The health system’s response strategies to the effects of climate change extreme weather events in Malawi. A policy analysis

The health system’s response strategies to the effects of climate change extreme weather events in Malawi. 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A policy analysis Chancy Skenard Chimatiro, Solange Mianda, Martina Lembani This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7128239/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Dec, 2025 Read the published version in Discover Public Health → Version 1 posted 10 You are reading this latest preprint version Abstract Introduction: The effects of climate change and extreme weather events on the health system are becoming unbearable globally. We conducted a health policy analysis to gain a deeper understanding of the health policy response strategies to the effects of climate change extreme weather events on the health system in Malawi and identified response gaps for improvement. Methods The policy triangle model was used to analyze health system policies. A list of policies was obtained from the Department of Policy, Planning, and Development at the Ministry of Health. We retrieved the policies from the Ministry of Health Website, and hard copies were obtained for those not published online. A data extraction form was created to capture all climate change-related themes and group them according to the policy triangle model, which includes: context, content, process, and actors. We also identified gaps in policy responses to climate change. Results In total, 32 health policy documents were listed and recommended by the Department of Planning at the Ministry of Health for analysis. Out of these, only three had climate change-related themes and strategies. Contextually, the policies were aligned with both local and international goals. The contents of the analysed policies have climate change themes and strategies. The process involved wide consultations with both national and international stakeholders. The actors involved included government ministries, local councils, development partners, community leaders, and international organizations. Lack of health system-specific climate change strategies and guidelines, lack of clear funding mechanisms, limited inclusion of local knowledge, and lack of response strategies to build capacity among health workers were some of the gaps identified. Conclusion The health system in Malawi is moving in the right direction to minimize the effects of climate change extreme weather events on health. The availability of climate change themes and strategies in the analyzed health policies provides evidence that the impact of climate change extreme weather events have affected the health system in the country. We recommend the formulation of climate change-specific health policy with clear strategies and financing mechanisms. Health systems health policy response policy triangle model Climate change extreme weather events health policy analysis health system strategies Figures Figure 1 Introduction The effects of Climate change on health systems are becoming more unbearable globally. Low- and middle-income countries have been disproportionately impacted by the unpredictable occurrences of climate change extreme weather events, such as heatwaves, storms, and floods [ 1 ]. The Intergovernmental Panel on Climate Change (IPCC) defines Climate Change Extreme Weather Events (CCEWEs) as the occurrence of a value of a weather or climate variable above (or below) a threshold value near the upper (or lower) ends of the range of observed values of the variable [ 2 ]. It signifies a prolonged departure from everyday average weather event observations such as rainfall patterns, temperature, and wind speed [ 3 , 4 ]. The more apparent observed CCEWEs in recent years include increased temperature, drought, abnormal rainfall patterns, cyclones, floods, and air pollution [ 5 , 6 ]. The continuous occurrence of CCEWEs is the major driver for the health system’s vulnerability to climate change, which affects its performance and is likely to increase in the coming years [ 3 , 7 ]. According to the World Bank report, Malawi is among the Sub-Saharan African Countries vulnerable to CCEWEs [ 8 ]. A study conducted by ActionAid indicates that the country has experienced increased CCEWEs such as floods, droughts, and temperature rises between 1970 and 2020 [ 9 ]. Despite the CCEWEs being felt countrywide, Coulibaly et al (2015) reported that some districts are more prone to CCEWEs than others [ 10 ]. Unfortunately, an increase in any of the CCEWEs translates into unintended outcomes such as dry spells, droughts, intense rainfall, or floods [ 11 , 12 , 13 , 14 ], which disrupt the delivery of health services, reduce health system performance at large, and affect the health of the population. The CCEWEs have exacerbated the existing health burdens while creating new health risks. Some of the CCEWEs' health risks include the emergence and re-emergence of diseases, increased malnutrition among children, disease outbreaks, infrastructure damage, direct body injuries, and loss of lives [ 15 ]. CCEWEs have affected the health system's operation and performance in many ways. The occurrence of any of the CCEWE in the country limits the delivery of healthcare services. It disrupts communication channels, overwhelms the capacity of human resources to respond and provide services, increases demand for medicinal and vaccine products, and damages infrastructures [ 16 , 17 ]. For instance, floods may damage roads, limiting health services accessibility, and increase chances for the development and spread of waterborne diseases due to damaged water, sanitary, and hygiene facilities [ 18 , 19 , 20 ]. On the other hand, drought might lead to food insecurity, which may cause an upsurge in malnutrition among children, especially those under five, and lower the quality of food supply in terms of micronutrients [ 12 , 21 ]. Similar situations are experienced in many Sub-Saharan African countries as the operations of the health systems are disrupted whenever CCEWEs occur due to poor infrastructure, inadequate human resources and medicinal product supplies, and economic dependency [ 22 , 23 , 24 ]. Worth noting is the fact that the effects of CCEWEs are also experienced at the household and individual levels. Increased mortality and morbidity due to vector-borne diseases, psychological stress, air pollution-related respiratory diseases, and accidents have been reported to affect households and individuals in Malawi and other sub-Saharan countries [ 25 , 26 ]. Following the Paris agreement on climate change, some countries have formulated climate change-specific health policies, while others have integrated climate change strategies into the national health policies [ 27 ]. However, there is variation in health systems' policy response strategies to the effects of CCEWEs globally. So far, the majority of developed countries are focusing on reducing greenhouse gas emissions, building resilient health systems, and adapting to the health risks [ 28 , 29 ]. In low and middle-income countries, the strategies are focusing more on environmental health, disease prevention, and health promotion with little attention on strengthening the overall health system [ 30 , 31 ]. In a study conducted by Nhamo and Muchuru (2019) in African countries, they found that all countries sampled had some form of legal and policy provisions in response to climate change, although not health system specific [ 31 ]. In Ghana, climate change health policy strategies focusing on capacity building, vulnerability assessment, early warning systems, and health research have been developed [ 32 ]. The policy approach taken in responding to CCEWEs globally accelerates the desire to achieve the Sustainable Development Goals, especially goal no. 3, of ensuring quality health for all by the year 2030 [ 33 ]. In response to the global call to address the effects of CCEWEs, the government of Malawi developed the National Adaptation Programme of Action (NAPA) [ 34 ] and the Malawi Nationally Determined Contributions (MNDC) [ 35 ]. The main aim of NAPA is to reduce the country’s vulnerability to the effects of CCEWEs by building adaptive capacity and resilience while integrating climate change-related themes into relevant national policies, programs, and activities (27). The MNDC aimed at minimizing greenhouse gas emissions and scaling up adaptation actions to reduce the long-term impacts of CCEWEs [ 36 , 37 ]. In addition, the country developed its Vision 2063 in line with the Africa Agenda 2063 with seven enablers to guide, promote, and accelerate national development agendas [ 38 ]. Attaining Universal Health Coverage (UHC) is a desired health-specific agenda for ensuring quality, equitable, and affordable healthcare provision at all levels of the health systems in the country. It further indicates the country’s commitment to minimizing the effects of CCEWEs on the environment by ensuring adequate waste disposal, treatment, and recycling, air and water pollution management, and prudent water resource management by 2063 [ 38 ]. However, little has been done on the effects of CCEWEs on health and the health system in the country as compared to the economic and agricultural aspects [ 39 , 40 ]. Moreover, Malawi’s health system has numerous health policies, both disease-specific and program-based, intended to address identifiable health-related problems to minimize probable outcomes and their impact on population