Climate change and health in Ethiopia: To what extent have the health dimensions of climate change been integrated into the Climate ‐ Resilient Green Economy?

Ethiopia is experiencing an increasing frequency and intensity of slow ‐ onset and acute disasters caused by climate change, with signi ﬁ cant health impacts. Understanding and addressing these impacts involves trade ‐ offs, which are central to effective priority setting in health and overarching efforts to meet the Sustainable Development Goals. Despite minimal historic greenhouse gas emissions, Ethiopia has been at the forefront of climate action since launching the Climate ‐ Resilient Green Economy (CRGE) in 2011, a low ‐ carbon development strategy. To learn from the Ethiopian approach, this paper examines to what extent health has been integrated into the CRGE. We found that the early years of the CRGE prioritized developing the ﬁ nancial basis of the green economy, while the health impacts of climate change have only been tentatively considered to date and remain detached from broader health strategies. Further analysis of climate adaptation measures, “ health co ‐ bene ﬁ ts, ” and reducing speci ﬁ c vulnerabilities of the health sector could help improve health and build climate resilience.

-Early years of CRGE prioritised the economic foundations while the health impacts of climate change have only been tentatively considered to date and remain detached from broader health strategies. -Further analysis integrating adaptation measures, health co-benefits of non-health interventions and ways to reduce specific vulnerabilities of the health sector could help identify synergies and build resilience to climate change in Ethiopia. -The current conflict in the Tigray region presents an ongoing risk of wider destabilisation across the country. -Post-conflict reconstruction and development efforts to follow should seek to better integrate the climate resilience dimension into the health system.

K E Y W O R D S
climate change, Climate-Resilient Green Economy, sustainable development BACKGROUND Climate change is a present and growing threat to health and wellbeing across the world (Hoegh-Guldberg et al., 2018;Watts et al., 2015). Ethiopia, located in the Horn of Africa, is considered by the Notre Dame Global Adaptation Initiative to be among the most vulnerable countries with a low capacity to adapt to the negative impacts of climate change (Notre Dame Global Adaptation Initiative, n.d.). There are several overlapping reasons for this, including the combination of landlocked geography, drought-prone weather systems, and the socioeconomic dimensions of rural poverty (Climate Security Expert Network, 2019). Climate change is already exacerbating the risks of acute and chronic food insecurity, internal displacement, poor sanitation, and conflict, undermining broader human, and economic development goals, which could help adapt to these challenges (Ethiopian Panel on Climate Change, 2015b; Federal Ministry of Health, 2018). Despite having had one of the world's fastest-growing economies and steadily increasing life expectancy-increasing almost 1 year, every year, for the last 20 years-avoidable mortality in Ethiopia remains high (Norheim et al., 2015) and also increasingly precarious in the face of the climate change, the COVID-19 pandemic, and geopolitical unrest, including the conflict in Tigray. Ethiopia is a home to rapidly growing population of 110 million people, making it the second-most populous country in Africa and one of the youngest in the world, with a median age of only 19.5 years (United Nations, n.d.). The country has a federal government divided into ten regional states and two self-governing city-states. Development policy has been primarily the responsibility of the Federal Government, whereas regional governments have focused on implementation. Small-scale rain-fed farming remains a principal source of employment, which means food security remains intricately entwined with livelihoods, health, and the climate (Climate Security Expert Network, 2019; Robinson et al., 2013). Access to electricity remains a major challenge, especially in rural areas, and there is a continued reliance on biomass fuels for cooking, which has a direct health effect of indoor air pollution as well as a range of other indirect health effects (Medhin & Mekonnen, 2019).
Environmental risks have been increasingly recognized in the policies and laws of the country since the 1990s, not least because of the awareness created by the devastating 1984 drought. The Disaster Prevention and Preparedness Commission launched in 1995 included a comprehensive disease risk management approach, including social, economic, and food security, coordinated by a newly established high-level committee to oversee the implementation. Similarly, Ethiopia's first environmental policy (Federal Democratic Republic of Ethiopia, 1997) launched in 1997 articulated the interdependence of people and the environment, encapsulating the Rio Principles of Sustainable Development and laying the foundation for the country's poverty reduction strategy ever since (Ethiopian Environmental Protection Agency, 2012).
The Climate-Resilient Green Economy (CRGE) strategy, launched in 2011, is a multisectoral approach to developing a climate-resilient, middle-income economy within 15 years. The approach focuses on meeting the twin goals of human and economic development in a warming world through a net-zero growth in carbon emissions, to a large extent based on reversing deforestation and increasing forest cover (Federal Democratic Republic of Ethiopia, 2011).
The CRGE strategy had four key pillars focused on carbon mitigation from high-emission sectors (agriculture, forestry, and transport) together with the expansion of hydropower electricity. It received strong cross-governmental commitment, which has been sustained after a change in government (Federal Democratic Republic of Ethiopia, 2011, p. 20). The strategy mirrored the first 5-year Growth and Transformation Plan ("GTP I"), though it featured heavily in the second GTP ("GTP II"), thereby mainstreaming climate change into central planning. An overarching National Adaptation Plan was released in 2019 (Federal Government of Ethiopia, 2019). Health-specific resilience plans were first released in -2015(Federal Ministry of Health, 2014, followed by a broader National Adaptation Plan for Health in 2018 (Federal Ministry of Health, 2018).
Over the last 5 years, there has been increasing acknowledgment among Ethiopian policymakers of the need for parity between carbon mitigation and societal adaptation, with growing interest in health (Admasu & Debessa, 2015;Simane et al., 2016;United Nations Development Programme, 2015). To our knowledge, the health dimensions of the CRGE have not been systematically explored. Incorporating the trade-offs of different approaches to tackling climate change is central to effective health priority setting (Johansson et al., 2019) and meeting the overarching Sustainable Development Goals . In the face of public health threats, such as undernutrition, food insecurity, and noncommunicable diseases, tackling climate change can have benefits-the 2015 Lancet Commission on Health and Climate Change described these synergies as "the greatest global health opportunity of the 21st century" (Watts et al., 2015). This paper will assess to what extent the health dimensions of climate change have been integrated into the Climate-Resilient Green Economy process, and report on which aspects have been incorporated and identify gaps in the research base.

