population on health risk associated to improper handling of health care waste Lead: HPA ME, EPA Number of awareness program conducted 2000 2000 2000 2000 2000 10000 3.Establish waste management facilities for waste segregation, autoclaving, incineration and storage in domestic industrial waste.  Establish community level waste management facilities in Male’ and outer islands.  Proper handling, transportation, storage Lead: MoEE, Partner: MoH, HPA, LGA Number of community level waste management facilities established., Number of waste treatment plant established, Number of waste treatment plants established. 4000 4000 4000 4000 4000 20000 24 and disposal Establish waste treatment plants 4.Establish proper mechanisms for Monitoring and Evaluation of solid waste management in the country Lead: MoEE, Partner: MoH, HPA, LG Monitoring and Evaluation report 2000 - - 2000 - 4000 Total Budget for Waste Management 13,000 11,000 11,000 13,000 11,000 59,000 Strategic Component 8: Built Environment Improved Health through Promotion of healthy living environment Strategic Objectives - Promote healthy and sustainable built environment that creates better environment for healthier life - Promote green climate smart healthy concept in all health care facilities (HCF) 1. Build outdoor recreational spaces for each island for kids, adults, elderly etc. (selective islands in a year) Lead: MoPI Partners: MoH/HPA, LGA. Number of outdoor recreational spaced built for kids, adults, elderly etc. Number of island where outdoor recreational spaced built for kids, adults, elderly etc. 5000 5000 5000 5000 5000 25000 2.Advocate and initiate greening of the work environment by adopting environment friendly technologies and using energy efficient services Lead: HPA Partner: MoEE, MoE, MoFA, MoT, MoHI, LGA, MNDF, MPS, Higher Education Proportion of workers using safety measures, Number of industries/instituti 3000 3000 3000 3000 3000 15000 25  Plant trees in open spaces, parks, roads etc.  Develop domestic and public infrastructure enabling UV protection Access of quality protective measures to minimize UV radiation Sector, Fishermen’s Association, MACI etc. ons establishing outdoor activities in morning and evening Number of industries assessing quality of protective measures 3.Advocate to develop safe swimming areas in each island (selective islands in a year) Lead: HPA Partners: LGA., MoT Number of safe swimming areas built Number of islands where safe swimming space is built 1500 1500 1500 1500 1500 7500 4.Incooporate and Strengthen policy implementation regarding disable and environment friendly infrastructural designs Lead: Planing Ministry Partners: MoH/HPA, LGA. Number of disability and environmental friendly infrastructure 2500 1500 1500 1000 1000 7500 5.Develop and disseminate awareness materials on ventilation and noise reduction in public places Lead: MoH/HPA Partners: MoHI, LGA. Number of awareness program conducted - - 1500 - - 1500 6.Develop standards for Green Climate Smart health care facility Lead: MoH/HPA Partner: HCF’s Number of green health care facilities - 3000 - - - 3000 Total Budget for Built Environment 12000 11000 15500 10500 10500 59500 Strategic Component 10: Emergency Preparedness and Management Strengthen country capacities to Strategic Objective: - Effectively respond to climate change and disaster risk reduction 1.Streamline sectoral Lead: NDMC Number of - 1500 1500 - - 3000 26 respond to emergencies. emergency plans from different sectors Partner: MoH/HPA sectoral emergency plan streamlined 2.Endorse national emergency operations and national disaster plan Lead: NDMC Partner: MoH/HPA Endorsement of national emergency operation and national disaster plan - 2000 - - - 2000 3.Update and monitor disaster resources inventory twice a year. Lead: NDMC Inventory of disaster resources 500 500 500 500 500 2500 4.Establish and build community emergency response forces in each inhabited islands Lead: NDMC, Partner: MNDF, MRC, MoH/HPA, LGA. Number of community emergency response forces established 2000 2000 2000 2000 2000 10000 5.Conduct Training to TOTs on peripheral islands Lead: NDMC Partner:MoH, MRC, LGA, NGOs. Number of TOT conducted Number of peripheral island covered by TOT - 2500 1000 1000 1000 5500 6.Conduct awareness trainings among the communities about climate change and disaster risk reduction Lead: NDMC Number of awareness program conducted at community level on climate change and disaster risk reduction 1500 1500 1500 1500 1500 7500 7.Conduct regular drills to test current emergency plans Lead: MoH/HPA Partner: LGA/councils, MNDF, MRC