Climate change policies fail to protect child health

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A. Bradshaw, Peter N. Le Souëf, Melinda A. Judge This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6670422/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Aug, 2025 Read the published version in Globalization and Health → Version 1 posted 7 You are reading this latest preprint version Abstract Background National policies are essential for countries to adapt to the negative health impacts of climate change. Children are disproportionately affected by climate-sensitive health risks and must be at the heart of adaptation policies to address their vulnerabilities across sectors. Adaptation commitments worldwide are integrated into national adaptation plans, nationally determined contributions, national communications, and other multisectoral policies. We aimed to evaluate how effectively national climate change policies worldwide plan to protect child health, considering a range of determinants for successful policy implementation. Results National adaptation policies worldwide had poor planning for child health, with 43% of countries not mentioning child health at all. Around half of policies acknowledged the disproportionate health impacts of climate change on children, but most did not provide further explanation of these impacts. One-quarter (24%) of countries described goals and/or actions to promote child health but lacked clear targets for success. Six per cent of countries outlined monitoring and evaluation mechanisms, but none measured child health outcomes directly. Eleven per cent of countries involved multiple stakeholders in policy design and implementation, but rarely described the obligations of each party. Conclusions The design of national policies must be strengthened across multiple areas to protect child health from the harms of climate change. Policies should explicitly acknowledge children and provide a holistic description of their unique health risks. Goals should be both time- and age-sensitive with clear health targets, accompanied by actions that holistically address child health risks and evaluate policy outcomes in the region concerned. A clear strategy for resource allocation and mobilisation will improve the success of policy actions. These interventions should be regularly monitored and reviewed to facilitate continuous adaptation to the changing climate. Multi-level stakeholders must be involved in policy design and implementation, and their responsibilities should be clearly outlined to improve implementation success. climate change health policy policy adaptation child health Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 INTRODUCTION Active engagement of governments and stakeholders is necessary to adapt to the worsening climate crisis (1). As the increase in average global surface temperatures continues, humanity faces devastating impacts on health, livelihoods, and infrastructure (2). These impacts are not distributed equally — children under five years old bear an estimated 88% of the additional disease burden caused by climate change (3). As the global human population grows, an increasing number of children will be exposed to lifelong health impacts on every organ system: these include adverse pregnancy outcomes (4, 5), respiratory illnesses (6–13), food-, water- (14–16) and vector-borne diseases (17), type 2 diabetes (18–21), kidney damage (22, 23), heat-stroke organ failure (24, 25), and negative mental health effects (26). Climate change also induces long-term social and economic instability due to economic loss, forced displacement, violence, civil and armed conflict, and degraded environments, which exacerbate children’s vulnerability to health risks (26–28). Low- and middle-income countries are the most severely affected, due to their increased exposure to extreme weather events, poorer infrastructure and political leadership, and lack of access to financial and social resources (29). National adaptation planning is necessary, with consideration of competing development needs, vulnerabilities, and existing plans of each region (30). The United Nations Framework Convention on Climate Change has published technical guidelines for national adaptation planning: successful planning should comprehensively assess available information on climate change impacts, critically appraise adaptation options, develop a long-term national adaptation implementation strategy with multilateral coordination between stakeholders, and evaluate success using iterative monitoring (30). Globally, adaptation commitments are integrated in national adaptation plans (30), nationally determined contributions (31), national communications (32), and other multisectoral policies. Policies must be child-sensitive by explicitly acknowledging their rights and holistically addressing their vulnerabilities across sectors (33). Evaluating whether health policies are successful for improving health outcomes is essential, with recent progress in evaluating the prioritisation of child health within climate change policies. An analysis of 160 national climate change-adaptation plans found that they had limited recognition of and action on child health, and tended towards overly simplistic conceptualisations of children across age, social roles, genders, and agency (34). However, that review only examined themes and did not evaluate other policy determinants, such as policy backgrounds, goals, resource mobilisation, monitoring and evaluation frameworks, or stakeholder collaboration (35, 36). Furthermore, the specific adaptation commitments to address child health outlined in nationally determined contributions, national communications, and broad climate change strategies remain unexplored. The likely magnitude of impact and implementation is unclear. Our aim was therefore to consider a range of policy determinants to evaluate the effectiveness of adaptation planning for child health in national climate change policies worldwide. METHODS The question we aimed to answer was: how effectively do climate change-adaptation policies address child health worldwide? We collated each country’s most recent national climate change plan published up to 12 July 2024, systematically searching by country from the UNFCCC National Adaptation Plan Ecosystem (37) and Nationally Determined Contribution Registry (38), Climate Change Laws of the World database (39), and the Food and Agricultural Organization of the United Nations database (40). The term ‘country’ refers to any sovereign state, including areas and territories, where appropriate. We prioritised policies with a focus on health adaptation, followed by generalised adaptation policies, then nationally determined contributions, national communications, and national adaptation programmes of action, respectively to ensure that we collected the most up-to-date, relevant, and legally binding document for each country. We excluded all policies with a period of implementation that ended during or before 2023. We evaluated each policy using criteria (Table 1 ) adapted from Cheung at al. (35), with some additional items adapted from the World Health Organization Quality Criteria for Health National Adaptation Plans (41) and Paz-Soldán et al. (42). We assigned each policy a quality score based on the number of items achieved from the checklist (0–23). We also assigned quality levels to each policy for all determinant areas: an area was weak if no criteria were fulfilled, needs improvement if some were fulfilled, and strong if all were fulfilled (35). To identify relevant information, we searched for key words relating to children (‘child’, ‘infant’, ‘pregnant’, ‘young’, ‘youth’) and read sections on health in full. We provide a comprehensive explanation justifying the changes made to the original Cheung et al. (35) criteria in Supplementary File 1. Table 1 Criteria for evaluation of climate change-policy determinants for child health adaptation. Determinant area Sub-items Criteria Accessibility Policy document is accessible (hard-copy and online) policy background 1 Children recognised as disproportionately affected by the impacts of climate change ** 2 Minimum of two context-specific climate-sensitive health risks for children identified ** (42) 3 Source of background is explicit* - authority (one or more persons, books, scientific articles or sources of information) - quantitative or qualitative analysis - deduction (premises that have been established from authority, observation, intuition or all three) The policy encompasses some set of feasible alternatives goals 4 Goals for child health explicitly stated * 5 Goals are concrete enough (quantitative where possible and qualitative where not) to be evaluated later 6 Goal is clear in its intent and in the mechanism with which to achieve the desired goals, yet does not attempt to prescribe in detail what the change must be 7 Action/s outlined to improve child health * 8 Mechanisms by which children and/or pregnant women will be specifically targeted by the action are explicitly stated ** 9 Minimum of two actions ** (42) The policy is supported by evidence of external consistency in logically drawing a health outcome from the goals and policy outcome The policy is supported by internal validity in logically drawing a health outcome from the goals and policy outcome 10 Actions comprehensively address climate-sensitive health risks identified in policy background ** (41) resources 11 Financial resources addressed * The cost of condition to community has been mentioned - estimated financial resources for implementation of the action/s given - allocated financial resources for implementation of the action/s clear - rewards/sanctions for spending allocated resources on other programs 12 Human resources addressed 13 Organisational capacity addressed 14 Policy indicated strategies to mobilise required resources** (41) monitoring and evaluation 15 Policy indicated monitoring and evaluation mechanisms to track progress on goals for child health* 16 Policy nominated a committee or independent body to do evaluation 17 Outcome measures identified for each of the explicit and implicit objectives 18 Data for evaluation will be collected before, during, and after introduction of the new policy 19 Follow-up takes place after sufficient period to allow the effects of policy change to become evident 20 Other factors that could have produced the change (other than policy) identified 21 Criteria for evaluation adequate or clear Public opportunities Obligations implementation* 22 Multiple stakeholders involved in the design and implementation of the action/s * Primary concerns of stakeholders are recognised and acknowledged to obtain long-term support 23 Obligations of the various implementers specified – who has to do what? Scientific results are compelling for action * reworded or altered items ** new items excluded items italicised items adapted from the World Health Organization criteria (41) and Paz-Soldán et al. (42) indicated RESULTS Climate-change policies worldwide had ineffective planning to safeguard child health, with 43% of countries obtaining a score of 0 (no mention of child health). Thirty-eight per cent of countries achieved a score of 1–3; these generally acknowledged the disproportionate health burden on children without providing any goals or actions. Low- and middle-income countries performed better than high-income countries, noticeably in South America, sub-Saharan Africa, and South Asia (Figure 1). Policy backgrounds were the strongest areas overall, while most policies fulfilled no criteria in Resources and Monitoring and evaluation (Figure 2). No policies were strong (fulfilled all criteria) across all policy determinants (Table 2). We provide a full list of policies evaluated and explanations for their scores in Supplementary File 2. Policy background About half of the policies recognised that children were disproportionately affected by climate change, referring to them as a vulnerable group. The most common climate risks identified (Figure 3) were malnutrition and food insecurity ( n = 40), heat-related illnesses ( n = 36), and extreme weather events ( n = 30). The least-common areas were displacement and forced migration ( n = 3) and noncommunicable diseases ( n = 5). Low- and middle-income countries focused on malnutrition, and food-, water-, and vector-borne diseases. High-income countries focused on heat-related illnesses (Figure 4). Where explicitly stated, the sources of policy backgrounds included multi-level stakeholder consultations, scientific articles, World Health Organization or UNICEF data, government publications, and vulnerability assessments. Goals Goals were rarely specific enough to be evaluated later for success. Only four countries described measurable child health outcomes, including malnutrition and diarrhoea (Sudan), childhood asthma (Virgin Islands), and general morbidity and mortality (India and Argentina). Child health goals in low ( n = 4), lower middle- ( n = 5), and upper middle-income countries ( n = 4) focused on improving health care, disaster-risk management, knowledge of health impacts, adaptive capacity, or physical and mental resilience, and reducing morbidity, mortality, violence against women and girls, or preventing harm. Goals rarely described specific climate-related health risks — where present, these included malnutrition, diarrhoeal disease, and extreme weather. High-income countries ( n = 2) pledged to improve healthcare for