health. Some of these policies have brought desirable results by reducing disease burden among the population [ 41 , 42 ]. However, it is not known whether the health system policies have strategies and guidelines in response to the health threats posed by climate change. Therefore, we conducted a health policy analysis to gain a deeper understanding of the policy response strategies to the effects of CCEWEs on the health system in Malawi and identified response gaps for improvement. Policy analysis is described as a wide range of techniques used to holistically scrutinize developed policies' features, processes, and relevance, considering given priority areas and targets [ 43 ]. It includes various methods, techniques, and tools used to create awareness and improve the effects of the developed and implemented policies [ 44 ]. In regard to the definitions of climate change [ 45 , 46 ], which emphasizes the decade as a period, we considered policies formulated between 2010 and 2024 in this analysis, as the period covers a decade. Method We obtained a list of all health policies formulated between 2010–2024 from the Ministry of Health (MoH), Department of Policy, Planning and Development. Additionally, we included the Health Sector Strategic Plan documents as they are deemed a master plan that guides the operation of the health sector in the country. To access the full document, we searched the MoH website and requested hard copies of those policies that were not published online. Each policy was screened for climate change-related themes, goals, objectives, and strategies. The inclusion criteria were; National health policies formulated between 2010 and 2024. Health policies with themes such as climate change, floods, droughts, cyclones, or other extreme weather events. The exclusion criteria were; Disease-specific policies with no mention of climate change-related themes Program-based policies with no mention of climate change-related themes. Policies formulated before 2010 Analytical framework We used the 1994 Policy Analysis Triangle Model by Walt and Gilson [ 47 ] to analyze the selected health policies (Fig. 1). This model provides a structured approach to policy analysis by examining the interactions between policy context, content, process, and actors. It helps to understand how policies are formulated, implemented, and influenced by various stakeholders. To operationalize this model, we applied the context, content, process, and actor’s framework as translated by Ahmed et al. (2021). They translate context as national, provincial, or even international political, economic, social, and cultural factors that affect health policy. In addition, they define content as the area of health problems the policy aims to address, while process indicates steps taken in policy formulation, ways of implementation, and means of evaluation. They define actors as individuals, communities, groups, institutions, or government departments that may influence health policy [ 48 ]. Data collection and analysis Data collection was conducted between September and December 2024. A data extraction form was developed with key headings, including title, climate change themes, content, context, process, and actors. The analysis used a deductive approach based on the study objectives to identify climate change themes within the selected policies. Each policy was read multiple times to ensure familiarity, and all sections containing climate change themes were highlighted for detailed examination. This process helped to create a summary document capturing key points from the policies. Then, all climate change-related sections were critically analyzed to identify codes. The analysis was conducted manually, focusing on key policy areas including objectives, formulation processes, stakeholder involvement, and implementation strategies. The codes were organized in the data extraction form according to their relevant thematic areas. We then grouped the identified codes into content, context, process, and actors before entering them into the data extraction form (Table 1). Finally, health system response gaps related to climate change strategies were identified and documented. This structured approach enabled a comprehensive identification and analysis of climate change issues available in the analysed health policies. Results The Department of Policy, Planning, and Development in the Ministry of Health listed and recommended 32 policy documents and two strategic plans. However, only two policy documents and one strategic plan met the inclusion criteria (Table 2). These include the Malawi Health Sector Strategic Plan III 2023–2030 (HSSP III), National Environmental Health Policy-2018 (NEHP), and National Population Policy-2023 (NPP). These are the documents that were reviewed and analyzed. The results have been presented using the policy triangle framework to systematically capture issues related to policy content, context, processes, actors, as well as identified response gaps. The context The two policies and a strategic plan analyzed were not specifically developed in response to the effects of CCEWEs on the health system. Our analysis reveals that climate change themes and strategies were integrated into the policies and the strategic plan. The Health Sector Strategic Plan III (HSSP III) The HSSP III was developed as a master plan for accelerating the desire to achieve Universal Health Coverage to improve health status, financial risk protection, and client satisfaction among the population. This was developed as a successor to the Health Sector Strategic Plan II. It emphasizes the service integration through one plan, one budget, and one report. At the national level, the strategic plan was formulated in line with Malawi's Agenda 2063. Furthermore, the World Health Organisation (WHO) building block framework was used to inform the thematic areas. The strategic plan was further aligned with the World Bank framework. The National Environmental Health Policy (NEHP) The contextual element that led to the development of the NEHP was the increase in sanitation and hygiene-related diseases. The focus area of the policy was to improve waste management, sanitation and hygiene, food safety and hygiene, occupational health and safety, vector disease control and emergencies, climate change, and human health. Climate change issues were incorporated as they influence disease outbreaks and sanitation-related issues. The policy was formulated in line with the Constitution of Malawi, Malawi Vision 2020, and Malawi Growth and Development Strategy (MDGS) 2017–2022. In addition, the analysis shows that the policy was aligned with international declarations such as the United Nations Sustainable Development Goals, the Paris Declaration on Aid Effectiveness 2005, the Astana Declaration on Primary Health Care, and the African Agenda 2063. The National Population Policy (NPP) The NPP was developed in response to the rapid population growth that undermines the development of quality human capital by limiting the resources that individuals, families, and the government spend on general livelihoods, including housing, agriculture, education, and health care. The policy was formulated in line with the Constitution of Malawi, Malawi Vision 2020, Malawi Growth and Development Strategy (MDGS) 2017–2022, and Malawi Agenda 2063. In addition, the analysis shows that the policy was aligned with international declarations such as the United Nations Sustainable Development Goals, the Paris Declaration on Aid Effectiveness 2005, and the Astana Declaration on Primary Health Care. The content The contents of the analyzed policies and the strategic plan had climate change themes and strategies. However, the analysis revealed that the themes and strategies were not specifically framed in response to the effects of CCEWEs on the health system. The Health Sector Strategic Plan III The HSSP III has a focus on social determinants of health aimed at improving overall environmental health, and prevention to improve and reduce disease burden as the climate change thematic area. It recognizes the climate change impacts on health systems as it exacerbates disease burden, disrupts food and water systems, and damages health infrastructures. The climate change strategy in HSSP III is to address health and health delivery effects of climate change with several activities including the completion of the inter-sectoral assessment of current and projected climate change effects on health, participation in the development of a mitigation plan with emphasis on health and health delivery response, and the creation of policies, operational plans and laws such as limiting deforestation. The National Environmental Health Policy The climate change thematic area in the NEHP was to reduce the impacts of public health emergencies and the effects of climate change on human health with several strategies. The strategies outlined in the policy were to promote research on climate change effects and adaptation, strengthen core national and district capacities to facilitate the development of strong and resilient public health, and address the impact of climate change on human health. The policy had several activities to be implemented within its lifespan. Some of the activities were to establish and strengthen surveillance systems through the integration of health and climate change information for early warning and emergency preparedness and planning, strengthening adaptation and mitigation measures for climate change-sensitive diseases