etc Number of drills conducted 500 500 500 500 500 2500 Total budget for Emergency Preparedness and Management 4500 10500 7000 5500 5500 33000 27 Strategic Component 12: Evidence Generation and Advocacy Health system strengthened to protect and improve population health in the face of changing climate Strategic Objective: - Reduce morbidity and mortality related to climate sensitive diseases 1.Conduct evidence based research study on climate change and health Lead: HPA Partner: MoH, NDMC, MNDF, MRC and other related agencies Research conducted on climate change and health - 3500 2000 - - 5500 2.Conduct annual policy level meeting to foster related policy updates and awareness among policy makers Lead: MoH/HPA Number of policy level meetings focused to climate change and health - - - - - - 3.Conduct public awareness campaigns nationwide to create awareness on health and climate change Lead: MoH/HPA Partner: NDMC, MNDF, MRC and other related agencies Number of nationwide awareness campaign conducted on climate change and health 1500 1000 1000 1500 1000 6000 Total budget for Health and Climate Change 1500 4500 3000 1500 1000 11500 Strategic Component 13: Climate and Health Financing Ensured Sustainable funding HNAP for implementation Strategic Objective: - Ensure sustained financing on health and climate change adaptation and mitigation 1.Conduct high level advocacy meetings to establish healthcare funds Lead: MoH/HPA Partner: NDMC, MOFT Establishment of healthcare funds - 3000 - 2000 - 5000 2.Identify existing donor funded programmes/projects and map potential donors to approach for future funding Lead: MOEE Partner: MoH/HPA NDMC and MoFT. Inventory of climate financing - - - - - - 3. Establish monitoring mechanism to track the financial records and documentations. Lead: MoH/HPA Establishment of monitoring mechanism - - 2500 - - 2500 28 4.Integrate Climate Change aspects into health planning and programs Lead: MOH/HPA Number of policies developed from climate change perspectives - 2000 - - - 2000 Total budget for climate change and health financing - 5000 2500 2000 - 9500 29 CHAPTER FOUR 4.2 Cross Sectorial Collaboration A memorandum of understanding can be signed between Ministry of Health and other relevant partners to establish a stronger understanding with specific roles and responsibilities to ensure the implementation of HNAP. Figure 4.3 Implementation Framework Ministry of Health MoFT, WHO/GCF/GEF/SIDS Fund and other Funding agencies Environmental and Occupational Health Division HNAP Steering Committee HNAP Implementing Units 1. Minister of Health 2. Presidents Office Rep 3. Director General, HPA 3. Director of Environment Health Member 4. DG/DDG / Director Institute/Agency/Comp/ (MoFA, MMS, MoEE, EPA, Stelco, MWSC, MoHI, MoE, MNDF, NDMC, MPS, MNU, LRA etc) Secretary: Program Officer 1. HPA (HPCDD, CD, EH, PH, PHPSE) Surveillance, 2. MoH (PIH, RAHS, MFDA, QA, ) 3. Met Services, MoFA 4. Government Institutions/Agency/ Ministry 5. NGO/ International Liaisons (MRC/WHO) HNAP Technical Working Group 1. Director EH, HPA 2. Senior Program Officer (HPA, HPCDD, CDm EH, PH, PHPSE) 3. Rep. of. NHRC, MoH. 4. Rep., Div. of Meteorology, 5. Technical Focal Points from relevant Min. Agency, Dept. (MoHI, MYS, EPA, MoEE ETC) 6. NGO/ International Liaisons (MRC/WHO/Alliance) Secretary: Program Officer EH HNAP Implementation Steering Committee (Chaired by Minister of Health) HNAP Implementation Technical Committee HPA 30 5.4 Monitoring and Evaluation of climate change adaptation/ mitigation measure Indicators for M&E The Ministry of Health will primarily be responsible for monitoring and evaluating the implementation of this Health National Adaptation Plan (HNAP). The MoH will prepare and implement monitoring and evaluation indicators. The concerned divisions of Ministry of Health and other ministries will be responsible for maintaining work progress and resolving implementation issues. The local institutions will implement, monitor and evaluate the local level programs in a prescribed format and report to the MoH. The budget, annual program and progress of the projects/programs related to climate change will be submitted to the MoH. Monitoring of both the implementation of this HNAP and the extent to which its aim to build climate resilient health systems is achieved, is fundamental for it to be effective. The intended ultimate impact of implementing the M&E operational framework will be a decrease the burden of climate-sensitive diseases, and a strengthening in the overall climate resilient health system. 31 REFERENCE 1. The Lancet Planetary Health.