vulnerable groups, including children, and to decrease general climate-related health impacts. Forty-seven countries described actions that we categorised into ( i ) research and surveillance, ( ii ) provision of health resources, ( iii ) infrastructure, ( iv ) social services, ( v ) nutritional interventions, ( vi ) empowerment of youth, ( vii ) communication, and ( viii ) empowerment of women. Actions could be categorised into multiple themes. Communication of climate-related health information was the most common theme ( n = 26) (Figure 5). The provision of health resources, social services, research and surveillance programs and nutritional interventions was concentrated in low- and middle- income countries (Figure 6). High-income countries rarely described actions apart from communication strategies. We provide summaries of each category below. i. Communication Communication of climate-related health risks and adaptation behaviours was commonly described across all country income categories. In low- and middle-income countries, health information was communicated via social media campaigns, documentaries, exhibitions, libraries, brochures, television and radio shows, advocacy by community groups, school curricula, and demonstrations. Where the health information topics were specified, they mainly related to nutrition (dietary guidelines, nutritional deficiencies, and/or gastro-intestinal infections). Other topics included disaster preparedness and biomass smoke exposure within the home. The development of emergency response monitoring and communication systems for extreme weather events was also described. Information was targeted to women, school students, and primary healthcare personnel. In high-income countries, communication strategies included school initiatives, websites, webinars, and integration of health information in the early education curriculum. Specific topics included extreme weather alerts (particularly for heatwaves), natural hazards, and disaster-risk management targeted to parents and school students. ii . Research and surveillance Low- and lower middle-income countries described strengthening information-management systems for child health outcomes. Some outlined regular nutritional screening of children as well as pregnant and lactating women. Upper middle-income countries pledged to evaluate various health indicators ranging from vector-, food-, and water-borne diseases, extreme temperature exposure, food insecurity, impacts on medical infrastructure and the public health system, and healthy practices (unspecified). Japan was the only high-income country to address this theme, describing increasing scientific knowledge about the health effects of climate change on vulnerable populations (including children). iii. Social services Various social services and welfare programs were outlined in low- and lower middle-income countries. These included livelihood diversification, improved access to financial safety nets and insurance, free healthcare for mothers and children, and agribusiness enhancement to ensure food security and income generation. Lithuania was the only high-income country to describe social services that included subsidised tick-borne encephalitis vaccination for people under 18 years old, as well as free public transport for students (although this was not explicitly linked to child health). iv. Infrastructure No low-income countries outlined actions relating to infrastructure. Middle-income countries described the construction of climate-resilient emergency shelters and healthcare facilities, and retrofitting school buildings with insulation. Two high-income countries provided actions — Austria pledged to improve the climate-resilience of schools via shading solutions and drinking water fountains, and South Korea described retrofitting residential buildings with insulation. v. Nutritional interventions Interventions to improve food security were concentrated in low- and lower middle-income countries. These included the implementation or scale-up of feeding programmes and guidelines, actions to diversify household diets, the expansion and promotion of fortified food consumption, and the enhancement of crop quality and harvesting techniques. Paraguay (upper middle income) described the construction of agroecological gardens in schools. Lithuania was the only high-income country to include a nutritional intervention: the expansion and promotion of organic products at pre-school education establishments. vi. Empowerment of women Some policies linked improvements in child health to female empowerment, due to the disproportionate burden of childcare and household management faced by women. These were predominantly from low- and lower middle-income countries in sub-Saharan Africa. Cross-sectoral actions to reduce personal risk for women and girls in search of clean water were described, such as improving access to clean water and sanitation facilities and implementing local rainwater harvesting. Other actions included establishing a helpline for reporting gender-based violence and child marriage during and after disasters, training women in agricultural practices, providing access to enterprise funds, increasing income-generating opportunities, and generating gender-disaggregated indicators to improve emergency medical services. One upper middle-income country (Botswana) aimed to ensure the full participation of women and female-headed households in disaster management public gatherings. No high-income countries made commitments for empowering women. vii. Provision of health resources Provision of equipment, implements, and medicines was only in low- and lower middle-income countries. Specific resources included energy-saving cooking stoves in rural households and emergency kits. Burkina Faso was the only country to provide preventive malaria treatment for pregnant women and children. Cameroon intensified vaccine distribution programmes for a range of climate-affected diseases (diarrhoea, cholera, measles, typhoid, and others). viii. Empowerment of youth Three lower middle-income countries facilitated the participation of children and young people in disaster risk management initiatives — for example, by establishing youth-led volunteer groups for emergency response, rescue, and evacuation during disasters (Bangladesh). No other specific mechanisms were stated. Resources Only nine countries stated the estimated or allocated financial resources for child-health actions, in the form of annual budgets or total estimated costs. No countries incentivised with rewards or imposed sanctions for spending the allocated resources on other programs. Human resources or organisational capacity was not addressed in any of the policies. Five low- and middle-income countries provided strategies to mobilise the allocated financial resources. Funding sources included government treasuries and international financing partners, such as the World Health Organization, United Nations International Children's Emergency Fund (UNICEF), and other United Nations agencies. Monitoring and evaluation Measurable child-health indicators were rarely included; where present, these included preterm birth, malnutrition, respiratory disease incidence, and hypertension or other comorbidity rates in pregnant people. Timelines for data collection were similarly rare ( n = 3), with follow-up occurring at one- or five-year intervals. Implementation Stakeholders involved in implementation included youth-led organisations, schoolteachers, various government departments, experts, senior policymakers, media companies, community organisations, and faith-based organisations. The responsibilities of individual implementers were rarely defined. DISCUSSION National climate-change policies worldwide lack adequate planning to adapt to the harms of climate change on child health and evidence that existing policies are effective. This was clearly visible in the poor quality of policies across all determinant areas we assessed. Around two in five policies did not make any reference to child health. Policies lacked time-sensitive goals to improve specific child-health outcomes, as well as age-disaggregated monitoring mechanisms for health, leading to unclear indicators for success. Policies that indicated child health goals and/or actions rarely addressed resource allocation or stakeholder responsibilities, creating a lack of accountability for policy implementation. The lack of monitoring and evaluation means that the impact of current policy interventions, where present, is unknown. Existing policies might therefore be sub-optimal, or even ineffective. The state of national policies in the context of current climate change literature highlights the inequity of this issue. The current literature largely focuses on the impacts of climate change on health, and less so on adaptation strategies (240). Studies on adaptation interventions for children are even more limited and of inconsistent quality (241). National policy action to improve child health is similarly limited, with poor performance across all policy dimensions we examined in this study. This indicates that children are under-prioritised in both research and policy despite being the most affected by the long-term impacts of climate change. It also suggests that current policy interventions are largely based on opinion, due to the lack of scientific evidence as well as monitoring and evaluation mechanisms. Further inequities arise when observing the geographical distribution of literature and policy actions. High-income countries are taking the least policy action despite being overrepresented in research, representing 41% of studies on child-health interventions (241), but comprising 32% of countries. In contrast, low- and middle-income countries place a greater priority on child health in policy, while having the lowest access to scientific evidence to implement successful interventions (241). Children in these countries face the worst health effects of climate change due to poorer infrastructure, limited access to resources, and heightened exposure to extreme weather events (29). Without robust scientific evidence to guide policy translation, the child health disparities between high-income and low- and middle-income countries will remain unaddressed and likely grow. Limitations For each country, we assessed one national climate change policy that was most relevant to health adaptation. However, additional adaptation activities could have been included in local-level policies or policies not explicitly focussed on climate change. Nonetheless, it is beneficial for adaptation activities to be centralised within one national policy to establish clear commitments for child-health protection. We translated non-English policies ( n = 58) using DeepL (242) when no English translation was available, which might have produced errors. Recommendations Policy background: Policies should provide comprehensive coverage of child-health risks specific for their region. A national vulnerability and adaptation assessment can identify current and future health risks and adaptation options, while considering the unique vulnerabilities faced by children (41) (Fig. 7). The data collected must be age-disaggregated to capture these vulnerabilities. Evaluating the magnitude of each health risk can determine the highest-priority areas to guide resource allocation, which is especially useful for resource-limited settings (41). Case Study 1: Third National Communication of Yemen (235) Yemen did a national vulnerability and adaptation assessment and identified vulnerable populations (including children), climatic factors affecting each group, health effects, and overall impact. They analysed Demographic and Health Surveys data (243), and developed structured interviews targeting leaders in the Ministry of Public Health and Population to address the limitations of health data within the region. The assessment identified increased temperatures as a major climatic risk factor with a moderate to high impact on under-5 malnutrition. Consultations continued to develop strategies to build resilience in vulnerable groups. These included establishing an epidemiological surveillance system, enhancing disaster preparedness, and improving healthcare access and capacity. This assessment prioritised the health of vulnerable populations and identified the greatest-priority health risks to guide resource allocation in a low-income setting. Goals Goals to improve child health would be more likely to be met if they are specific, measurable, achievable, realistic/relevant, and timed (SMART) (244), combined with a clear action plan (245). A national vulnerability and adaptation assessment (246) should guide the design of realistic goals that consider resource constraints and other determinants (41). Several goals set at regular intervals might be helpful to provide direction for continuous improvement of health. Policy actions should be evidence-based — monitoring and evaluation mechanisms can guide the regular review of actions (247) given the scarcity of literature. National-, state-, and local-scale actors should be consulted to address various intersectional factors (248). Actions should comprehensively address the climate risks relevant to each country (41). Case Study 2: 2023–2050 National Adaptation Plan (Bangladesh) (68) Bangladesh described extensive actions that focused on disaster-risk management and improving well-being. Under each action, specific mechanisms were outlined to