and conditions such as malaria, diarrhea, and malnutrition, strengthening and promoting multi-sectoral collaboration on health and climate change and strengthening governance structures for the management of emergencies and climate change effects on health. The National Population Policy The NPP focused on two thematic areas, which included climate change adaptation and resilience. The policy refers to adaptation as changes in processes, practices, and structures to moderate potential damages or to benefit from opportunities associated with climate change. The climate change strategies in the policy were focused on mainstreaming and integrating climate change adaptation and resilience in sexual reproductive health and rights, population, and development programming. Another strategy was to raise awareness of vulnerable groups and promote engagement and participation of vulnerable populations in policies and programs that deal with climate change adaptation and resilience. The policy had a clear implementation plan aligned to the responsible offices with estimated budgets and timelines. The process The processes for formulating the policy documents and strategic plan were similar and involved the identification of thematic areas, goals, objectives, and strategies to be followed during the implementation phase. The analysis revealed that consultations were made during the formulation process of the analyzed policies and strategic plan. The consultation was made with government officials, religious groups, traditional leaders, Members of Parliament, development partners, members of academia, the private sector, Civil Society Organizations, young people, District Councils, and officials from various Government Ministries, Departments, and Agencies. However, the approach used during consultation for both policies was not clearly stated as to whether it was bottom-up or not. Furthermore, the consultations left out health system structures such as Health Advisory Committees (HAC), now called Health Centre Management Committees, which represent and act as a mouthpiece for communities that limited the inclusion of indigenous knowledge. The actors Both national and international actors were involved in the formulation of the three analyzed documents. The actors involved at the national level were the Ministry of Health Directorates, District Health Offices, Other Government Ministries, Departments, and Agencies, Regulatory Bodies, international and local non-governmental organizations, Civil Society Organizations, patient groups, Members of parliament, and some traditional leaders. The international actors involved include United Nations International Children's Education Fund (UNICEF), WHO, Red Cross, WaterAid, the World Bank, the United Nations Population Fund (UNFPA), the United States Agency for International Development (USAID), the African Institute for Development Policy (AFIDEP), the UKAid Foreign and Commonwealth & Development Office (FCDO). The policy response gaps to CCEWEs The analysis identified several gaps with the analyzed policies and the strategic plan for an effective health system response to the CCEWEs. The identified gaps include lack of specific climate change strategies and guidelines targeting health system to ably respond to the effects of CCEWEs, lack of funding mechanisms for effective implementation of the policies as only one policy included budget provision under its implementation strategies, limited inclusion of local knowledge on climate change responses and lack of strategies to train health workers on climate change and health were among the gaps identified. Discussion Our policy analysis on the health system’s response strategies to the effects of CCEWEs establishes a lack of climate change-specific health policy in Malawi. This analysis further reveals that climate change issues have been incorporated in some policies formulated in response to other health problems [ 48 , 49 , 50 ]. Despite a lack of climate change-specific health policy, the country recognizes climate change as an emerging health threat that requires urgent attention. The actions taken so far indicate the country’s commitment to the fight against CCEWEs on health. All the analyzed documents reflect political and technical will as the policies contained themes and strategies to deal with the CCEWEs in the country. Globally, various approaches are used to strengthen health systems in response to climate change. For instance, integration of climate change adaptation plans into national health policies [ 51 ], formulation of climate change-specific health policies [ 52 ], and integration of climate risk monitoring into health programs [ 53 ] are some of the approaches used. Contextually, our analysis has revealed that the policies and strategic plan were formulated by considering both local and international regulations and declarations. Interestingly, many considerations were made on socio-economic, political, and administrative factors that influence policy formulation, development, and implementation. Our findings on the contextual factors that influence policy formulation are similar to what was reported in another study on the analysis and evolution of health policies in Iran [ 54 ]. The policies analyzed further highlight that the country is also responding to global health challenges, as all analysed documents were aligned with international commitments and declarations [ 48 , 49 , 50 ]. This analysis considers the linkage of the national health policies with the international or global agendas as the best practice in response to the rapid spread of diseases due to globalization [ 55 , 56 ]. However, it is worth noting that some national health policy strategies in the country are aligned with international strategies in response to external pressure to get support and incentives [ 57 , 58 ]. A similar situation was reported in the Estonian case study, where the European Union was reported to influence monitoring of administrative systems adaptive to emerging climate change-related health effects [ 59 ]. Even though the analysed documents contain climate change themes and strategies, they conspicuously lacked explicit strategies to improve the overall health system performance to respond to the effects of CCEWEs. Similar findings have been reported in some developing countries. In South Africa, for example, a lack of health system climate change adaptation strategies in health policy documents has been reported [ 60 ]. Likewise, an Iranian study, conducted to analyse policy protecting households against catastrophic health expenditures, reported on weak and a lack of strategies [ 61 ]. Regarding climate change and health systems, the WHO Operational Framework (2015) for building climate-resilient health systems [ 62 ] illustrated several strategies to serve as a platform for considerations into the national climate change-specific health system policies. In this regard, we presume that the lack of climate change health system-specific strategies in the analysed documents came about as the policies had other goals and directions, and climate change issues were just incorporated. Lack of specific response strategies in health policies has been observed and reported as a barrier to the health system's response to climate change [ 27 ] This analysis further reveals that there was a wide consultation and involvement of different actors, both local and international, during the formulation of the analysed documents. However, the analysis shows inadequate inclusion of local knowledge as health system structures that represent community members, such as Health Advisory Committees, now called Health Management Committees [ 48 ], were left out during consultation, while organizational and international interests were highly considered. Our findings are consistence with what was reported in another study that was conducted in Malawi to understand stakeholder engagement in the health policy process, where a lack of inclusiveness and meaningful engagement of local people were reported as barriers [ 63 ]. The perception of local people can influence the implementation of the health policy, as they can either welcome or resist the change coming with the policy. In the case of climate change, it has been argued that indigenous people use their knowledge to predict extreme weather events, prepare for them, and live through them [ 64 , 65 ]. In Iran, for instance, it was reported that the political, social, and economic environments during policy implementation were influenced by the behavior and conflicts of interest of local individual beliefs [ 66 ]. Furthermore, a study conducted in Kenya reported on the underrepresentation of traditional knowledge and lack of community engagement to have affected the implementation of climate change health-related issues [ 67 ]. In this line, our study findings necessitate the need for effective inclusion of local knowledge and participation. Our analysis also found that some policies had/have no clear funding mechanism with partial decentralization of duties and responsibilities to the district councils, which might have affected the implementation of the climate change-related strategies. Effective policy implementation requires well-defined, sound financing mechanisms with a clear estimated budget [ 68 , 69 ], which is not the case with two of the three analysed polices. For instance, during the operation period of HSSP III, the financing approach will be one budget, one plan, and one report with an emphasis on service