METHODS
We undertook a scoping review exploring the health dimensions of Ethiopia's CRGE initiative. A scoping review aims to identify research gaps and including different sources and types of evidence are especially valuable in mapping out the key concepts in areas, which have not been comprehensively reviewed (Arksey & O'Malley, 2005). A scoping review is therefore appropriate because the health dimension of climate change policies is in general poorly understood. We followed the five-stage Arksey

Identifying the research question
To what extent have the health dimensions of climate change been integrated into the CRGE? This study question formed a starting point for the search strategy, which was narrowed as the overview of the field was improved.

Identifying relevant studies
The scoping review aims to identify all relevant literature, regardless of study design or data source (Arksey & O'Malley, 2005 Extensive use of "snowballing" (the examination of citation lists) was used to identify additional policy documents and relevant unpublished literature.

Study selection
Establishing the relevance criteria is an iterative process, refined with increasing familiarity with the literature (Arksey & O'Malley, 2005). This review is primarily interested in policy documents from within the Ethiopian CRGE. However, as the CRGE is a broad, multisectoral initiative, not all documents are relevant; conversely, many relevant health documents are aligned to, but not part of the CRGE. We, therefore, included material within the Ethiopian CRGE initiative and Ethiopian government policy documents relevant to the CRGE published since 2010, a year before the formal launch, during which time preparatory documents, such as regional assessments, were being prepared. We included external articles and nongovernmental reviews, which were published after 2011 and directly addressed the CRGE, with no restrictions on study design. The review excluded material that was not available in English. Our reliance on English language searches and databases may be one factor limiting our ability to locate all the regional policy documents.

Charting the data
Using a descriptive-analytic method, data were collected on author, year, document type, stated purpose, and health dimensions in line with our study aims.

Collating, summarizing, and reporting the results
We mapped our findings against the analytic framework used in the 2019 report of the Lancet Countdown on health and climate change (Watts et al., 2019), a leading, international, multidisciplinary research initiative tracking the impact of climate change on health and ways to prevent these harms. "Health threats" correlates with Section 1 of the Lancet Countdown ("Climate change impacts"), which includes health impacts and health sector vulnerability (i.e., infrastructure, electricity supply, transportation). "Health opportunities" correlates with Sections 2 and 3 of the Lancet Countdown ("Adaptation" and "Mitigation and Health Co-benefits"), which include adaptations to improve health and health co-benefits (i.e., health gains from nonhealth interventions). To help understand the relevance for health, the author, title, stated aim, and priority CRGE sector is given for each item included in the results.

Overall profile of documents identified
The literature search identified 25 government policy documents, five published articles, and seven nongovernmental reports, of which 15 government policy documents,one published article, and six reports were included in the review. Out of the 15 included government policy documents, four (27%) were Federal Government documents, three (20%) were regional government documents, five (33%) were from the health ministry, and three (20%) were from other government ministries. We included one (33%) of the published articles and four (57%) of the nongovernmental reports, all of which were released between 2013 and 2016. Regional adaptation plans were all published in 2010, national policies were published throughout the period 2011-2019, and sectoral-specific policies (including health) were published between 2014 and 2018. The key findings are in Tables 1-4. Adaptations to improve health are outlined in six out of seven documents, focusing on the health system, improving access to health services, and developing early warning systems. The health co-benefits of nonhealth interventions were mentioned in six out of seven of documents, though not systematically or as in depth as has been done elsewhere (Haines et al., 2009;Scovronick et al., 2019). Reduced indoor air pollution from the use of fuelefficient stoves and improved access to clean water were the most frequently described. The NAP noted the historical omission of health from the priority CRGE sectors (Federal Government of Ethiopia, 2019) and mentioned the health dimensions of a range of intersectoral initiatives, including integrated health and environmental surveillance (see Annex 2 in Federal Government of Ethiopia, 2019, for further information).