target children and pregnant women: provide lactation and maternal facilities in climate-resilient shelters; develop youth-led volunteer groups for emergency response; update the education curriculum to raise awareness of the effects of climate change on abuse, early marriage, and domestic violence, and adaptive mechanisms; enforce laws against domestic violence and child abuse; expand green space and sports initiatives; and improve emergency neonatal services. The descriptions of specific mechanisms ensure that the unique challenges faced by children are addressed. The actions were associated with goals to improve the health of the general population, but the policy would be strengthened by providing child-specific goals. Resources Policies should provide estimated/allocated financial resources for each child-health action (41). They should consider rewards or sanctions for spending allocated resources on other programs, which can affect their likelihood of success (35). Importantly, policies should state the human resources and organisational capacity required for implementation (41). They should outline a plan to mobilise the required resources, including funding sources, which is especially pertinent in low- and middle-income regions to maximise impact within resource constraints (41). Case Study 3: Health National Adaptation Plan for 2020–2024 (Timor-Leste) (197) Timor-Leste provided a yearly budget for each year of the policy implementation period (2020–2024). US$20,000 and US$30,000 were allocated for the provision of food supplies to pregnant women, and the education of school students, respectively. Funding sources included the World Health Organization, Open Grid Europe, and the Global Environmental Facility. The policy would be improved by specifying the human resources and organisational capacity required for implementation. Monitoring and Evaluation Detailed monitoring and evaluation plans should be provided within policies (41). Indicators that directly measure child health outcomes should be provided (e.g., mortality rates, asthma incidence rates). Data should be collected before, during, and after policy implementation to evaluate progress from the baseline. Data should be collected regularly after a sufficient period to allow the effects of policy to be realised depending on the context (247). The data should be used for continuous policy review, leading to increased accountability and progressive improvement of interventions (247-249). Case Study 4: National Adaptation Plan 2021–2050 (Nepal) (91) Nepal described a monitoring and evaluation plan with age- and gender-disaggregated data to capture the different impacts of adaptation actions on vulnerable groups. Targets for improved water and sanitation services are provided at five-yearly intervals from 2030–2050, and represent continuous improvement over the policy implementation period. Outcomes are measured by the percentage of the population targeted and the number of activities. The plan would be strengthened if child-health outcomes are measured directly. Data should have been collected before the introduction of the policy in 2021 to provide a baseline for comparison. Implementation Policy implementation should involve coordination of actors, institutions, and levels of governance, which can increase their impact and mitigate unintended negative impacts on health equity (250). The Ministry of Health (or equivalent government department) should lead these efforts, providing necessary sector-specific expertise and ensuring that actions are effectively embedded in the health sector (41). The obligations of individual implementers should be specified to create clear expectations. A strong implementation strategy would reduce the time lag between research and translation, and optimise resource use to support evidence-based practices (248). Case Study 5: National Programme on Climate Change & Human Health (India) (202) India outlined various actions to raise awareness of health risks, detect diseases and improve nutrition in children. The actions were designed after four regional consultations with states and Union Territories in 2017–2018. These consultations had participants from health and non-health departments, as well as representatives from the World Health Organization and research institutions. The nodal department/ministry and suggested supporting departments were listed under each action, and a breakdown of the responsibilities of each implementer was provided. For example, to address respiratory diseases, the health sector was nominated to map vulnerabilities, strengthen surveillance, and develop a case management and resource plan. The Ministry of Human Resource Development was nominated as a supporting actor, with the responsibility for health education and regular disease screening in schools. This clear delegation of responsibilities ensures a synergistic approach across government departments (250). The consultation and coordination with a diverse range of stakeholders improves health equity by considering the environmental, economic and social dimensions unique to children (250). The policy would be improved if children were explicitly involved as active stakeholders throughout this process (33). Conclusion Policies must strengthen planning for child health across all policy dimensions to create sustainable improvements amid the accelerating climate crisis. Children must be explicitly prioritised as major stakeholders and they and/or their parents or caregivers should be active participants throughout policy development. Policies should provide age-sensitive health-improvement goals and associated action plans; national vulnerability and adaptation assessments could provide guidance for each region on what health areas to prioritise. Governments should allocate financial and human resources for child-health interventions, and should strategise methods to mobilise these resources, which would improve the likelihood of implementation. The responsibilities of implementers should be clearly defined to increase accountability. It is important for low- and middle-income countries to be supported in policy development because they have fewer resources and access to published scientific evidence to guide interventions, despite facing the worst effects of climate change. High-income countries must place a greater priority on child health because they have weaker policy design across all determinants assessed. Adopting a holistic approach to strengthen adaptation policy will enable effective translation to protect child health against the harms of climate change. Declarations Clinical trial number: Not applicable. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Availability of data and materials: All data generated or analysed during this study are included in this published article and its supplementary information files. Competing interests: The authors declare that they have no competing interests. Funding : Not applicable. Authors’ contributions: JU: conceptualisation, methodology, investigation, writing – original draft, writing – review & editing, visualisation.CJAB: writing – review & editing. PNLS: writing – review & editing. MAJ: conceptualisation, writing – review & editing, supervision. Acknowledgements : Future Child Health (futurechildhealth.org). References United Nations Framework Convention on Climate Change. 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Supplementary Files SupplementaryFile1.docx SupplementaryFile2.docx Table2.docx Cite Share Download PDF Status: Published Journal Publication published 12 Aug, 2025 Read the published version in Globalization and Health → Version 1 posted Editorial decision: Revision requested 09 Jul, 2025 Reviews received at journal 16 Jun, 2025 Reviewers agreed at journal 05 Jun, 2025 Reviewers invited by journal 22 May, 2025 Editor assigned by journal 22 May, 2025 Submission checks completed at journal 22 May, 2025 First submitted to journal 15 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6670422","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":458028945,"identity":"6df85822-8879-4c89-9db1-f2ba403f9aae","order_by":0,"name":"Jhermayne Ubalde","email":"data:image/png;base64,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","orcid":"","institution":"University of Western Australia","correspondingAuthor":true,"prefix":"","firstName":"Jhermayne","middleName":"","lastName":"Ubalde","suffix":""},{"id":458028946,"identity":"ac1a6968-4a4e-48cd-8e5d-4a57ddc41b5b","order_by":1,"name":"Corey J. A. Bradshaw","email":"","orcid":"","institution":"Flinders University","correspondingAuthor":false,"prefix":"","firstName":"Corey","middleName":"J. A.","lastName":"Bradshaw","suffix":""},{"id":458028947,"identity":"585f1b5b-eb75-42e8-a883-f71628424d15","order_by":2,"name":"Peter N. Le Souëf","email":"","orcid":"","institution":"The Kids Research Institute Australia","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"N. Le","lastName":"Souëf","suffix":""},{"id":458028948,"identity":"50412bac-9ca9-4a9d-bda9-0bbc93fa3005","order_by":3,"name":"Melinda A. Judge","email":"","orcid":"","institution":"The Kids Research Institute Australia","correspondingAuthor":false,"prefix":"","firstName":"Melinda","middleName":"A.","lastName":"Judge","suffix":""}],"badges":[],"createdAt":"2025-05-15 08:23:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6670422/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6670422/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12992-025-01142-3","type":"published","date":"2025-08-12T15:56:58+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":83292784,"identity":"c78ed296-8e2c-40e0-9b2c-eca07643f587","added_by":"auto","created_at":"2025-05-22 13:21:00","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":64272,"visible":true,"origin":"","legend":"\u003cp\u003eGlobal distribution of climate-change policy scores for child health adaptation.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6670422/v1/639b5f85a41754beff65a632.jpg"},{"id":83294546,"identity":"1868721b-e956-464b-a451-1461f247fbee","added_by":"auto","created_at":"2025-05-22 13:37:00","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":58037,"visible":true,"origin":"","legend":"\u003cp\u003ePercentage of countries that fulfil none of the scored criteria (\u003cem\u003eweak\u003c/em\u003e), some criteria (\u003cem\u003eneeds\u003c/em\u003e \u003cem\u003eimprovement\u003c/em\u003e) or all criteria (\u003cem\u003estrong\u003c/em\u003e) across each policy determinant area.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6670422/v1/12dd3ae0db10a9a19a25fbb2.jpg"},{"id":83292791,"identity":"a5868f2e-7e52-442e-a2b3-30d04578e347","added_by":"auto","created_at":"2025-05-22 13:21:00","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":71993,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of countries that identified specific climate-sensitive health risks for children in their policy backgrounds.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6670422/v1/f9c3f25ea61a95aaf76ffda6.jpg"},{"id":83294085,"identity":"8e7027fd-c73f-481d-b5c5-0fa83981c530","added_by":"auto","created_at":"2025-05-22 13:29:00","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":160522,"visible":true,"origin":"","legend":"\u003cp\u003eGlobal distribution of climate risks disproportionately affecting children identified in policy backgrounds. We categorised risks into (a) malnutrition and food insecurity, (b) heat, (c) extreme weather events, (d) respiratory illnesses, (e) food- and water-borne diseases, (f) vector-borne diseases, (g) impacts on health care systems and infrastructure, (h) mental and psychosocial health, (i) noncommunicable diseases, (j) displacement and forced migration.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6670422/v1/e2381a67374298d663247466.jpg"},{"id":83294083,"identity":"d5ec09a7-4c07-420d-8584-0c0199aa7278","added_by":"auto","created_at":"2025-05-22 13:29:00","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":47543,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of countries that identified actions to protect child health.\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6670422/v1/6993743b1e31b6e00b4fd4ad.jpg"},{"id":83292796,"identity":"a93dc6ed-02d7-4662-9ff1-f7ee4d549277","added_by":"auto","created_at":"2025-05-22 13:21:00","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":121156,"visible":true,"origin":"","legend":"\u003cp\u003eGlobal distribution of policy actions to improve child health categorised into (a) communication, (b) research and surveillance, (c) social services, (d) infrastructure, (e) nutritional interventions, (f) empowerment of women, (g) provision of health resources, (h) empowerment of youth.\u003c/p\u003e","description":"","filename":"6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6670422/v1/0f1c3725c360d71d9d5ea920.jpg"},{"id":83292794,"identity":"7841aa70-6ad5-4b57-9253-e81da3255f13","added_by":"auto","created_at":"2025-05-22 13:21:00","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":109273,"visible":true,"origin":"","legend":"\u003cp\u003eProcess for a child-sensitive national vulnerability and adaptation assessment, adapted from the World Health Organization (2021) (41) and UNICEF (2021) (33).