integration [ 49 ]. Much as we commend this approach as the best way for the efficient use of the available resources [ 69 ], however, prioritization of activities becomes a challenge and requires proper planning. We assume that climate change activities might not be prioritized as health workers do not have enough knowledge on climate change and its effects on the health systems [ 70 , 71 ]. Likewise, in the agricultural sector in Malawi, lack of knowledge about climate change and its effects was reported to affect the adoption of adaptation strategies, leading to inadequate implementation of interventions [ 72 ]. Similar incidents concerning low funding prioritization for climate change-related activities among health workers were also reported elsewhere [ 73 ]. This analysis also revealed that there were no strategies aimed at improving the capacity of the health workers on the climate change effects on the health system. In this regard, the inclusion of climate change themes and strategies in these policies were supposed to be supported with the inclusion of strategies to improve the capacity of health workers during the early years of implementation. Health workers could have been given enough knowledge to initiate sound plans and activities to deal with climate change challenges that could have attracted funding opportunities. Lack of capacity among health workers impeding the linkages between climate change and health was also reported in a study done in Burkina Faso due to limited knowledge [ 74 ]. Therefore, the introduction of climate change and health curriculum in health training institutions in the country during the early years of implementation could have enhanced the capacity of health workers to better understand the relationship between climate change and health. Study limitations One well-known limitation is that our study did not include policies from other relevant sectors involved in climate change response, which could have highlighted a broader situation in Malawi. This could not happen as our main focus was on health system strengthening. Another limitation is that we reduced the policy period to 14 years, covering a decade and some years, which made it difficult to determine the first health policy formulated in Malawi, where climate change issues were included. However, our focus was on a decade to meet the definition of climate change, which is enough to determine the achievements made so far. Conclusion and recommendations The analyzed health policy documents suggest that the health system in Malawi is moving in the right direction to minimize the effects of CCEWEs. The policy documents provided evidence that CCEWEs have impacted the country's health system. However, a lack of climate change-specific health policy might hinder the health system’s response to CCEWEs. In this regard, our study recommends the formulation of climate change-specific health policy with clear strategies, activities, and funding mechanisms for the health system to effectively respond to the perceived risks. Considerations should be made for the inclusion of local stakeholders who have indigenous knowledge to mitigate or adapt to the effects of CCEWEs. We further recommend the inclusion of climate change curricula in health institutions to equip health workers with knowledge on the effects of climate change on health and the health system. More research should be conducted to explore how climate change has impacted the health system and to examine evidence-based strategies for mitigating the effects of climate change in the country. It is vital to consider strengthening multi-sectoral collaboration in health policies, especially in climate change health policy, as the global community advocates for a one health approach. Declarations Authors’ contributions CSC and ML conceived the study. CSC conducted the analysis, reviewed the literature, and drafted the manuscript. SM and ML critically revised several drafts of the manuscript. All authors read and approved the final manuscript. Ethics approval and consent to participate Not applicable. Funding Declaration The project received no funds. Competing interests The authors declare that they have no competing interests. Clinical trial number Not applicable. 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Malawi National Population Policy [Internet]. Malawi Government; 2023 [cited 2024 Oct 10]. Available from: https://www.usaid.gov/sites/default/files/2023-07/MALAWI%20NATIONAL%20POPULATION%20POLICY_FINAL.pdf Malawi Government. Malawi National Environmental Health Policy [Internet]. 2018 [cited 2024 Oct 10]. Available from: https://wesnetwork.org/wp-content/uploads/2020/03/Environmental-Health-Policy.pdf Schnitter R, Verret M, Berry P, Fook TCT, Hales S, Lal A et al. An assessment of climate change and health vulnerability and adaptation in dominica. Int J Environ Res Public Health 2019;16. https://doi.org/10.3390/ijerp h16010070 Nhamo G, Muchuru S, United Nations Framework Convention on Climate Change National Communications. Jamba: Journal of Disaster Risk Studies. Climate adaptation in the public health sector in Africa: Evidence from. 2019; 11:1–10. https://www.doi.org/10.4102/JAMBA.V11I1.644 . 26. Boyer CJ, Bowen K, Murray V, Hadley J, Hilly JJ, Hess JJ et al. Using implementation science for health adaptation: Opportunities for pacifc island countries. Health Af. 2020; 39:2160–7. https://www.doi.org/10.1377/hlthaf . 2020.01101. Doshmangir L, Behzadifar M, Shahverdi A, Martini M, Ehsanzadeh SJ, Azari S, et al. Analysis and evolution of health policies in Iran through policy triangle framework during the last thirty years: a systematic review of the historical period from 1994 to 2021. J PREV MED HYG. 2023;64:E107–17. Mukanu MM, Zulu JM, Mweemba C, Mutale W. Responding to non-communicable diseases in Zambia: a policy analysis. Health Res Policy Syst. 2017;15(34). Huynen MM, Martens P, BM Hilderink H. The health impacts of globalisation: a conceptual framework. Glob Health. 2005;1(14). Bender K, Keller S, Willing H. The Role of International Policy Transfer and Diffusion for Policy Change in Social Protection@. A Review of the State of the Art; 2015. Odoch WD, Senkubuge E, Ann Bosibori Masese AB, Hongoro C. How are global health policies transferred to sub-Saharan Africa countries? A systematic critical review of literature, 18:25, 2022. https://www.doi.org/10.1186/s12992-022-00821-9 Orru K, Tillmann M, Ebi LK, Orru H. Making Administrative Systems Adaptive to Emerging Climate Change-Related Health Effects: Case of Estonia. J Atmos. 2018;2(221). https://www.doi:10.3390/atmos9060221 . Hedayati M, Asl MI, Maleki M, Fazaeli AA, Goharinezhad S. Policy analysis of the protection of Iranian households against catastrophic health expenditures: a qualitative analysis. BMC Health Serv Res. 2023;23:445. https://www.doi.org/10.1186/s12913-023-09275-0 . Quintana VA, Susannah H, Mayhew HS, Kovats S, Gilson L. A story of (in)coherence: climate adaptation for health in South African policies. Health Policy Plann. 2024;39(4):400–41. https://www.doi.org/10.1093/heapol/czae011 . WHO. Operational framework for building climate resilient health systems [Internet]. Geneva: World Health Organisation. 2015. Available from: https://www.who.int/publications/i/item/9789241565073 Masefield 1CS, Msosa A, Chinguwo KF, Grugel J. Stakeholder engagement in the health policy process in a low income country: a qualitative study of stakeholder perceptions of the challenges to effective inclusion in Malawi. BMC Health Serv Res. 2021;21:984. https://www.doi.org/10.1186/s12913-021-07016-9 . Dorji T, Rinchen K, Morrison-Saunders A, Blake D, Banham V, Pelden S. Understanding How Indigenous Knowledge Contributes to Climate Change Adaptation and Resilience: A Systematic Literature Review. Environ Manage. 2024;1101–23. Soropa G, Gwatibaya S, Musiyiwa K, Rusere F, Mavima GA, Kasasa P. Indigenous knowledge system weather forecasts as a climate change adaptation strategy in smallerholder farming systems in Zimbabwe. A case of Murehwa. Tsholotsho and Chiredzi districts. Afr J Agr Res. 2025. https//www.doi.org/10.5897/AJAR2013.7205 . Hedayati M, Asl IM, Maleki M, Fazaeli AA, Goharinezhad S. Policy analysis of the protection of Iranian households against catastrophic health expenditures: a qualitative analysis. BMC Health Serv Res. 2023;23(445). WHO. Operational framework for building climate resilient health systems [Internet]. Geneva: World Health Organisation. 2015. Available from: https://www.who.int/publications/i/item/9789241565073 Bloma MI, Otienob AM, Mayhewe S, Spicere N, Hainesa A, Whitmee S. Towards anet-zero healthcare system in Kenya: Stakeholder perspectives on opportunities, challenges and priorities. J Clim Change Health. 2025;22(100417). https://www.doi.org/10.1016/j.joclim.2025.100417 . Sakala JJ, Chimatiro CS, Salima R, Kapachika A, Kalepa J, Stones W. The Integration of vertical and horizontal programmes for health systems strengthening in Malawi: a case study. Malawi Med J. 2022;34(3):206–12. Mulwa R, Nyukuri E, Kigundu K, Musembi E. Advancing climate and health policies in Kenya; insights from national policy stakeholders. Kenya: University of Nairobi; 2024. https://www.climatechangecommunication.org/all/advancing-and-integrating-climate-and-health-policies-in-kenya/ . Chiwatakwenda A. Capitalising on local expertise to protect the health of Malawi communities from climate change: Case Study on Climate Change and Health [Internet]. World Health Organisation; 2021. Available from: https://www.who.int/news-room/feature-stories/detail/protecting-health-of-malawi-communities-from-climate-change Munthali CK, Kasulo V, Matamula S. Smallholder farmers perception on climate change in Rumphi District. Malawi. 