Policy documents-Regional governments
We included three regional plans on climate change resilience as outlined in Table 2. All identified health as especially vulnerable to climate change and focused primarily on adaptations to improve health. For more details on regional plans see Federal Government of Ethiopia (2019).

Health threats
Health impacts of climate change were discussed in all regional plans and common themes were malnutrition, the spread of malaria at higher altitudes, and water-borne diseases. In contrast to the national policies (Table 1), regional policies discussed some specific vulnerabilities of the health sector to climate change, focusing on poverty, education, and poor access to health services.

Health opportunities
All documents identified several adaptations to improve health. The main themes were the need for increased awareness, early warning systems, and improved basic health services. One document mentioned health co-benefits (reduced indoor air pollution from switching firewood for clean fuels).

Policy documents-Health ministry
Health sector-specific policy documents, shown in Table 3, were first released in 2014, 3 years after the CRGE launch. The National Framework of Climate-Resilient Health Sector (Federal Ministry of Health, 2014) began the process of developing a comprehensive health sectoral response, strengthened a year later in the Health Vulnerability and Adaptation Assessment (Federal Ministry of Health, 2015b). In 2015, the CRGE was mainstreamed into GTP II on which the Health Sector Transformation Plan (HSTP) is based-the HSTP is, therefore, included here.

Health threats
All CRGE-related documents describe a wide range of health impacts from climate change, including malnutrition, water-borne diseases, and vector-borne diseases, and heat mortality. The HSTP states that the risk of higher obesity, diabetes, and heart disease-related deaths if climate change is not mitigated but does not substantiate upon the causes or interventions needed. Specific vulnerabilities of the health sector identified to focus on equipment and staffing and the physical integrity of buildings limiting sectoral resilience. Structural social problems, such as poverty and access to clean water and sanitation, are included in the vulnerability and adaptation assessment but not substantiated in either the HSTP or the National Health Adaptation Plan. The HSTP does not discuss specific vulnerabilities of the health sector and makes no reference to either the Vulnerability and Adaptation Assessment or the CRGE initiative.

Health opportunities
All documents included in this review identified a range of adaptations to improve health, including investing in public health infrastructure, staffing, and data systems, and developing early warning systems. Other specific adaptations include developing community social security schemes, improving access to clean water and sanitation, and increasing awareness of climate change. The interrelationship between health and the wider social and environmental context was not a clear narrative within these documents. Health co-benefits of public health interventions outside the health sector received scant attention and no detailed analysis to indicate the potential benefits of interventions mentioned, such as promoting active transport or decreasing air pollution.

Reviews-Scientific articles and reports
Outlined in Table 4 are published review articles and nongovernmental reports. The articles (the Ethiopian Panel on Climate Change chapter on health, the accompanying summary for policymakers, and a "status gap and analysis") focus on health and climate change in Ethiopia, though not specifically on the CRGE. The nongovernmental reports are not healthfocused, although two reports highlight the centrality of health analysis to delivering the aims of the CRGE.
An article ("status gap and analysis") suggested establishing climate and health research centers to monitor the impacts and build capacity, alignment of climate, and health data to monitor climate-sensitive diseases and increase intersectoral collaboration. The Ethiopian Panel on Climate Change (2015) highlighted the need to incorporate health into broader climate change strategies. This is echoed in the nongovernmental reports-which highlight gaps in health sector analysis and the importance of health to achieving CRGE goals. Recommendations within the nongovernmental reports include developing a broad set of green growth principles, including health, and greater attention to interlinkages between sectors and initiatives.