\u003c/p\u003e","description":"","filename":"7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6670422/v1/0514d92001a93aaa449f3dc4.jpg"},{"id":89310501,"identity":"b49611cc-362e-4d55-860f-2730e38d9426","added_by":"auto","created_at":"2025-08-18 16:04:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1444694,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6670422/v1/29734af2-8083-427c-9de7-285998c34199.pdf"},{"id":83292788,"identity":"6445330c-a875-4811-9113-416eed55f89f","added_by":"auto","created_at":"2025-05-22 13:21:00","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":25315,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6670422/v1/9fbfcc3191a02d3814f36ab6.docx"},{"id":83294084,"identity":"eddf452c-fa6a-42bc-94b2-40280cfe13c0","added_by":"auto","created_at":"2025-05-22 13:29:00","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":942099,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6670422/v1/a1b6e935fd269cca2ec2af01.docx"},{"id":83292785,"identity":"4f3d3e03-30af-481e-98d7-ee099f6060e5","added_by":"auto","created_at":"2025-05-22 13:21:00","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":60445,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6670422/v1/fcc060607b340e1bb1b38b62.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Climate change policies fail to protect child health","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eActive engagement of governments and stakeholders is necessary to adapt to the worsening climate crisis (1). As the increase in average global surface temperatures continues, humanity faces devastating impacts on health, livelihoods, and infrastructure (2). These impacts are not distributed equally \u0026mdash; children under five years old bear an estimated 88% of the additional disease burden caused by climate change (3). As the global human population grows, an increasing number of children will be exposed to lifelong health impacts on every organ system: these include adverse pregnancy outcomes (4, 5), respiratory illnesses (6\u0026ndash;13), food-, water- (14\u0026ndash;16) and vector-borne diseases (17), type 2 diabetes (18\u0026ndash;21), kidney damage (22, 23), heat-stroke organ failure (24, 25), and negative mental health effects (26). Climate change also induces long-term social and economic instability due to economic loss, forced displacement, violence, civil and armed conflict, and degraded environments, which exacerbate children\u0026rsquo;s vulnerability to health risks (26\u0026ndash;28). Low- and middle-income countries are the most severely affected, due to their increased exposure to extreme weather events, poorer infrastructure and political leadership, and lack of access to financial and social resources (29).\u003c/p\u003e \u003cp\u003eNational adaptation planning is necessary, with consideration of competing development needs, vulnerabilities, and existing plans of each region (30). The United Nations Framework Convention on Climate Change has published technical guidelines for national adaptation planning: successful planning should comprehensively assess available information on climate change impacts, critically appraise adaptation options, develop a long-term national adaptation implementation strategy with multilateral coordination between stakeholders, and evaluate success using iterative monitoring (30). Globally, adaptation commitments are integrated in national adaptation plans (30), nationally determined contributions (31), national communications (32), and other multisectoral policies. Policies must be child-sensitive by explicitly acknowledging their rights and holistically addressing their vulnerabilities across sectors (33).\u003c/p\u003e \u003cp\u003eEvaluating whether health policies are successful for improving health outcomes is essential, with recent progress in evaluating the prioritisation of child health within climate change policies. An analysis of 160 national climate change-adaptation plans found that they had limited recognition of and action on child health, and tended towards overly simplistic conceptualisations of children across age, social roles, genders, and agency (34). However, that review only examined themes and did not evaluate other policy determinants, such as policy backgrounds, goals, resource mobilisation, monitoring and evaluation frameworks, or stakeholder collaboration (35, 36). Furthermore, the specific adaptation commitments to address child health outlined in nationally determined contributions, national communications, and broad climate change strategies remain unexplored. The likely magnitude of impact and implementation is unclear. Our aim was therefore to consider a range of policy determinants to evaluate the effectiveness of adaptation planning for child health in national climate change policies worldwide.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThe question we aimed to answer was: how effectively do climate change-adaptation policies address child health worldwide? We collated each country\u0026rsquo;s most recent national climate change plan published up to 12 July 2024, systematically searching by country from the \u003cem\u003eUNFCCC National Adaptation Plan Ecosystem\u003c/em\u003e (37) and \u003cem\u003eNationally Determined Contribution Registry\u003c/em\u003e (38), \u003cem\u003eClimate Change Laws of the World\u003c/em\u003e database (39), and the \u003cem\u003eFood and Agricultural Organization of the United Nations\u003c/em\u003e database (40). The term \u0026lsquo;country\u0026rsquo; refers to any sovereign state, including areas and territories, where appropriate. We prioritised policies with a focus on health adaptation, followed by generalised adaptation policies, then nationally determined contributions, national communications, and national adaptation programmes of action, respectively to ensure that we collected the most up-to-date, relevant, and legally binding document for each country. We excluded all policies with a period of implementation that ended during or before 2023.\u003c/p\u003e \u003cp\u003eWe evaluated each policy using criteria (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) adapted from Cheung at al. (35), with some additional items adapted from the World Health Organization Quality Criteria for Health National Adaptation Plans (41) and Paz-Sold\u0026aacute;n \u003cem\u003eet al.\u003c/em\u003e (42). We assigned each policy a quality score based on the number of items achieved from the checklist (0\u0026ndash;23). We also assigned quality levels to each policy for all determinant areas: an area was \u003cem\u003eweak\u003c/em\u003e if no criteria were fulfilled, \u003cem\u003eneeds improvement\u003c/em\u003e if some were fulfilled, and \u003cem\u003estrong\u003c/em\u003e if all were fulfilled (35). To identify relevant information, we searched for key words relating to children (\u0026lsquo;child\u0026rsquo;, \u0026lsquo;infant\u0026rsquo;, \u0026lsquo;pregnant\u0026rsquo;, \u0026lsquo;young\u0026rsquo;, \u0026lsquo;youth\u0026rsquo;) and read sections on health in full. We provide a comprehensive explanation justifying the changes made to the original Cheung et al. (35) criteria in Supplementary File 1.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCriteria for evaluation of climate change-policy determinants for child health adaptation.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeterminant area\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-items\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCriteria\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAccessibility\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ePolicy document is accessible (hard-copy and online)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003epolicy background\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChildren recognised as disproportionately affected by the impacts of climate change\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinimum of two context-specific climate-sensitive health risks for children identified\u003csup\u003e**\u003c/sup\u003e (42)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSource of background is explicit*\u003c/p\u003e \u003cp\u003e- authority (one or more persons, books, scientific articles or sources of information)\u003c/p\u003e \u003cp\u003e- quantitative or qualitative analysis\u003c/p\u003e \u003cp\u003e- deduction (premises that have been established from authority, observation, intuition or all three)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eThe policy encompasses some set of feasible alternatives\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003egoals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGoals for child health explicitly stated\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGoals are concrete enough (quantitative where possible and qualitative where not) to be evaluated later\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGoal is clear in its intent and in the mechanism with which to achieve the desired goals, yet does not attempt to prescribe in detail what the change must be\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAction/s outlined to improve child health\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMechanisms by which children and/or pregnant women will be specifically targeted by the action are explicitly stated\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMinimum of two actions\u003csup\u003e**\u003c/sup\u003e (42)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eThe policy is supported by evidence of external consistency in logically drawing a health outcome from the goals and policy outcome\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eThe policy is supported by internal validity in logically drawing a health outcome from the goals and policy outcome\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eActions comprehensively address climate-sensitive health risks identified in policy background\u003csup\u003e**\u003c/sup\u003e (41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eresources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFinancial resources addressed\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eThe cost of condition to community has been mentioned\u003c/em\u003e\u003c/p\u003e \u003cp\u003e- estimated financial resources for implementation of the action/s given\u003c/p\u003e \u003cp\u003e- allocated financial resources for implementation of the action/s clear\u003c/p\u003e \u003cp\u003e- rewards/sanctions for spending allocated resources on other programs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHuman resources addressed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOrganisational capacity addressed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePolicy indicated strategies to mobilise required resources** (41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003emonitoring and evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePolicy indicated monitoring and evaluation mechanisms to track progress on goals for child health*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePolicy nominated a committee or independent body to do evaluation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOutcome measures identified for each of the explicit and implicit objectives\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eData for evaluation will be collected before, during, and after introduction of the new policy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFollow-up takes place after sufficient period to allow the effects of policy change to become evident\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOther factors that could have produced the change (other than policy) identified\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCriteria for evaluation adequate or clear\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cem\u003ePublic opportunities\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eObligations\u003c/em\u003e\u003c/p\u003e \u003cp\u003eimplementation*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultiple stakeholders involved in the design and implementation of the action/s\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ePrimary concerns of stakeholders are recognised and acknowledged to obtain long-term support\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObligations of the various implementers specified \u0026ndash; who has to do what?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eScientific results are compelling for action\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003e*\u003c/sup\u003ereworded or altered items\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003e**\u003c/sup\u003enew items\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eexcluded items italicised\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eitems adapted from the World Health Organization criteria (41) and Paz-Sold\u0026aacute;n et al. (42) indicated\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eClimate-change policies worldwide had ineffective planning to safeguard child health, with 43% of countries obtaining a score of 0 (no mention of child health). Thirty-eight per cent of countries achieved a score of 1\u0026ndash;3; these generally acknowledged the disproportionate health burden on children without providing any goals or actions. Low- and middle-income countries performed better than high-income countries, noticeably in South America, sub-Saharan Africa, and South Asia (Figure 1). \u003cem\u003ePolicy backgrounds\u0026nbsp;\u003c/em\u003ewere the strongest areas overall, while most policies fulfilled no criteria in \u003cem\u003eResources\u003c/em\u003e and \u003cem\u003eMonitoring and evaluation\u0026nbsp;\u003c/em\u003e(Figure 2). No policies were strong (fulfilled all criteria) across all policy determinants (Table 2). We provide a full list of policies evaluated and explanations for their scores in Supplementary File 2.