2016;8(10):202–10. Nigatu AS, Asamoah BO, Kloos H. Knowledge and perceptions about the health impact of climate change among health sciences students in Ethiopia: a cross-sectional study. BMC Public Health. 2014;14(587). Sorgho R, Bhatt M, Danquah I, Sauerborn R. Institutional barriers to climate change and health adaptation in Burkina Faso. Clim Change Dev. 2023;15(7). Tables Table 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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A policy analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe effects of Climate change on health systems are becoming more unbearable globally. Low- and middle-income countries have been disproportionately impacted by the unpredictable occurrences of climate change extreme weather events, such as heatwaves, storms, and floods [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The Intergovernmental Panel on Climate Change (IPCC) defines Climate Change Extreme Weather Events (CCEWEs) as the occurrence of a value of a weather or climate variable above (or below) a threshold value near the upper (or lower) ends of the range of observed values of the variable [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It signifies a prolonged departure from everyday average weather event observations such as rainfall patterns, temperature, and wind speed [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The more apparent observed CCEWEs in recent years include increased temperature, drought, abnormal rainfall patterns, cyclones, floods, and air pollution [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The continuous occurrence of CCEWEs is the major driver for the health system’s vulnerability to climate change, which affects its performance and is likely to increase in the coming years [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAccording to the World Bank report, Malawi is among the Sub-Saharan African Countries vulnerable to CCEWEs [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A study conducted by ActionAid indicates that the country has experienced increased CCEWEs such as floods, droughts, and temperature rises between 1970 and 2020 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Despite the CCEWEs being felt countrywide, Coulibaly et al (2015) reported that some districts are more prone to CCEWEs than others [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Unfortunately, an increase in any of the CCEWEs translates into unintended outcomes such as dry spells, droughts, intense rainfall, or floods [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], which disrupt the delivery of health services, reduce health system performance at large, and affect the health of the population. The CCEWEs have exacerbated the existing health burdens while creating new health risks. Some of the CCEWEs' health risks include the emergence and re-emergence of diseases, increased malnutrition among children, disease outbreaks, infrastructure damage, direct body injuries, and loss of lives [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCCEWEs have affected the health system's operation and performance in many ways. The occurrence of any of the CCEWE in the country limits the delivery of healthcare services. It disrupts communication channels, overwhelms the capacity of human resources to respond and provide services, increases demand for medicinal and vaccine products, and damages infrastructures [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. For instance, floods may damage roads, limiting health services accessibility, and increase chances for the development and spread of waterborne diseases due to damaged water, sanitary, and hygiene facilities [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. On the other hand, drought might lead to food insecurity, which may cause an upsurge in malnutrition among children, especially those under five, and lower the quality of food supply in terms of micronutrients [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Similar situations are experienced in many Sub-Saharan African countries as the operations of the health systems are disrupted whenever CCEWEs occur due to poor infrastructure, inadequate human resources and medicinal product supplies, and economic dependency [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Worth noting is the fact that the effects of CCEWEs are also experienced at the household and individual levels. Increased mortality and morbidity due to vector-borne diseases, psychological stress, air pollution-related respiratory diseases, and accidents have been reported to affect households and individuals in Malawi and other sub-Saharan countries [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFollowing the Paris agreement on climate change, some countries have formulated climate change-specific health policies, while others have integrated climate change strategies into the national health policies [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, there is variation in health systems' policy response strategies to the effects of CCEWEs globally. So far, the majority of developed countries are focusing on reducing greenhouse gas emissions, building resilient health systems, and adapting to the health risks [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In low and middle-income countries, the strategies are focusing more on environmental health, disease prevention, and health promotion with little attention on strengthening the overall health system [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In a study conducted by Nhamo and Muchuru (2019) in African countries, they found that all countries sampled had some form of legal and policy provisions in response to climate change, although not health system specific [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In Ghana, climate change health policy strategies focusing on capacity building, vulnerability assessment, early warning systems, and health research have been developed [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The policy approach taken in responding to CCEWEs globally accelerates the desire to achieve the Sustainable Development Goals, especially goal no. 3, of ensuring quality health for all by the year 2030 [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn response to the global call to address the effects of CCEWEs, the government of Malawi developed the National Adaptation Programme of Action (NAPA) [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] and the Malawi Nationally Determined Contributions (MNDC) [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The main aim of NAPA is to reduce the country’s vulnerability to the effects of CCEWEs by building adaptive capacity and resilience while integrating climate change-related themes into relevant national policies, programs, and activities (27). The MNDC aimed at minimizing greenhouse gas emissions and scaling up adaptation actions to reduce the long-term impacts of CCEWEs [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn addition, the country developed its Vision 2063 in line with the Africa Agenda 2063 with seven enablers to guide, promote, and accelerate national development agendas [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Attaining Universal Health Coverage (UHC) is a desired health-specific agenda for ensuring quality, equitable, and affordable healthcare provision at all levels of the health systems in the country. It further indicates the country’s commitment to minimizing the effects of CCEWEs on the environment by ensuring adequate waste disposal, treatment, and recycling, air and water pollution management, and prudent water resource management by 2063 [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. However, little has been done on the effects of CCEWEs on health and the health system in the country as compared to the economic and agricultural aspects [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMoreover, Malawi’s health system has numerous health policies, both disease-specific and program-based, intended to address identifiable health-related problems to minimize probable outcomes and their impact on population health. Some of these policies have brought desirable results by reducing disease burden among the population [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. However, it is not known whether the health system policies have strategies and guidelines in response to the health threats posed by climate change. Therefore, we conducted a health policy analysis to gain a deeper understanding of the policy response strategies to the effects of CCEWEs on the health system in Malawi and identified response gaps for improvement. Policy analysis is described as a wide range of techniques used to holistically scrutinize developed policies' features, processes, and relevance, considering given priority areas and targets [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. It includes various methods, techniques, and tools used to create awareness and improve the effects of the developed and implemented policies [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. In regard to the definitions of climate change [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], which emphasizes the decade as a period, we considered policies formulated between 2010 and 2024 in this analysis, as the period covers a decade.