(2018). The world's biggest threats are environmental risks, The Lancet Planetary Healt. 2(2): p. e51. doi: https://doi.org/10.1016/S2542-5196(17)30164-X 2. WHO. (2017). Launch of special initiative to address climate change impact on health in small developing states. Retrieved from https://www.who.int/en/news-room/detail/12- 11-2017-launch-of-special-initiative-to-address-climate-change-impact-on-health-in- small-island-developing-states 3. Ministry of Environment. (2006). National Adaptation Programme of Action. Retrieved from https://unfccc.int/resource/docs/napa/mdv01.pdf 4. Ministry of Environment and Energy. (2016). Second National Communication of Maldives to the United Nations Framework Convention on Climate Change. Retrieved from file:///C:/Users/mariyam shyz/Downloads/20161030-Pub- Second National Communication of Maldives%20(2).pdf 5. Latheef, A. (2014). Overview of Climate Change Health Impacts in Maldives. retrieved from 6. WHO. (2019). Malaria- free Maldives, Malaria. Retrieved from http://www.searo.who.int/entity/malaria/documents/maldives free/en/ 7. Grace,I,D., Lachlan, M., Yoonhee, K., Masahiro, H., Steven,I., & Vibol,C. (2015). Water borne diseases and extreme weather events in cambodia: Review of impacts and implications of climate change, Environmental Research and Public health. Doi 10.3390/ijerph120100191 8. U.S. Global Change Research Program. (2016). Climate and Health Assessment, The impacts of climate change on human health in united states: a Scientific assessment. Retrieved from https://health2016.globalchange.gov/ 9. Climate and Clean air coalition. (2017). New WHO report: Air pollution is a leading contributor to noncommunicable diseases, Environmental factors are main causes of NCD with 12.6 million deaths a year linked to the environment. Retrieved from http://www.ccacoalition.org/en/news/new-who-report-air-pollution-leading-contributor- noncommunicable-diseases 10. European Centre for Disease Prevention and Control. (2017). Climate change in Europe, Air borne diseases. Retrieved from https://ecdc.europa.eu/en/climate-change/climate-change- europe/air-borne-diseases 11. Centers for Disease Control and Prevention. (2018). the National Institute for Occupational Safety and Health, Hear Stress 24/7. Retrieved from https://www.cdc.gov/niosh/topics/heatstress/ 12. Friel. S., Bowen.K., Lendrum. C.D., Frumkin.H., McMicheal.AJ., Rasanathan.K. (2011). Climate change, noncommunicable disease, and development: the relationships and common policy opportunities. 32:133-47. doi: 10.1146/annurev-publhealth-071910-140612. 13. The Lancet. (2016). Climate change and non-communicable diseases, The Lancet Oncology, 1(17), P1. doi: https://doi.org/10.1016/S1470-2045(15)00568-9 14. WHO. (2014). Strengthening Health Resilience to Climate Change. Retrieved from https://unfccc.int/files/parties observers/submissions from observers/application/pdf/684.pdf https://doi.org/10.1016/S2542-5196(17)30164-X https://www.who.int/en/news-room/detail/12-11-2017-launch-of-special-initiative-to-address-climate-change-impact-on-health-in-small-island-developing-states https://www.who.int/en/news-room/detail/12-11-2017-launch-of-special-initiative-to-address-climate-change-impact-on-health-in-small-island-developing-states https://www.who.int/en/news-room/detail/12-11-2017-launch-of-special-initiative-to-address-climate-change-impact-on-health-in-small-island-developing-states file:///C:/Users/mariyam shyz/Downloads/20161030-Pub-Second National Communication of Maldives%20(2).pdf file:///C:/Users/mariyam shyz/Downloads/20161030-Pub-Second National Communication of Maldives%20(2).pdf https://dx.doi.org/10.3390%2Fijerph120100191 https://health2016.globalchange.gov/ http://www.ccacoalition.org/en/news/new-who-report-air-pollution-leading-contributor-noncommunicable-diseases http://www.ccacoalition.org/en/news/new-who-report-air-pollution-leading-contributor-noncommunicable-diseases https://www.cdc.gov/niosh/topics/heatstress/ https://doi.org/10.1016/S1470-2045(15)00568-9 https://unfccc.int/files/parties observers/submissions from observers/application/pdf/684.pdf 32 15. Herlihy. N, et al. (2016). Climate Change and human health: what are the research trends? A scoping review protocol, British Medical Journal 6(12). Doi 10.1136/bmjopen-2016-012022 16. Ministry of Health and Family (2009). Maldives Demographic health survey, Preliminary Report. Retrieved from http://www.health.gov.mv/Uploads/Downloads//Informations/Informations(60).pdf 17. T.F. Stocker, et al. (2013). Climate change 2013 the physical science basis, Working