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePolicy background\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAbout half of the policies recognised that children were disproportionately affected by climate change, referring to them as a vulnerable group. The most common climate risks identified (Figure 3) were malnutrition and food insecurity (\u003cem\u003en\u003c/em\u003e = 40), heat-related illnesses (\u003cem\u003en\u003c/em\u003e = 36), and extreme weather events (\u003cem\u003en\u003c/em\u003e = 30). The least-common areas were displacement and forced migration (\u003cem\u003en\u003c/em\u003e = 3) and noncommunicable diseases (\u003cem\u003en\u003c/em\u003e = 5). Low- and middle-income countries focused on malnutrition, and food-, water-, and vector-borne diseases. High-income countries focused on heat-related illnesses (Figure 4).\u003c/p\u003e\n\u003cp\u003eWhere explicitly stated, the sources of policy backgrounds included multi-level stakeholder consultations, scientific articles, World Health Organization or UNICEF data, government publications, and vulnerability assessments.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eGoals\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGoals were rarely specific enough to be evaluated later for success. Only four countries described measurable child health outcomes, including malnutrition and diarrhoea (Sudan), childhood asthma (Virgin Islands), and general morbidity and mortality (India and Argentina).\u003c/p\u003e\n\u003cp\u003eChild health goals in low (\u003cem\u003en\u003c/em\u003e = 4), lower middle- (\u003cem\u003en\u003c/em\u003e = 5), and upper middle-income countries (\u003cem\u003en\u003c/em\u003e = 4) focused on improving health care, disaster-risk management, knowledge of health impacts, adaptive capacity, or physical and mental resilience, and reducing morbidity, mortality, violence against women and girls, or preventing harm. Goals rarely described specific climate-related health risks \u0026mdash; where present, these included malnutrition, diarrhoeal disease, and extreme weather. High-income countries (\u003cem\u003en\u003c/em\u003e = 2) pledged to improve healthcare for vulnerable groups, including children, and to decrease general climate-related health impacts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eForty-seven countries described actions that we categorised into (\u003cem\u003ei\u003c/em\u003e) research and surveillance, (\u003cem\u003eii\u003c/em\u003e) provision of health resources, (\u003cem\u003eiii\u003c/em\u003e) infrastructure, (\u003cem\u003eiv\u003c/em\u003e) social services, (\u003cem\u003ev\u003c/em\u003e) nutritional interventions, (\u003cem\u003evi\u003c/em\u003e) empowerment of youth, (\u003cem\u003evii\u003c/em\u003e) communication, and (\u003cem\u003eviii\u003c/em\u003e)\u003cem\u003e\u0026nbsp;\u003c/em\u003eempowerment of women. Actions could be categorised into multiple themes. Communication of climate-related health information was the most common theme (\u003cem\u003en\u0026nbsp;\u003c/em\u003e= 26) (Figure 5). The provision of health resources, social services, research and surveillance programs and nutritional interventions was concentrated in low- and middle- income countries (Figure 6). High-income countries rarely described actions apart from communication strategies.\u003c/p\u003e\n\u003cp\u003eWe provide summaries of each category below.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ei. Communication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCommunication of climate-related health risks and adaptation behaviours was commonly described across all country income categories. In low- and middle-income countries, health information was communicated via social media campaigns, documentaries, exhibitions, libraries, brochures, television and radio shows, advocacy by community groups, school curricula, and demonstrations. Where the health information topics were specified, they mainly related to nutrition (dietary guidelines, nutritional deficiencies, and/or gastro-intestinal infections). Other topics included disaster preparedness and biomass smoke exposure within the home. The development of emergency response monitoring and communication systems for extreme weather events was also described. Information was targeted to women, school students, and primary healthcare personnel.\u003c/p\u003e\n\u003cp\u003eIn high-income countries, communication strategies included school initiatives, websites, webinars, and integration of health information in the early education curriculum. Specific topics included extreme weather alerts (particularly for heatwaves), natural hazards, and disaster-risk management targeted to parents and school students.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eii\u003c/em\u003e. \u003cem\u003eResearch and surveillance\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eLow- and lower middle-income countries described strengthening information-management systems for child health outcomes. Some outlined regular nutritional screening of children as well as pregnant and lactating women. Upper middle-income countries pledged to evaluate various health indicators ranging from vector-, food-, and water-borne diseases, extreme temperature exposure, food insecurity, impacts on medical infrastructure and the public health system, and healthy practices (unspecified). Japan was the only high-income country to address this theme, describing increasing scientific knowledge about the health effects of climate change on vulnerable populations (including children).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eiii. Social services\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eVarious social services and welfare programs were outlined in low- and lower middle-income countries. These included livelihood diversification, improved access to financial safety nets and insurance, free healthcare for mothers and children, and agribusiness enhancement to ensure food security and income generation. Lithuania was the only high-income country to describe social services that included subsidised tick-borne encephalitis vaccination for people under 18 years old, as well as free public transport for students (although this was not explicitly linked to child health).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eiv. Infrastructure\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNo low-income countries outlined actions relating to infrastructure. Middle-income countries described the construction of climate-resilient emergency shelters and healthcare facilities, and retrofitting school buildings with insulation. Two high-income countries provided actions \u0026mdash; Austria pledged to improve the climate-resilience of schools via shading solutions and drinking water fountains, and South Korea described retrofitting residential buildings with insulation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ev. Nutritional interventions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eInterventions to improve food security were concentrated in low- and lower middle-income countries. These included the implementation or scale-up of feeding programmes and guidelines, actions to diversify household diets, the expansion and promotion of fortified food consumption, and the enhancement of crop quality and harvesting techniques. Paraguay (upper middle income) described the construction of agroecological gardens in schools.\u003c/p\u003e\n\u003cp\u003eLithuania was the only high-income country to include a nutritional intervention: the expansion and promotion of organic products at pre-school education establishments.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003evi. Empowerment of women\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome policies linked improvements in child health to female empowerment, due to the disproportionate burden of childcare and household management faced by women. These were predominantly from low- and lower middle-income countries in sub-Saharan Africa. Cross-sectoral actions to reduce personal risk for women and girls in search of clean water were described, such as improving access to clean water and sanitation facilities and implementing local rainwater harvesting. Other actions included establishing a helpline for reporting gender-based violence and child marriage during and after disasters, training women in agricultural practices, providing access to enterprise funds, increasing income-generating opportunities, and generating gender-disaggregated indicators to improve emergency medical services. One upper middle-income country (Botswana) aimed to ensure the full participation of women and female-headed households in disaster management public gatherings. No high-income countries made commitments for empowering women.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003evii. Provision of health resources\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eProvision of equipment, implements, and medicines was only in low- and lower middle-income countries. Specific resources included energy-saving cooking stoves in rural households and emergency kits. Burkina Faso was the only country to provide preventive malaria treatment for pregnant women and children. Cameroon intensified vaccine distribution programmes for a range of climate-affected diseases (diarrhoea, cholera, measles, typhoid, and others).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eviii. Empowerment of youth\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThree lower middle-income countries facilitated the participation of children and young people in disaster risk management initiatives \u0026mdash; for example, by establishing youth-led volunteer groups for emergency response, rescue, and evacuation during disasters (Bangladesh). No other specific mechanisms were stated.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResources\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOnly nine countries stated the estimated or allocated financial resources for child-health actions, in the form of annual budgets or total estimated costs. No countries incentivised with rewards or imposed sanctions for spending the allocated resources on other programs. Human resources or organisational capacity was not addressed in any of the policies. Five low- and middle-income countries provided strategies to mobilise the allocated financial resources. Funding sources included government treasuries and international financing partners, such as the World Health Organization, United Nations International Children\u0026apos;s Emergency Fund (UNICEF), and other United Nations agencies.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMonitoring and evaluation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMeasurable child-health indicators were rarely included; where present, these included preterm birth, malnutrition, respiratory disease incidence, and hypertension or other comorbidity rates in pregnant people. Timelines for data collection were similarly rare (\u003cem\u003en\u003c/em\u003e = 3), with follow-up occurring at one- or five-year intervals.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eImplementation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStakeholders involved in implementation included youth-led organisations, schoolteachers, various government departments, experts, senior policymakers, media companies, community organisations, and faith-based organisations. The responsibilities of individual implementers were rarely defined.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eNational climate-change policies worldwide lack adequate planning to adapt to the harms of climate change on child health and evidence that existing policies are effective. This was clearly visible in the poor quality of policies across all determinant areas we assessed. Around two in five policies did not make any reference to child health. Policies lacked time-sensitive goals to improve specific child-health outcomes, as well as age-disaggregated monitoring mechanisms for health, leading to unclear indicators for success. Policies that indicated child health goals and/or actions rarely addressed resource allocation or stakeholder responsibilities, creating a lack of accountability for policy implementation. The lack of monitoring and evaluation means that the impact of current policy interventions, where present, is unknown. Existing policies might therefore be sub-optimal, or even ineffective.