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eWe obtained a list of all health policies formulated between 2010–2024 from the Ministry of Health (MoH), Department of Policy, Planning and Development. Additionally, we included the Health Sector Strategic Plan documents as they are deemed a master plan that guides the operation of the health sector in the country. To access the full document, we searched the MoH website and requested hard copies of those policies that were not published online. Each policy was screened for climate change-related themes, goals, objectives, and strategies.\u003c/p\u003e\u003cp\u003eThe inclusion criteria were;\u003c/p\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eNational health policies formulated between 2010 and 2024.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eHealth policies with themes such as climate change, floods, droughts, cyclones, or other extreme weather events.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003cp\u003eThe exclusion criteria were;\u003c/p\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eDisease-specific policies with no mention of climate change-related themes\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eProgram-based policies with no mention of climate change-related themes.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePolicies formulated before 2010\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003cp\u003e\u003cb\u003eAnalytical framework\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe used the 1994 Policy Analysis Triangle Model by Walt and Gilson [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] to analyze the selected health policies (Fig.\u0026nbsp;1). This model provides a structured approach to policy analysis by examining the interactions between policy context, content, process, and actors. It helps to understand how policies are formulated, implemented, and influenced by various stakeholders. To operationalize this model, we applied the context, content, process, and actor’s framework as translated by Ahmed et al. (2021). They translate context as national, provincial, or even international political, economic, social, and cultural factors that affect health policy. In addition, they define content as the area of health problems the policy aims to address, while process indicates steps taken in policy formulation, ways of implementation, and means of evaluation. They define actors as individuals, communities, groups, institutions, or government departments that may influence health policy [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eData collection and analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eData collection was conducted between September and December 2024. A data extraction form was developed with key headings, including title, climate change themes, content, context, process, and actors. The analysis used a deductive approach based on the study objectives to identify climate change themes within the selected policies. Each policy was read multiple times to ensure familiarity, and all sections containing climate change themes were highlighted for detailed examination. This process helped to create a summary document capturing key points from the policies. Then, all climate change-related sections were critically analyzed to identify codes.\u003c/p\u003e\u003cp\u003eThe analysis was conducted manually, focusing on key policy areas including objectives, formulation processes, stakeholder involvement, and implementation strategies. The codes were organized in the data extraction form according to their relevant thematic areas. We then grouped the identified codes into content, context, process, and actors before entering them into the data extraction form (Table\u0026nbsp;1). Finally, health system response gaps related to climate change strategies were identified and documented. This structured approach enabled a comprehensive identification and analysis of climate change issues available in the analysed health policies.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe Department of Policy, Planning, and Development in the Ministry of Health listed and recommended 32 policy documents and two strategic plans. However, only two policy documents and one strategic plan met the inclusion criteria (Table\u0026nbsp;2). These include the Malawi Health Sector Strategic Plan III 2023\u0026ndash;2030 (HSSP III), National Environmental Health Policy-2018 (NEHP), and National Population Policy-2023 (NPP). These are the documents that were reviewed and analyzed. The results have been presented using the policy triangle framework to systematically capture issues related to policy content, context, processes, actors, as well as identified response gaps.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe context\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe two policies and a strategic plan analyzed were not specifically developed in response to the effects of CCEWEs on the health system. Our analysis reveals that climate change themes and strategies were integrated into the policies and the strategic plan.\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe Health Sector Strategic Plan III (HSSP III)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe HSSP III was developed as a master plan for accelerating the desire to achieve Universal Health Coverage to improve health status, financial risk protection, and client satisfaction among the population. This was developed as a successor to the Health Sector Strategic Plan II. It emphasizes the service integration through one plan, one budget, and one report. At the national level, the strategic plan was formulated in line with Malawi's Agenda 2063. Furthermore, the World Health Organisation (WHO) building block framework was used to inform the thematic areas. The strategic plan was further aligned with the World Bank framework.\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe National Environmental Health Policy (NEHP)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe contextual element that led to the development of the NEHP was the increase in sanitation and hygiene-related diseases. The focus area of the policy was to improve waste management, sanitation and hygiene, food safety and hygiene, occupational health and safety, vector disease control and emergencies, climate change, and human health. Climate change issues were incorporated as they influence disease outbreaks and sanitation-related issues. The policy was formulated in line with the Constitution of Malawi, Malawi Vision 2020, and Malawi Growth and Development Strategy (MDGS) 2017\u0026ndash;2022. In addition, the analysis shows that the policy was aligned with international declarations such as the United Nations Sustainable Development Goals, the Paris Declaration on Aid Effectiveness 2005, the Astana Declaration on Primary Health Care, and the African Agenda 2063.\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe National Population Policy (NPP)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe NPP was developed in response to the rapid population growth that undermines the development of quality human capital by limiting the resources that individuals, families, and the government spend on general livelihoods, including housing, agriculture, education, and health care. The policy was formulated in line with the Constitution of Malawi, Malawi Vision 2020, Malawi Growth and Development Strategy (MDGS) 2017\u0026ndash;2022, and Malawi Agenda 2063. In addition, the analysis shows that the policy was aligned with international declarations such as the United Nations Sustainable Development Goals, the Paris Declaration on Aid Effectiveness 2005, and the Astana Declaration on Primary Health Care.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe content\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe contents of the analyzed policies and the strategic plan had climate change themes and strategies. However, the analysis revealed that the themes and strategies were not specifically framed in response to the effects of CCEWEs on the health system.\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe Health Sector Strategic Plan III\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe HSSP III has a focus on social determinants of health aimed at improving overall environmental health, and prevention to improve and reduce disease burden as the climate change thematic area. It recognizes the climate change impacts on health systems as it exacerbates disease burden, disrupts food and water systems, and damages health infrastructures. The climate change strategy in HSSP III is to address health and health delivery effects of climate change with several activities including the completion of the inter-sectoral assessment of current and projected climate change effects on health, participation in the development of a mitigation plan with emphasis on health and health delivery response, and the creation of policies, operational plans and laws such as limiting deforestation.