DISCUSSION
This review investigated to what extent health is integrated into the Ethiopian CRGE. We found that the CRGE identified priority areas (Table 1) on the basis of the economic importance of sectors and the potential for reduced emissions (Federal Democratic Republic of Ethiopia, 2011). Though health and climate resilience were central to the regional adaptation plans (see Table 3) compiled a year before the CRGE launch, the first 5 years of the CRGE were characterized by a focus on building the Green Economy.
Health remains at a less developed stage than other aspects of the strategy. This perhaps reflects delays initiating the health technical subcommittee and undertaking healthspecific analysis-it was 3 years before a preliminary analysis was undertaken and 7 years until a comprehensive national health adaptation plan was launched. It may, with sound reasons, not have been a priority. For example, the Ethiopian health Minister in 2015 wrote that the health co-benefits of interventions to tackle climate change "cannot be overemphasized" but agriculture and energy security are the keys to broader development goals (Admasu & Debessa, 2015).
Another barrier to incorporating health into the CRGE earlier may have been the indirect nature of the relationship between climate change and health (Watts et al., 2019, Section 4). It has traditionally been difficult to directly quantify the health impacts of climate change (McMichael et al., 2003, chap. 7). The World Bank report on the economics of adaptation to climate change in Ethiopia, partly informing the CRGE, explicitly did not consider the healthrelated implications (World Bank, 2010). Incorporating emerging evidence-for example, the health co-benefits of interventions to improve air quality (Markandya et al., 2018;Vandyck et al., 2018), low-carbon urban transport systems (Shaw et al., 2014), and uptake of a planetary diet (Willett et al., 2019)-through an overarching public health approach could strengthen the CRGE.
The Health Sector Transformation Plan states in the foreword that "Climate change is the greatest global health threat of the 21st century" (Federal Democratic Republic of Ethiopia, 2015b) though does not follow up with coherent actions to mitigate the risks. This mismatch is far from unique to Ethiopia (Ethiopian Panel on Climate Change, 2015b; Watts et al., 2015). However, this challenge may be compounded by a lack of technical expertise (Mitike et al., 2016)-addressing deficits in country-specific, localized data remain a major challenge for designing effective policies across the world.
As indicated by the Ethiopian public health community (Simane et al., 2016), independent reviews ( fragmented within the CRGE. The potential public health benefits of pursuing a green economic development path have been underutilized. Ultimately, many of the health impacts of climate change are dependent on how human systems respond (16); building climate resilience is key to avoid losing hard-won progress in health (Smith et al., 2014). Ethiopia's 5-year HSTPs present ongoing opportunities to develop synergies between these agendas.

LIMITATIONS
Within this review, we were unable to satisfactorily explore the relationship between national policy making and regional implementation. This paper is intended to form the basis for future in-depth qualitative interviews exploring the implementation of the CRGE. However, given the growing importance of effective integration between health and climate policy across the world (Watts et al., 2015), we believe this study provides useful insights for policymakers engaged in this urgent challenge.

Conclusion and policy implications
Understanding and addressing the health impacts of climate change on health are essential for effective priority setting in health and meeting the overarching SDGs. This study set out to evaluate to what extent the health dimensions of climate change have been integrated into the CRGE of Ethiopia. We found that the early years of the CRGE prioritized developing the financial basis of the green economy, whereas the potential health impacts-and benefits-of climate change mitigation and adaption have only been tentatively considered within the CRGE to date and are not currently coordinated in the health-specific analysis or broader health strategies. Further analysis integrating the necessary adaptation measures, health co-benefits of nonhealth interventions and steps to reduce specific vulnerabilities of the health sector could help identify synergies and build resilience. Updating regional adaptation plans may facilitate this process. Fuller's integration of the health dimensions of climate change is key to its success.
A key factor we must acknowledge impeding the successful implementation of the CRGE vision is the conflict in the Tigray region with the ongoing risk of wider destabilization across the country. Tigray's health system has been a major casualty of the violence, with widespread damage and looting of facilities, a lack of remaining health personnel, and occupation by armed soldiers jeopardizing the safe access to health care and compounding the conflict's human toll (MSF, 2021). Post-conflict reconstruction and development efforts to follow should seek to better integrate the climate resilience dimension into the health system.
The Ethiopian CRGE program remains a leading example of a transformational, lowcarbon, climate-resilient economic development agenda, which offers insights for countries across sub-Saharan Africa pursuing a similar path, such as Kenya, Uganda, Ghana, Rwanda, and South Africa (see Green Growth Knowledge Platform, n.d.). The sub-Saharan Africa region faces the dual challenge of improving the health and welfare of citizens through the as yet little tested green developmental path-that is, renewable energy-led socioeconomic development, rather than fossil fuels-while contending with, and building resilience to, climate risks, such as extreme weather events. Well-informed, medium-to longterm decision-making is, therefore, essential to prepare for this uncertain future.
As the then Prime Minister of Ethiopia, Meles Zenawi, said at the launch of the CRGE in 2011: "While we did not cause climate change, we must protect ourselves from its impact. We have the opportunity to demonstrate that in the 21st century a new form of green growth is possible" (United Nations Development Programme, n.d.). One way the research community, both in sub-Saharan Africa and across the world, can support this effort is through undertaking national and cross-country comparative research on health and the green economy agenda to refine policy development, disseminate best practice and fulfill the greater mission of a climate-resilient society for all.