\u003c/p\u003e\n\u003cp\u003eThe state of national policies in the context of current climate change literature highlights the inequity of this issue. The current literature largely focuses on the impacts of climate change on health, and less so on adaptation strategies (240). Studies on adaptation interventions for children are even more limited and of inconsistent quality (241). National policy action to improve child health is similarly limited, with poor performance across all policy dimensions we examined in this study. This indicates that children are under-prioritised in both research and policy despite being the most affected by the long-term impacts of climate change. It also suggests that current policy interventions are largely based on opinion, due to the lack of scientific evidence as well as monitoring and evaluation mechanisms. Further inequities arise when observing the geographical distribution of literature and policy actions. High-income countries are taking the least policy action despite being overrepresented in research, representing 41% of studies on child-health interventions (241), but comprising 32% of countries. In contrast, low- and middle-income countries place a greater priority on child health in policy, while having the lowest access to scientific evidence to implement successful interventions (241). Children in these countries face the worst health effects of climate change due to poorer infrastructure, limited access to resources, and heightened exposure to extreme weather events (29). Without robust scientific evidence to guide policy translation, the child health disparities between high-income and low- and middle-income countries will remain unaddressed and likely grow.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor each country, we assessed one national climate change policy that was most relevant to health adaptation. However, additional adaptation activities could have been included in local-level policies or policies not explicitly focussed on climate change. Nonetheless, it is beneficial for adaptation activities to be centralised within one national policy to establish clear commitments for child-health protection. We translated non-English policies (\u003cem\u003en\u003c/em\u003e = 58) using DeepL (242) when no English translation was available, which might have produced errors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePolicy background:\u0026nbsp;\u003c/em\u003ePolicies should provide comprehensive coverage of child-health risks specific for their region. A national vulnerability and adaptation assessment can identify current and future health risks and adaptation options, while considering the unique vulnerabilities faced by children (41) (Fig. 7). The data collected must be age-disaggregated to capture these vulnerabilities. Evaluating the magnitude of each health risk can determine the highest-priority areas to guide resource allocation, which is especially useful for resource-limited settings (41).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCase Study 1: Third National Communication of Yemen (235)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYemen did a national vulnerability and adaptation assessment and identified vulnerable populations (including children), climatic factors affecting each group, health effects, and overall impact. They analysed \u003cem\u003eDemographic and Health Surveys\u003c/em\u003e data (243), and developed structured interviews targeting leaders in the Ministry of Public Health and Population to address the limitations of health data within the region. The assessment identified increased temperatures as a major climatic risk factor with a moderate to high impact on under-5 malnutrition.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;Consultations continued to develop strategies to build resilience in vulnerable groups. These included establishing an epidemiological surveillance system, enhancing disaster preparedness, and improving healthcare access and capacity. This assessment prioritised the health of vulnerable populations and identified the greatest-priority health risks to guide resource allocation in a low-income setting.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eGoals\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGoals to improve child health would be more likely to be met if they are specific, measurable, achievable, realistic/relevant, and timed (SMART) (244), combined with a clear action plan (245). A national vulnerability and adaptation assessment (246) should guide the design of realistic goals that consider resource constraints and other determinants (41). Several goals set at regular intervals might be helpful to provide direction for continuous improvement of health.\u003c/p\u003e\n\u003cp\u003ePolicy actions should be evidence-based \u0026mdash; monitoring and evaluation mechanisms can guide the regular review of actions (247) given the scarcity of literature. National-, state-, and local-scale actors should be consulted to address various intersectional factors (248). Actions should comprehensively address the climate risks relevant to each country (41).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCase Study 2: 2023\u0026ndash;2050 National Adaptation Plan (Bangladesh) (68)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eBangladesh described extensive actions that focused on disaster-risk management and improving well-being. Under each action, specific mechanisms were outlined to target children and pregnant women:\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eprovide lactation and maternal facilities in climate-resilient shelters;\u003c/li\u003e\n \u003cli\u003edevelop youth-led volunteer groups for emergency response;\u003c/li\u003e\n \u003cli\u003eupdate the education curriculum to raise awareness of the effects of climate change on abuse, early marriage, and domestic violence, and adaptive mechanisms;\u003c/li\u003e\n \u003cli\u003eenforce laws against domestic violence and child abuse;\u003c/li\u003e\n \u003cli\u003eexpand green space and sports initiatives; and\u003c/li\u003e\n \u003cli\u003eimprove emergency neonatal services.\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eThe descriptions of specific mechanisms ensure that the unique challenges faced by children are addressed. The actions were associated with goals to improve the health of the general population, but the policy would be strengthened by providing child-specific goals.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eResources\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePolicies should provide estimated/allocated financial resources for each child-health action (41). They should consider rewards or sanctions for spending allocated resources on other programs, which can affect their likelihood of success (35). Importantly, policies should state the human resources and organisational capacity required for implementation (41). They should outline a plan to mobilise the required resources, including funding sources, which is especially pertinent in low- and middle-income regions to maximise impact within resource constraints (41).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCase Study 3: Health National Adaptation Plan for 2020\u0026ndash;2024 (Timor-Leste) (197)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eTimor-Leste provided a yearly budget for each year of the policy implementation period (2020\u0026ndash;2024). US$20,000 and US$30,000 were allocated for the provision of food supplies to pregnant women, and the education of school students, respectively. Funding sources included the World Health Organization, Open Grid Europe, and the Global Environmental Facility. The policy would be improved by specifying the human resources and organisational capacity required for implementation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eMonitoring and Evaluation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDetailed monitoring and evaluation plans should be provided within policies (41). Indicators that directly measure child health outcomes should be provided (e.g., mortality rates, asthma incidence rates). Data should be collected before, during, and after policy implementation to evaluate progress from the baseline. Data should be collected regularly after a sufficient period to allow the effects of policy to be realised depending on the context (247). The data should be used for continuous policy review, leading to increased accountability and progressive improvement of interventions (247-249).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCase Study 4: National Adaptation Plan 2021\u0026ndash;2050 (Nepal) (91)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNepal described a monitoring and evaluation plan with age- and gender-disaggregated data to capture the different impacts of adaptation actions on vulnerable groups. Targets for improved water and sanitation services are provided at five-yearly intervals from 2030\u0026ndash;2050, and represent continuous improvement over the policy implementation period. Outcomes are measured by the percentage of the population targeted and the number of activities. The plan would be strengthened if child-health outcomes are measured directly. Data should have been collected before the introduction of the policy in 2021 to provide a baseline for comparison.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eImplementation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePolicy implementation should involve coordination of actors, institutions, and levels of governance, which can increase their impact and mitigate unintended negative impacts on health equity (250). The Ministry of Health (or equivalent government department) should lead these efforts, providing necessary sector-specific expertise and ensuring that actions are effectively embedded in the health sector (41). The obligations of individual implementers should be specified to create clear expectations. A strong implementation strategy would reduce the time lag between research and translation, and optimise resource use to support evidence-based practices (248).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCase Study 5: National Programme on Climate Change \u0026amp; Human Health (India) (202)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eIndia outlined various actions to raise awareness of health risks, detect diseases and improve nutrition in children. The actions were designed after four regional consultations with states and Union Territories in 2017\u0026ndash;2018. These consultations had participants from health and non-health departments, as well as representatives from the World Health Organization and research institutions.\u003c/p\u003e\n \u003cp\u003eThe nodal department/ministry and suggested supporting departments were listed under each action, and a breakdown of the responsibilities of each implementer was provided. For example, to address respiratory diseases, the health sector was nominated to map vulnerabilities, strengthen surveillance, and develop a case management and resource plan. The Ministry of Human Resource Development was nominated as a supporting actor, with the responsibility for health education and regular disease screening in schools.\u003c/p\u003e\n \u003cp\u003eThis clear delegation of responsibilities ensures a synergistic approach across government departments (250). The consultation and coordination with a diverse range of stakeholders improves health equity by considering the environmental, economic and social dimensions unique to children (250). The policy would be improved if children were explicitly involved as active stakeholders throughout this process (33).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePolicies must strengthen planning for child health across all policy dimensions to create sustainable improvements amid the accelerating climate crisis. Children must be explicitly prioritised as major stakeholders and they and/or their parents or caregivers should be active participants throughout policy development. Policies should provide age-sensitive health-improvement goals and associated action plans; national vulnerability and adaptation assessments could provide guidance for each region on what health areas to prioritise. Governments should allocate financial and human resources for child-health interventions, and should strategise methods to mobilise these resources, which would improve the likelihood of implementation. The responsibilities of implementers should be clearly defined to increase accountability. It is important for low- and middle-income countries to be supported in policy development because they have fewer resources and access to published scientific evidence to guide interventions, despite facing the worst effects of climate change. High-income countries must place a greater priority on child health because they have weaker policy design across all determinants assessed. Adopting a holistic approach to strengthen adaptation policy will enable effective translation to protect child health against the harms of climate change.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e All data generated or analysed during this study are included in this published article and its supplementary information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions:\u0026nbsp;\u003c/strong\u003eJU: conceptualisation, methodology, investigation, writing – original draft, writing – review \u0026amp; editing, visualisation.CJAB: writing – review \u0026amp; editing. PNLS: writing – review \u0026amp; editing. MAJ: conceptualisation, writing – review \u0026amp; editing, supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: Future Child Health (futurechildhealth.org).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eUnited Nations Framework Convention on Climate Change. Adaptation and resilience [Internet]. Bonn; 2024 [cited 2024 Aug 26]. Available from: https://unfccc.int/topics/adaptationand-resilience/the-big-picture/introduction.\u003c/li\u003e\n \u003cli\u003eLee H, Calvin K, Dasgupta D, Krinner G, Mukherji A, Thorne P, et al. Climate Change 2023: Synthesis Report. Geneva, Switzerland: Intergovernmental Panel on Climate Change; 2023.