\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe National Environmental Health Policy\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe climate change thematic area in the NEHP was to reduce the impacts of public health emergencies and the effects of climate change on human health with several strategies. The strategies outlined in the policy were to promote research on climate change effects and adaptation, strengthen core national and district capacities to facilitate the development of strong and resilient public health, and address the impact of climate change on human health. The policy had several activities to be implemented within its lifespan. Some of the activities were to establish and strengthen surveillance systems through the integration of health and climate change information for early warning and emergency preparedness and planning, strengthening adaptation and mitigation measures for climate change-sensitive diseases and conditions such as malaria, diarrhea, and malnutrition, strengthening and promoting multi-sectoral collaboration on health and climate change and strengthening governance structures for the management of emergencies and climate change effects on health.\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe National Population Policy\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe NPP focused on two thematic areas, which included climate change adaptation and resilience. The policy refers to adaptation as changes in processes, practices, and structures to moderate potential damages or to benefit from opportunities associated with climate change. The climate change strategies in the policy were focused on mainstreaming and integrating climate change adaptation and resilience in sexual reproductive health and rights, population, and development programming. Another strategy was to raise awareness of vulnerable groups and promote engagement and participation of vulnerable populations in policies and programs that deal with climate change adaptation and resilience. The policy had a clear implementation plan aligned to the responsible offices with estimated budgets and timelines.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe process\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe processes for formulating the policy documents and strategic plan were similar and involved the identification of thematic areas, goals, objectives, and strategies to be followed during the implementation phase. The analysis revealed that consultations were made during the formulation process of the analyzed policies and strategic plan. The consultation was made with government officials, religious groups, traditional leaders, Members of Parliament, development partners, members of academia, the private sector, Civil Society Organizations, young people, District Councils, and officials from various Government Ministries, Departments, and Agencies. However, the approach used during consultation for both policies was not clearly stated as to whether it was bottom-up or not. Furthermore, the consultations left out health system structures such as Health Advisory Committees (HAC), now called Health Centre Management Committees, which represent and act as a mouthpiece for communities that limited the inclusion of indigenous knowledge.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe actors\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBoth national and international actors were involved in the formulation of the three analyzed documents. The actors involved at the national level were the Ministry of Health Directorates, District Health Offices, Other Government Ministries, Departments, and Agencies, Regulatory Bodies, international and local non-governmental organizations, Civil Society Organizations, patient groups, Members of parliament, and some traditional leaders. The international actors involved include United Nations International Children's Education Fund (UNICEF), WHO, Red Cross, WaterAid, the World Bank, the United Nations Population Fund (UNFPA), the United States Agency for International Development (USAID), the African Institute for Development Policy (AFIDEP), the UKAid Foreign and Commonwealth \u0026amp; Development Office (FCDO).\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe policy response gaps to CCEWEs\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe analysis identified several gaps with the analyzed policies and the strategic plan for an effective health system response to the CCEWEs. The identified gaps include lack of specific climate change strategies and guidelines targeting health system to ably respond to the effects of CCEWEs, lack of funding mechanisms for effective implementation of the policies as only one policy included budget provision under its implementation strategies, limited inclusion of local knowledge on climate change responses and lack of strategies to train health workers on climate change and health were among the gaps identified.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur policy analysis on the health system\u0026rsquo;s response strategies to the effects of CCEWEs establishes a lack of climate change-specific health policy in Malawi. This analysis further reveals that climate change issues have been incorporated in some policies formulated in response to other health problems [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Despite a lack of climate change-specific health policy, the country recognizes climate change as an emerging health threat that requires urgent attention. The actions taken so far indicate the country\u0026rsquo;s commitment to the fight against CCEWEs on health. All the analyzed documents reflect political and technical will as the policies contained themes and strategies to deal with the CCEWEs in the country. Globally, various approaches are used to strengthen health systems in response to climate change. For instance, integration of climate change adaptation plans into national health policies [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], formulation of climate change-specific health policies [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], and integration of climate risk monitoring into health programs [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] are some of the approaches used.\u003c/p\u003e\u003cp\u003eContextually, our analysis has revealed that the policies and strategic plan were formulated by considering both local and international regulations and declarations. Interestingly, many considerations were made on socio-economic, political, and administrative factors that influence policy formulation, development, and implementation. Our findings on the contextual factors that influence policy formulation are similar to what was reported in another study on the analysis and evolution of health policies in Iran [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. The policies analyzed further highlight that the country is also responding to global health challenges, as all analysed documents were aligned with international commitments and declarations [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. This analysis considers the linkage of the national health policies with the international or global agendas as the best practice in response to the rapid spread of diseases due to globalization [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. However, it is worth noting that some national health policy strategies in the country are aligned with international strategies in response to external pressure to get support and incentives [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. A similar situation was reported in the Estonian case study, where the European Union was reported to influence monitoring of administrative systems adaptive to emerging climate change-related health effects [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEven though the analysed documents contain climate change themes and strategies, they conspicuously lacked explicit strategies to improve the overall health system performance to respond to the effects of CCEWEs. Similar findings have been reported in some developing countries. In South Africa, for example, a lack of health system climate change adaptation strategies in health policy documents has been reported [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Likewise, an Iranian study, conducted to analyse policy protecting households against catastrophic health expenditures, reported on weak and a lack of strategies [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. Regarding climate change and health systems, the WHO Operational Framework (2015) for building climate-resilient health systems [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e] illustrated several strategies to serve as a platform for considerations into the national climate change-specific health system policies. In this regard, we presume that the lack of climate change health system-specific strategies in the analysed documents came about as the policies had other goals and directions, and climate change issues were just incorporated. Lack of specific response strategies in health policies has been observed and reported as a barrier to the health system's response to climate change [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThis analysis further reveals that there was a wide consultation and involvement of different actors, both local and international, during the formulation of the analysed documents. However, the analysis shows inadequate inclusion of local knowledge as health system structures that represent community members, such as Health Advisory Committees, now called Health Management Committees [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], were left out during consultation, while organizational and international interests were highly considered. Our findings are consistence with what was reported in another study that was conducted in Malawi to understand stakeholder engagement in the health policy process, where a lack of inclusiveness and meaningful engagement of local people were reported as barriers [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. The perception of local people can influence the implementation of the health policy, as they can either welcome or resist the change coming with the policy. In the case of climate change, it has been argued that indigenous people use their knowledge to predict extreme weather events, prepare for them, and live through them [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. In Iran, for instance, it was reported that the political, social, and economic environments during policy implementation were influenced by the behavior and conflicts of interest of local individual beliefs [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Furthermore, a study conducted in Kenya reported on the underrepresentation of traditional knowledge and lack of community engagement to have affected the implementation of climate change health-related issues [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. In this line, our study findings necessitate the need for effective inclusion of local knowledge and participation.