Group I Contribution to the Fifth Assessment Report of the Intergovernmental Panel on Climate Chang. Retrieved from https://www.ipcc.ch/site/assets/uploads/2017/09/WG1AR5 Frontmatter FINAL.pdf 18. Ministry of Environment and Energy. (2015). Maldives’ Intended Nationally Determined Contribution. Retrieved from file:///C:/Users/mariyam shyz/Downloads/20150913-Dld- Draft Maldivian INDC for public commenting.pdf 19. Ministry of Planning and National Development. (2006). Key priorities and sectors in the seventh National Development Plan 2006–2010. Retrieved from http://www.maldivespartnershipforum.gov.mv/doc/paper%20on%20ndp%20final.pdf 20. Dokken, K.J et.al. (2014). IPCCC. Climate Change 2014: Impacts, Adaptation, and Vulnerability. Part A: Global and Sectoral Aspects. Contribution of Working Group II to the Fifth Assessment Report of the Intergovernmental Panel on Climate Chang. Retrieved from https://www.eea.europa.eu/data-and-maps/indicators/heating-degree-days/ipcc-2007- contribution-of-working 21. Descloux, E., et al. (2012).Neglected Tropical diseases, Climate-based models for understanding and forecasting dengue epidemics. Doi https://doi.org/10.1371/journal.pntd.0001470 22. Jingchun, F. et al., (2014). Environmental Research and Public Health, A Systematic Review and Meta- Analysis of Dengue Risk with temperature change. Doi 10.3390/ijerph120100001 23. Bettadapura, J., Lara,J H., Adam,T & Suresh,M. (2013). Indian Journal of Medical Research, Approaches to the treatment of disease by chickungunya virus. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3928707/ 24. Lewis, M.D., et al., (2013). Emerging infectious diseases, Scrub Typhus re-emergence in the Maldives 9(12), p. 1638-1641. Doi 10.3201/eid0912.030212 25. WHO. (2015). Review of climate change and health activities in SEARO member states, Synthesis Report. Retrieved from http://www.searo.who.int/entity/water sanitation/review-of- cc.pdf?ua=1 26. WHO. (2013). Country Cooperation Strategy Republic of Maldives 2013-2017. 2013. p. 1-86. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/161129/B5000.pdf;jsessionid=FA1235573CC 6B3DF531A63FEC71AD735?sequence=1 27. Ministry of Health and Family. (2009). Maldives Demographic and Health Survey, Preliminary Report. Retrieved from http://www.health.gov.mv/Uploads/Downloads//Informations/Informations(60).pdf 28. Ministry of Health and Family, National Micronutrient Survey. 2007, UNICEF: Male', Maldives. https://dx.doi.org/10.1136%2Fbmjopen-2016-012022 https://www.ipcc.ch/site/assets/uploads/2017/09/WG1AR5 Frontmatter FINAL.pdf file:///C:/Users/mariyam shyz/Downloads/20150913-Dld-Draft Maldivian INDC for public commenting.pdf file:///C:/Users/mariyam shyz/Downloads/20150913-Dld-Draft Maldivian INDC for public commenting.pdf https://www.eea.europa.eu/data-and-maps/indicators/heating-degree-days/ipcc-2007-contribution-of-working https://www.eea.europa.eu/data-and-maps/indicators/heating-degree-days/ipcc-2007-contribution-of-working https://doi.org/10.1371/journal.pntd.0001470 https://dx.doi.org/10.3390%2Fijerph120100001 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3928707/ https://dx.doi.org/10.3201%2Feid0912.030212 http://www.searo.who.int/entity/water sanitation/review-of-cc.pdf?ua=1 http://www.searo.who.int/entity/water sanitation/review-of-cc.pdf?ua=1 https://apps.who.int/iris/bitstream/handle/10665/161129/B5000.pdf;jsessionid=FA1235573CC6B3DF531A63FEC71AD735?sequence=1 https://apps.who.int/iris/bitstream/handle/10665/161129/B5000.pdf;jsessionid=FA1235573CC6B3DF531A63FEC71AD735?sequence=1 http://www.health.gov.mv/Uploads/Downloads/Informations/Informations(60).pdf 33 CONTRIBUTORS Adam Manik (Ministry of fisheries and Agriculture) Ahmed Hassan (Male Water and Sewerage Company) Aishath Azla (Ministry of Fisheries and Agriculture) Aishath Rashfa (Ministry of environment) Ali Sajidh (State Electric Company pvt.ltd) Aminath Adheela (School of Nursing) Aminath Aroosha (Health Protection Agency) Aminath Shaufa (Health Protection Agency) Fathimath Rasheedha (Health Protection Agency) Fathimath Shaushan (National Disaster Management Center) Haleemath Nahula (Health Protection Agency) Mariyam Saadha (Ministry of youth and Sports) Mariyam Sheeza (Health Protection Agency) Moosa Haneef (Health Protection Agency) Sana Saleem (Health Protection Agency) Sarah Jamal (Health Protection Agency) Shaheeb Abdul Azeez (Maldives National University) Shamhooza Ahmed (Ministry of Housing and Infrastructure) Shifza Mohamed (Ministry of Health) REVIEWERS Aminath Shaufa (Health Protection Agency) Mariyam Sheeza (Health Protection Agency)