\u003c/li\u003e\n \u003cli\u003eUNICEF. Climate change [Internet]. Panama: UNICEF Latin American and the Caribbean Regional Office; 2024. 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Austria; 2017. 44\u003c/li\u003e\n \u003cli\u003eMinist\u0026egrave;re de l\u0026rsquo;Environnement, de l\u0026rsquo;Assainissement et du D\u0026eacute;veloppement Durable. Contribution D\u0026eacute;termin\u0026eacute;e au Niveau National R\u0026eacute;vis\u0026eacute;e. Mali; 2021.\u003c/li\u003e\n \u003cli\u003eGovernment of the Republic of Azerbaijan. Updated document on Nationally Determined Contributions (NDC). Azerbaijan; 2023.\u003c/li\u003e\n \u003cli\u003eMinistry for Resources and Rural Affairs. National Climate Change Adaptation Strategy. Malta; 2012.\u003c/li\u003e\n \u003cli\u003eNational Climate Change Committee. National Policy for the Adaptation to Climate Change. Bahamas; 2005.\u003c/li\u003e\n \u003cli\u003eGovernment of the Republic of the Marshall Islands. National Climate Change and Health Policy and Revised Action Plan. Marshall Islands; 2022.\u003c/li\u003e\n \u003cli\u003eSupreme Council for Environment. 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Nationally Determined Contribution of the Republic of Belarus to the reduction of greenhouse gas emissions until 2030. Belarus; 2021.\u003c/li\u003e\n \u003cli\u003eGovernment of the Federated States of Micronesia. Nationwide Integrated Disaster Risk Management and Climate Change Policy. Micronesia; 2013.\u003c/li\u003e\n \u003cli\u003eGovernment of Belgium. Vers une soci\u0026eacute;t\u0026eacute; r\u0026eacute;siliente au changement climatique \u0026agrave; l\u0026rsquo;horizon 2050. Belgium; 2023.\u003c/li\u003e\n \u003cli\u003eDirection de l\u0026rsquo;Environnement. Contribution D\u0026eacute;termin\u0026eacute;e au Niveau National De MONACO. Monaco; 2020.\u003c/li\u003e\n \u003cli\u003eCaribbean Community Climate Change Centre. A National Climate Change Policy, Strategy and Action Plan to Address Climate Change in Belize. Belize; 2014.\u003c/li\u003e\n \u003cli\u003eGovernment of Mongolia. National Action Programme on Climate Change. Mongolia; 2011. 45\u003c/li\u003e\n \u003cli\u003eMinist\u0026egrave;re du Cadre de Vie et du D\u0026eacute;veloppement Durable Direction G\u0026eacute;n\u0026eacute;rale de l\u0026rsquo;Environnement et du Climat (DGEC). Plan national d\u0026rsquo;adaptation aux changements climatiques du B\u0026eacute;nin. Benin; 2022.\u003c/li\u003e\n \u003cli\u003eGovernment of Montenegro. Climate Resilience Strategy and Action Plan. Montenegro; 2019.\u003c/li\u003e\n \u003cli\u003eNational Environment Commission. National Adaptation Plan (NAP) of the Kingdom of Bhutan. Bhutan; 2023.\u003c/li\u003e\n \u003cli\u003eMinist\u0026eacute;re de la Transition Energetique et du Developpement Durable. Plan National Strat\u0026eacute;gique d\u0026rsquo;Adaptation. Morocco; 2022.\u003c/li\u003e\n \u003cli\u003eMinisterio de Medio Ambiente y Agua. Nationally Determined Contribution (NDC) of the Plurinational State of Bolivia. Bolivia; 2021.\u003c/li\u003e\n \u003cli\u003eMinistry of Land and Environment. Mozambique National Adaptation Plan. Mozambique; 2023.\u003c/li\u003e\n \u003cli\u003eMinistry of Spatial Planning, Construction and Ecology of Republika Srpska. Bosnia and Herzegovina National Adaptation Plan \u0026ndash; NAP with proposed measures. Bosnia and Herzegovina; 2021.\u003c/li\u003e\n \u003cli\u003eMinistry of Natural Resources and Environmental Conservation. Myanmar Climate Change Master Plan (2018-2030). Myanmar; 2019.\u003c/li\u003e\n \u003cli\u003eGovernment of Botswana. A National Climate Change Action Plan for Botswana. Botswana; 2018.\u003c/li\u003e\n \u003cli\u003eMinistry of Environment \u0026amp; Tourism. National Policy on Climate Change for Namibia. Namibia; 2011.\u003c/li\u003e\n \u003cli\u003eMinistry of Environment. National Adaptation Plan to Climate Change. Brazil; 2016.\u003c/li\u003e\n \u003cli\u003eGovernment of the Republic of Nauru. Republic of Nauru Framework for Climate Change Adaptation and Disaster Risk Reduction. Nauru; 2015.\u003c/li\u003e\n \u003cli\u003eMinistry of Natural Resources and Labour. The Virgin Islands Climate Change Adaptation Policy. The Virgin Islands; 2012.\u003c/li\u003e\n \u003cli\u003eGovernment of Nepal. National Adaptation Plan of Nepal. Nepal; 2021.\u003c/li\u003e\n \u003cli\u003eBrunei Darussalam National Council on Climate Change. Brunei Darussalam National Climate Change Policy. Brunei Darussalam; 2020.\u003c/li\u003e\n \u003cli\u003eMinister of Infrastructure and the Environment. National Climate Adaptation Strategy 2016 (NAS). Netherlands; 2016.\u003c/li\u003e\n \u003cli\u003eGovernment of Bulgaria. National Climate Change Adaptation Strategy and Action Plan. Bulgaria; 2019. 46\u003c/li\u003e\n \u003cli\u003eMinistry for the Environment. Aotearoa New Zealand\u0026rsquo;s first national adaptation plan. New Zealand; 2022.\u003c/li\u003e\n \u003cli\u003eMinistry of Environment and Fishery Resources. Burkina Faso National Climate Change Adaptation Plan (NAP). Burkina Faso; 2015.\u003c/li\u003e\n \u003cli\u003eMinisterio del Ambiente y los Recursos Naturales. Contribuci\u0026oacute;n Nacionalmente Determinada de Nicaragua. Nicaragua; 2020.\u003c/li\u003e\n \u003cli\u003eMinistere de l\u0026rsquo;Environnement, de l\u0026rsquo;Agriculture et de l\u0026rsquo;Elevage. Plan National d\u0026rsquo;Adaptation Initial. Burundi; 2023.\u003c/li\u003e\n \u003cli\u003eConseil National de l\u0026rsquo;Environnement pour un Developpement Durable Secretariat Executif. Plan National d\u0026rsquo;Adaptation aux Changements Climatiques. Niger; 2022.\u003c/li\u003e\n \u003cli\u003eMinist\u0026eacute;rio da Agricultura e Ambiente. National Adaptation Plan of Cabo Verde. Cabo Verde; 2021.\u003c/li\u003e\n \u003cli\u003eGovernment of Nigeria. National Climate Change Policy for Nigeria 2021-2030. Nigeria; 2021.\u003c/li\u003e\n \u003cli\u003eThe General Secretariat of the National Council for Sustainable Development/Ministry of Environment. Cambodia\u0026rsquo;s Updated Nationally Determined Contribution. Cambodia; 2020.\u003c/li\u003e\n \u003cli\u003eGovernment of Niue. National Climate Change Policy. Niue; 2009.\u003c/li\u003e\n \u003cli\u003eMinistere de l\u0026rsquo;Environnement, de la Protection de la Nature et du Developpement Durable. Plan National d\u0026rsquo;Adaptation aux Changements Climatiques du Cameroun. Cameroon; 2015.\u003c/li\u003e\n \u003cli\u003eMinistry of Environment and Physical Planning. Long-term Strategy on Climate Action and Action Plan. North Macedonia; 2019.\u003c/li\u003e\n \u003cli\u003eEnvironment and Climate Change Canada. Canada\u0026rsquo;s National Adaptation Strategy. Canada; 2023.\u003c/li\u003e\n \u003cli\u003eGovernment of Norway. Strategi for klimatilpasning, forebygging av klimarelaterte katastrofer og sultbekjempelse. Norway; 2021.\u003c/li\u003e\n \u003cli\u003eMinist\u0026egrave;re de l\u0026rsquo;Environnement et du D\u0026eacute;veloppement Durable. Plan National Initial d\u0026rsquo;Adaptation aux Changements Climatiques de la R\u0026eacute;publique Centrafricaine. Central African Republic; 2022.\u003c/li\u003e\n \u003cli\u003eMinistry of Environment and Climate Affairs. National Strategy for Adaptation and Mitigation to Climate Change for the Sultanate of Oman (2020-2040). Oman; 2018.\u003c/li\u003e\n \u003cli\u003eGovernment of Chad. First National Climate Change Adaptation Plan of Chad. Chad; 2022.\u003c/li\u003e\n \u003cli\u003eMinistry of Climate Change \u0026amp; Environmental Coordination. National Adaptation Plan. Pakistan; 2023. 47\u003c/li\u003e\n \u003cli\u003eMinisterio del Medio Ambiente. Plan Nacional de Adaptaci\u0026oacute;n al Cambio Clim\u0026aacute;tico. Chile; 2014.\u003c/li\u003e\n \u003cli\u003eGovernment of Palau. Second National Communication. Palau; 2013.\u003c/li\u003e\n \u003cli\u003eChinese Ministry of Ecology and Environment. National Climate Change Adaptation Strategy 2035. China; 2022.\u003c/li\u003e\n \u003cli\u003eMinisterio de Ambiente. Contribuci\u0026oacute;n Determinada a Nivel Nacional de Panama (CDN1). Panama; 2020.\u003c/li\u003e\n \u003cli\u003eDepartamento Nacional de Planeaci\u0026oacute;n. Plan Nacional de Adaptaci\u0026oacute;n al Cambio Clim\u0026aacute;tico. Colombia; 2018.\u003c/li\u003e\n \u003cli\u003eClimate Change and Development Authority. Papua New Guinea National Adaptation Plan. Papua New Guinea; 2023.\u003c/li\u003e\n \u003cli\u003eMinist\u0026egrave;re de l\u0026rsquo;Agriculture, de la p\u0026ecirc;che, de l\u0026rsquo;Environnement, du Tourisme et de l\u0026rsquo;Artisanat. Contribution Determinee au Niveau National (CDN actualis\u0026eacute;e). Comoros; 2021.\u003c/li\u003e\n \u003cli\u003eMinisterio del Ambiente y Desarrollo Sostenible. Plan Nacional de Adaptaci\u0026oacute;n al Cambio Clim\u0026aacute;tico. Paraguay; 2022.\u003c/li\u003e\n \u003cli\u003eMinistere de l\u0026rsquo;Environnement, du Developpment Durable et du Bassin du Congo. Contribution Determinee au Niveau National (CDN) de la Republique du Congo. Republic of the Congo; 2021.\u003c/li\u003e\n \u003cli\u003eMinisterio del Ambiente. Plan Nacional de Adaptaci\u0026oacute;n al Cambio Clim\u0026aacute;tico del Per\u0026uacute;: un insumo para la actualizaci\u0026oacute;n de la Estrategia Nacional ante el Cambio Clim\u0026aacute;tico. Peru; 2021.\u003c/li\u003e\n \u003cli\u003eGovernment of the Cook Islands. Intended Nationally Determined Contributions. Cook Islands; 2016.\u003c/li\u003e\n \u003cli\u003eClimate Change Commission. National Adaptation Plan of the Philippines 2023-2050. Philippines; 2023.\u003c/li\u003e\n \u003cli\u003eMinisterio de Ambiente y Energ\u0026iacute;a. Plan Nacional de Adaptaci\u0026oacute;n al Cambio Clim\u0026aacute;tico. Costa Rica; 2022.\u003c/li\u003e\n \u003cli\u003eMinistry of the Environment. Polish National Strategy for Adaptation to Climate Change (NAS 2020). Poland; 2013.\u003c/li\u003e\n \u003cli\u003eGouvernement de C\u0026ocirc;te d\u0026apos;Ivoire. Contributions D\u0026eacute;termin\u0026eacute;es au niveau National (CDN) de la C\u0026ocirc;te d\u0026apos;Ivoire. C\u0026ocirc;te d\u0026apos;Ivoire; 2022.\u003c/li\u003e\n \u003cli\u003eMinist\u0026eacute;rio do Ambiente, Ordenamento do Territ\u0026oacute;rio e Energia. Estrat\u0026eacute;gia Nacional de Adapta\u0026ccedil;\u0026atilde;o \u0026agrave;s Altera\u0026ccedil;\u0026otilde;es Clim\u0026aacute;ticas. Portugal; 2015.\u003c/li\u003e\n \u003cli\u003eGovernment of the Republic of Croatia. Climate change adaptation strategy in the Republic of Croatia for the period up to 2040 with a view to 2070. Croatia; 2020.\u003c/li\u003e\n \u003cli\u003eState of Qatar. Nationally Determined Contribution. Qatar; 2021.\u003c/li\u003e\n \u003cli\u003eGobierno de Cuba. Primera Contribuci\u0026oacute;n Nacionalmente Determinada (Actualizada) Rep\u0026uacute;blica de Cuba. Cuba; 2020.\u003c/li\u003e\n \u003cli\u003eGovernment of the Republic of Korea. The Republic of Korea\u0026rsquo;s Enhanced Update of its First Nationally Determined Contribution. Republic of Korea; 2021.\u003c/li\u003e\n \u003cli\u003eMinistry of Agriculture, Rural Development and Environment. National Response to Prepare for Climate Change. Cyprus; 2017.\u003c/li\u003e\n \u003cli\u003eGovernment of the Republic of Moldova. National Program for Adaptation to Climate Change until 2030. Moldova; 2023.\u003c/li\u003e\n \u003cli\u003eMinistry of the Environment of the Czech Republic. Climate protection policy in the Czech Republic. Czech Republic; 2017.\u003c/li\u003e\n \u003cli\u003eGovernment of Romania. The National Strategy on Adaptation to Climate Change 2022- 2030. Romania; 2022.\u003c/li\u003e\n \u003cli\u003ePermanent Representative of the Democratic People\u0026rsquo;s Republic of Korea to the United Nations. Updated Nationally Determined Contribution of the DPRK. Democratic People\u0026rsquo;s Republic of Korea; 2019.\u003c/li\u003e\n \u003cli\u003eGovernment of the Russian Federation. Nationally Determined Contribution of the Russian Federation. Russia; 2015.\u003c/li\u003e\n \u003cli\u003eMinistry of the Environment and Sustainable Development. National Adaptation Plan to Climate Change (2022-2026). Democratic Republic of the Congo; 2021.\u003c/li\u003e\n \u003cli\u003eMinistry of Environment. National Environment and Climate Change Policy. Rwanda; 2019.\u003c/li\u003e\n \u003cli\u003eDanish Energy Agency. Danish strategy for adaptation to a changing climate. Denmark; 2008.\u003c/li\u003e\n \u003cli\u003eMinistry of Agriculture, Marine Resources, Cooperatives, Environment and Human Settlements. The National Climate Change Adaptation Strategy for Saint Christopher and Nevis. Saint Kitts and Nevis; 2018.\u003c/li\u003e\n \u003cli\u003eMinist\u0026egrave;re de l\u0026apos;Habitat, de l\u0026apos;Urbanisme et de l\u0026apos;Environnement. Contribution Pr\u0026eacute;vue D\u0026eacute;termin\u0026eacute;e au niveau National de la R\u0026eacute;publique de Djibouti. Djibouti; 2015.\u003c/li\u003e\n \u003cli\u003eMinistry of Education, Innovation, Gender Relations and Sustainable Development. Saint Lucia\u0026rsquo;s National Adaptation Plan (NAP): 2018\u0026ndash;2028. Saint Lucia; 2018.\u003c/li\u003e\n \u003cli\u003eClimate Resilience Executing Agency of Dominica. Dominica Climate Resilience and Recovery Plan 2020-2030. Dominica; 2020.\u003c/li\u003e\n \u003cli\u003eGovernment of St. Vincent and the Grenadines. National Adaptation Plan for St. Vincent and the Grenadines. Saint Vincent and the Grenadines; 2019. 