\u003c/p\u003e\u003cp\u003eOur analysis also found that some policies had/have no clear funding mechanism with partial decentralization of duties and responsibilities to the district councils, which might have affected the implementation of the climate change-related strategies. Effective policy implementation requires well-defined, sound financing mechanisms with a clear estimated budget [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e], which is not the case with two of the three analysed polices. For instance, during the operation period of HSSP III, the financing approach will be one budget, one plan, and one report with an emphasis on service integration [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Much as we commend this approach as the best way for the efficient use of the available resources [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e], however, prioritization of activities becomes a challenge and requires proper planning. We assume that climate change activities might not be prioritized as health workers do not have enough knowledge on climate change and its effects on the health systems [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. Likewise, in the agricultural sector in Malawi, lack of knowledge about climate change and its effects was reported to affect the adoption of adaptation strategies, leading to inadequate implementation of interventions [\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. Similar incidents concerning low funding prioritization for climate change-related activities among health workers were also reported elsewhere [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis analysis also revealed that there were no strategies aimed at improving the capacity of the health workers on the climate change effects on the health system. In this regard, the inclusion of climate change themes and strategies in these policies were supposed to be supported with the inclusion of strategies to improve the capacity of health workers during the early years of implementation. Health workers could have been given enough knowledge to initiate sound plans and activities to deal with climate change challenges that could have attracted funding opportunities. Lack of capacity among health workers impeding the linkages between climate change and health was also reported in a study done in Burkina Faso due to limited knowledge [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Therefore, the introduction of climate change and health curriculum in health training institutions in the country during the early years of implementation could have enhanced the capacity of health workers to better understand the relationship between climate change and health.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy limitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOne well-known limitation is that our study did not include policies from other relevant sectors involved in climate change response, which could have highlighted a broader situation in Malawi. This could not happen as our main focus was on health system strengthening. Another limitation is that we reduced the policy period to 14 years, covering a decade and some years, which made it difficult to determine the first health policy formulated in Malawi, where climate change issues were included. However, our focus was on a decade to meet the definition of climate change, which is enough to determine the achievements made so far.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion and recommendations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe analyzed health policy documents suggest that the health system in Malawi is moving in the right direction to minimize the effects of CCEWEs. The policy documents provided evidence that CCEWEs have impacted the country's health system. However, a lack of climate change-specific health policy might hinder the health system\u0026rsquo;s response to CCEWEs. In this regard, our study recommends the formulation of climate change-specific health policy with clear strategies, activities, and funding mechanisms for the health system to effectively respond to the perceived risks. Considerations should be made for the inclusion of local stakeholders who have indigenous knowledge to mitigate or adapt to the effects of CCEWEs. We further recommend the inclusion of climate change curricula in health institutions to equip health workers with knowledge on the effects of climate change on health and the health system. More research should be conducted to explore how climate change has impacted the health system and to examine evidence-based strategies for mitigating the effects of climate change in the country. It is vital to consider strengthening multi-sectoral collaboration in health policies, especially in climate change health policy, as the global community advocates for a one health approach.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCSC and ML conceived the study. CSC conducted the analysis, reviewed the literature, and drafted the manuscript. SM and ML critically revised several drafts of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe project received no funds.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO. 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Clim Change Dev. 2023;15(7).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health systems, health policy response, policy triangle model, Climate change extreme weather events, health policy analysis, health system strategies","lastPublishedDoi":"10.21203/rs.3.rs-7128239/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7128239/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e\u003cp\u003eThe effects of climate change and extreme weather events on the health system are becoming unbearable globally. We conducted a health policy analysis to gain a deeper understanding of the health policy response strategies to the effects of climate change extreme weather events on the health system in Malawi and identified response gaps for improvement.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThe policy triangle model was used to analyze health system policies. A list of policies was obtained from the Department of Policy, Planning, and Development at the Ministry of Health. We retrieved the policies from the Ministry of Health Website, and hard copies were obtained for those not published online. A data extraction form was created to capture all climate change-related themes and group them according to the policy triangle model, which includes: context, content, process, and actors. We also identified gaps in policy responses to climate change.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eIn total, 32 health policy documents were listed and recommended by the Department of Planning at the Ministry of Health for analysis. Out of these, only three had climate change-related themes and strategies. Contextually, the policies were aligned with both local and international goals. The contents of the analysed policies have climate change themes and strategies. The process involved wide consultations with both national and international stakeholders. The actors involved included government ministries, local councils, development partners, community leaders, and international organizations. Lack of health system-specific climate change strategies and guidelines, lack of clear funding mechanisms, limited inclusion of local knowledge, and lack of response strategies to build capacity among health workers were some of the gaps identified.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe health system in Malawi is moving in the right direction to minimize the effects of climate change extreme weather events on health. The availability of climate change themes and strategies in the analyzed health policies provides evidence that the impact of climate change extreme weather events have affected the health system in the country. We recommend the formulation of climate change-specific health policy with clear strategies and financing mechanisms.\u003c/p\u003e","manuscriptTitle":"The health system’s response strategies to the effects of climate change extreme weather events in Malawi. 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