49\u003c/li\u003e\n \u003cli\u003eConsejo Nacional para el Cambio Clim\u0026aacute;tico y el Mecanismo de Desarrollo Limpio. Pol\u0026iacute;tica Nacional de Cambio Clim\u0026aacute;tico (PNCC). Dominican Republic; 2016.\u003c/li\u003e\n \u003cli\u003eMinistry of Natural Resources and Environment. Samoa Climate Change Policy. Samoa; 2020.\u003c/li\u003e\n \u003cli\u003eMinisterio del Ambiente, Agua y Transici\u0026oacute;n Ecol\u0026oacute;gica. Plan Nacional de Adaptaci\u0026oacute;n al Cambio Clim\u0026aacute;tico del Ecuador (2023-2027). Ecuador; 2023.\u003c/li\u003e\n \u003cli\u003eGovernment of the Republic of San Marino. San Marino\u0026rsquo;s Intended Nationally Determined Contribution. San Marino; 2015.\u003c/li\u003e\n \u003cli\u003eMinistry of Environment. Egypt National Climate Change Strategy (NCCS) 2050. Egypt; n.d.\u003c/li\u003e\n \u003cli\u003eMinistry of Infrastructures and Natural Resources. Nationally Determined Contributions (NDC-STP) Updated. S\u0026atilde;o Tom\u0026eacute; and Principe; 2021.\u003c/li\u003e\n \u003cli\u003eMinisterio de Medio Ambiente y Recursos Naturales. Plan Nacional de Adaptaci\u0026oacute;n al Cambio Clim\u0026aacute;tico. El Salvador; 2019.\u003c/li\u003e\n \u003cli\u003eKingdom of Saudi Arabia. Updated First Nationally Determined Contribution. Saudi Arabia; 2021.\u003c/li\u003e\n \u003cli\u003eMinistero de Agricultura, Ganaderia, Bosques y Medio Ambiente. Contribuciones Determinadas a Nivel Nacional (CDN). Equatorial Guinea; 2022.\u003c/li\u003e\n \u003cli\u003eGouvernement du S\u0026eacute;n\u0026eacute;gal. Contribution D\u0026eacute;termin\u0026eacute;e au Niveau National du Senegal. Senegal; 2020.\u003c/li\u003e\n \u003cli\u003eGovernment of Eritrea. Nationally Determined Contributions (NDCs) Report to UNFCCC. Eritrea; 2018.\u003c/li\u003e\n \u003cli\u003eGovernment of the Republic of Serbia. Nationally Determined Contribution (NDC) of the Republic of Serbia for the 2021\u0026ndash;2030 period. Serbia; 2022.\u003c/li\u003e\n \u003cli\u003eMinistry of the Environment. Climate Change Adaptation Development Plan until 2030. Estonia; 2017.\u003c/li\u003e\n \u003cli\u003eThe Seychelles National Climate Change Committee. Seychelles National Climate Change Strategy. Seychelles; 2009.\u003c/li\u003e\n \u003cli\u003eMinistry of Tourism and Environmental Affairs. Swaziland National Climate Change Policy, 2016. Eswatini; 2016.\u003c/li\u003e\n \u003cli\u003eGovernment of Sierra Leone. National Adaptation Plan. Sierra Leone; 2021.\u003c/li\u003e\n \u003cli\u003eEnvironment, Forest and Climate Change Commission. Ethiopia\u0026rsquo;s Climate Resilient Green Economy: National Adaptation Plan. Ethiopia; 2019. 50\u003c/li\u003e\n \u003cli\u003eNational Climate Change Secretariat. Charting Singapore\u0026rsquo;s Low-Carbon and Climate Resilient Future. Singapore; 2020.\u003c/li\u003e\n \u003cli\u003eGovernment of the Republic of Fiji. Republic of Fiji National Adaptation Plan. Fiji; 2018.\u003c/li\u003e\n \u003cli\u003eMinisterstvo životn\u0026eacute;ho prostredia. Strat\u0026eacute;gia adapt\u0026aacute;cie Slovenskej republiky na nepriazniv\u0026eacute; d\u0026ocirc;sledky zmeny kl\u0026iacute;my. Slovakia; 2014.\u003c/li\u003e\n \u003cli\u003eMinistry of the Environment and Statistics Finland. Finland\u0026rsquo;s Eighth National Communication under the United Nations Framework Convention on Climate Change. Finland; 2022.\u003c/li\u003e\n \u003cli\u003eGovernment of the Republic of Slovenia. Slovenia\u0026rsquo;s Long-Term Climate STrategy to 2050. Slovenia; 2021.\u003c/li\u003e\n \u003cli\u003eMinist\u0026egrave;re de la Transition \u0026Eacute;cologique et Solidaire. Le Plan National d\u0026rsquo;Adaptation au Changement Climatique. France; 2017.\u003c/li\u003e\n \u003cli\u003eMinistry of Environment, Climate Change, Disaster Management and Meteorology Honiara, Solomon Islands. Solomon Islands 2021 Nationally Determined Contribution. Solomon Islands; 2021.\u003c/li\u003e\n \u003cli\u003eConseil National Climat. Plan National Climat Gabon. Gabon; 2012.\u003c/li\u003e\n \u003cli\u003eMinistry of Environment and Climate Change. Somalia National Climate Change Policy. Somalia; 2020.\u003c/li\u003e\n \u003cli\u003eGovernment of The Gambia. The Gambia 2050 Climate Vision. Gambia; 2021.\u003c/li\u003e\n \u003cli\u003eDepartment of Forestry, Fisheries and the Environment. National Climate Change Adaptation Strategy. South Africa; 2020.\u003c/li\u003e\n \u003cli\u003eGovernment of Georgia. Georgia\u0026rsquo;s 2030 Climate Change Strategy. Georgia; 2021.\u003c/li\u003e\n \u003cli\u003eMinistry of Environment and Forestry. First National Adaptation Plan for Climate Change. South Sudan; 2021.\u003c/li\u003e\n \u003cli\u003eGovernment of Germany. Adaptation Action Plan of the German Strategy for Adaptation to Climate Change. Germany; 2011.\u003c/li\u003e\n \u003cli\u003eMinisterio para la Transici\u0026oacute;n Ecol\u0026oacute;gica y el Reto Demogr\u0026aacute;fico. National Climate Change Adaptation Plan 2021-2030. Spain; 2020.\u003c/li\u003e\n \u003cli\u003eGovernment of Ghana. National Climate Change Adaptation Strategy. Ghana; 2012.\u003c/li\u003e\n \u003cli\u003eMinistry of Mahaweli Development and Environment. National Adaptation Plan for Climate Change Impacts in Sri Lanka. Sri Lanka; 2016.\u003c/li\u003e\n \u003cli\u003eMinistry of the Environment \u0026amp; Energy. National Strategy for Adaptation to Climate Change. Greece; 2016. 51\u003c/li\u003e\n \u003cli\u003eMinistry of Environment, Natural Resources \u0026amp; Physical Development. National Adaptation Plan. Sudan; 2016.\u003c/li\u003e\n \u003cli\u003eNational Climate Change Committee (NCCC). Second Nationally Determined Contribution. Grenada; 2020.\u003c/li\u003e\n \u003cli\u003eGovernment of Suriname. Suriname National Adaptation Plan. Suriname; 2019.\u003c/li\u003e\n \u003cli\u003eConsejo Nacional de Cambio Clim\u0026aacute;tico. Plan de acci\u0026oacute;n nacional de cambio clim\u0026aacute;tico. Guatemala; 2018.\u003c/li\u003e\n \u003cli\u003eInfrastrukturdepartementet. Sveriges integrerade nationella energi- och klimatplan. Sweden; 2020.\u003c/li\u003e\n \u003cli\u003eMinistere de l\u0026rsquo;Agriculture, de l\u0026rsquo;Elevage, de l\u0026rsquo;Environnement, des Eaux et Forets. Plan d\u0026rsquo;Action National d\u0026rsquo;Adaptation aux Changements Climatiques (PANA) de la R\u0026eacute;publique de Guinee. Guinea; 2007.\u003c/li\u003e\n \u003cli\u003eFederal Office for the Environment. Adaptation to climate change in Switzerland. Switzerland; 2012.\u003c/li\u003e\n \u003cli\u003eGovernment of Guinea-Bissau. Updated Nationally Determined Contribution in the Framework of the Paris Climate Agreement. Guinea-Bissau; 2021.\u003c/li\u003e\n \u003cli\u003eGovernment of the Syrian Arab Republic. Nationally Determined Contribution. Syrian Arab Republic; 2018.\u003c/li\u003e\n \u003cli\u003eOffice for Climate Change. National Climate Change Policy and Action Plan 2020-2030. Guyana; 2019.\u003c/li\u003e\n \u003cli\u003eMinistry of Environment. National Climate Change Action Guidelines. Taiwan; 2023.\u003c/li\u003e\n \u003cli\u003eGovernment of Haiti. Plan National d\u0026rsquo;Adaptation au Changement Climatique (PNA). Haiti; 2022.\u003c/li\u003e\n \u003cli\u003eGovernment of the Republic of Tajikistan. National strategy of adaptation to climate change of the Republic of Tajikistan for the period till 2030. Tajikistan; 2019.\u003c/li\u003e\n \u003cli\u003eHoly See. 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Iceland\u0026rsquo;s Climate Action Plan for 2018- 2030. Iceland; 2018.\u003c/li\u003e\n \u003cli\u003eMinistry of Meteorology, Energy, Information, Disaster Management, Environment, Climate Change and Communications. Joint National Action Plan 2 on Climate Change and Disaster Risk Management 2018-2028. Tonga; 2018.\u003c/li\u003e\n \u003cli\u003eMinistry of Health \u0026amp; Family Welfare. National Action Plan for Climate Change \u0026amp; Human Health. India; 2018.\u003c/li\u003e\n \u003cli\u003eMinistry of Planning and Development. National Adaptation Plan for The Republic of Trinidad and Tobago. Trinidad and Tobago; 2021.\u003c/li\u003e\n \u003cli\u003eGovernment of the Republic of Indonesia. Long-Term Strategy for Low Carbon and Climate Resilience 2050. Indonesia; 2021.\u003c/li\u003e\n \u003cli\u003eGovernment of Tunisia. Updated Nationally Determined Contribution (NDC). 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Available from: https://iris.who.int/bitstream/handle/10665/324736/9789289054119- eng.pdf#:~\u003cbr/\u003e:text=Coherence%20across%20all%20areas%20of%20public%20policy%20is,coordinated%20across%20actors%2C%20institutions%20and%20levels%20of%20governance\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 2 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"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":"globalization-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"glah","sideBox":"Learn more about [Globalization and Health](https://globalizationandhealth.biomedcentral.com/)","snPcode":"12992","submissionUrl":"https://submission.nature.com/new-submission/12992/3","title":"Globalization and Health","twitterHandle":"@GHJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"climate change, health policy, policy, adaptation, child health","lastPublishedDoi":"10.21203/rs.3.rs-6670422/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6670422/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eNational policies are essential for countries to adapt to the negative health impacts of climate change. Children are disproportionately affected by climate-sensitive health risks and must be at the heart of adaptation policies to address their vulnerabilities across sectors. Adaptation commitments worldwide are integrated into national adaptation plans, nationally determined contributions, national communications, and other multisectoral policies. We aimed to evaluate how effectively national climate change policies worldwide plan to protect child health, considering a range of determinants for successful policy implementation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eNational adaptation policies worldwide had poor planning for child health, with 43% of countries not mentioning child health at all. Around half of policies acknowledged the disproportionate health impacts of climate change on children, but most did not provide further explanation of these impacts. One-quarter (24%) of countries described goals and/or actions to promote child health but lacked clear targets for success. Six per cent of countries outlined monitoring and evaluation mechanisms, but none measured child health outcomes directly. Eleven per cent of countries involved multiple stakeholders in policy design and implementation, but rarely described the obligations of each party.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe design of national policies must be strengthened across multiple areas to protect child health from the harms of climate change. Policies should explicitly acknowledge children and provide a holistic description of their unique health risks. Goals should be both time- and age-sensitive with clear health targets, accompanied by actions that holistically address child health risks and evaluate policy outcomes in the region concerned. A clear strategy for resource allocation and mobilisation will improve the success of policy actions. These interventions should be regularly monitored and reviewed to facilitate continuous adaptation to the changing climate. Multi-level stakeholders must be involved in policy design and implementation, and their responsibilities should be clearly outlined to improve implementation success.\u003c/p\u003e","manuscriptTitle":"Climate change policies fail to protect child health","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-22 13:20:55","doi":"10.21203/rs.3.rs-6670422/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-09T15:39:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-16T09:36:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"327843391922483325884130021252522361316","date":"2025-06-05T08:14:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-22T14:22:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-22T10:14:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-22T10:11:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"Globalization and Health","date":"2025-05-15T08:19:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"globalization-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"glah","sideBox":"Learn more about [Globalization and Health](https://globalizationandhealth.biomedcentral.com/)","snPcode":"12992","submissionUrl":"https://submission.nature.com/new-submission/12992/3","title":"Globalization and Health","twitterHandle":"@GHJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"66804307-9f08-4a4d-8e92-842288971f12","owner":[],"postedDate":"May 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-18T15:58:48+00:00","versionOfRecord":{"articleIdentity":"rs-6670422","link":"https://doi.org/10.1186/s12992-025-01142-3","journal":{"identity":"globalization-and-health","isVorOnly":false,"title":"Globalization and Health"},"publishedOn":"2025-08-12 15:56:58","publishedOnDateReadable":"August 12th, 2025"},"versionCreatedAt":"2025-05-22 13:20:55","video":"","vorDoi":"10.1186/s12992-025-01142-3","vorDoiUrl":"https://doi.org/10.1186/s12992-025-01142-3","workflowStages":[]},"version":"v1","identity":"rs-6670422","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6670422","identity":"rs-6670422","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}