key: cord-0873249-wj02jbe2
authors: dos Santos, Monika; John, Juanette; Garland, Rebecca; Palakatsela, Romeo; Banos, Arnaud; Martens, Pim; Nemukula, Bono; Ramathuba, Murdock; Nkohla, Faith; Lenyibi, Keobakile
title: Climate change and health within the South African context: A thematic content analysis study of climate change and health expert interviews
date: 2022-03-30
journal: Afr J Prim Health Care Fam Med
DOI: 10.4102/phcfm.v14i1.3203
sha: a8baa036bbae188c90112a35b69e875c640b949b
doc_id: 873249
cord_uid: wj02jbe2

BACKGROUND: Climate change presents an unprecedented and urgent threat to human health and survival. South Africa’s health response will require a strong and effective intersectoral organisational effort. AIM: Exploratory interview outcomes are used to advance practice and policy recommendations, as well as for broad input in the development of a draft national framework for a health risk and vulnerability assessment (RVA) for national departments. SETTING: Nationally in South Africa. METHOD: Twenty key expert interviews were conducted with South African experts in the field of climate change and health. Interview data was analysed by means of thematic content analysis. RESULTS: Findings suggest that previously poor communities are most at risk to the impacts of climate change on health, as well as those with underlying medical conditions. Climate change may also serve as a catalyst for improving the healthcare system overall and should serve as the conduit to do so. A draft climate change and health RVA should take into account existing frameworks and should be implemented by local government. It is also critical that the health and health system impacts from climate change are well understood, especially in light of the plans to implement the (South African) National Health Insurance (NHI) scheme. CONCLUSION: Practice and policy initiatives should be holistic in nature. Consideration should be given to forming a South African National Department of Climate Change, or a similar coordinating body between the various national departments in South Africa, as health intercepts with all other domains within the climate change field.

Climate change presents an unprecedented international and urgent health threat to sustainable development, human health and survival, thus placing human lives at risk. All health professionals have a duty to advocate for action at all levels to mitigate and adapt to climate change and can or should play a critical role in mitigating and reducing risk. However, the global health sector has been slow to recognise the impact of climate change upon health. 1 To facilitate action to address the threat of climate change and its impact on the heath sector, the 2021 World Health Organization (WHO) Countries of Parties 26 (COP26) Special Report on Climate Change and Health provides 10 recommendations for governments to consider, namely (1) commit to a healthy recovery (postcoronavirus disease 2019 ); (2) our health is not negotiable; (3) harness the benefits of climate action; (4) build health resilience to climate risks; (5) create energy systems that protect and improve climate and health; (6) reimaging urban environments, transport and mobility; (7) protect and restore nature as the foundation of our health; (8) promote healthy, sustainable and resilient food systems; (9) finance a healthier, fairer and greener future to save lives and lastly, (10) listen to the health community and prescribe urgent climate action. 2 Of these WHO COP26 recommendations, points 1, 2, 3, 4, 9 and 10 are most relevant and intercept with this research's study objectives and findings.

Climate risk and vulnerability assessments (RVAs) have increasingly been used internationally for adaptation actions, development planning at local, national and regional levels and for the identification of climate change hotspots. The critical challenge in terms of climate change in South Africa is the way in which multiple stressors -such as the spread of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), the effects of economic globalisation, natural disasters, the privatisation of resources and geopolitical conflict, converge with climate change. 3, 4 The need for assessments in South Africa gained significance in the context of the (South African) National Climate Change Adaptation Strategy, which was first established in 2010 as part of the United Nations Framework Convention on Climate Change (UNFCCC) Cancun Adaptation Framework. The UNFCCC Cancun Adaptation Framework has been used to complement the existing short-term national adaptation programmes of action (NAPAs). 5, 6 The strategy indicates that in order to identify high-risk locations and groups, it is important that a national vulnerability assessment of the health sector be undertaken. 5 This project on climate change and health represents the first in South Africa that is being used to inform government practice, policy and a draft climate change and a health RVA framework.

This study forms part of a broader climate change and health scoping project commissioned by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) designed to inform the South African National Department of Health (NDoH) and South African National Department of Forestry, Fisheries and the Environment (NFFE) response to climate change in the health sector. The broader scoping exercise involved a desktop scoping review (which will inform a separate article). The subject of this article includes interviews with key stakeholders in the context of climate change-related health research, intervention and policy conducted in South Africa, to inform national practice and policy development and to use as broad input in developing a draft of climate change and health RVA template and framework. The RVA framework, which is currently being refined through a successive phase of the project in consultation with district health managers and local communities, was also a project deliverable. This article only focuses on the findings of the expert interview analyses, how it relates to practice and policy recommendations and how it broadly informs the development of the draft climate change and health RVA.

The University of South Africa (UNISA) led the scoping project, in consultation with researchers and academics from the Council for Scientific and Industrial Research (CSIR), Africa Health Placements (AHP), Centre national de la recherche scientifique (CNRS): UMR IDEES laboratory at the University of le Havre in France and the Maastricht Sustainability Institute, Maastricht University, the Netherlands. Twenty South African key expert participants in the field of climate change and public health, selected by Unisa and the CSIR, in consultation with the NDoH and the NDFFE, were interviewed. Two female climate change and health researchers from CSIR conducted 15 interviews, whilst two climate change and health Unisa researchers (one male and one female) conducted five interviews. The interviews took place between the months of July 2019 and November 2019. Where possible, interviews were conducted in person, tape-recorded and transcribed with the use of otter.ai, which is a web-based application providing speech to text transcription. 7 Where it was not possible to interview a participant in person, interviews were conducted via Skype, audio recorded and transcribed, otter.ai was also used.

The interview data were analysed by the researchers from Unisa and the CSIR by means of thematic content analysis, with the assistance of ATLAS.ti software. 8 In previous studies, thematic content analysis methods have been proven to be constructive in the advancement of public health interventions. 9, 10 It is implemented in the disaggregation and interpretation of core themes and is a multistep process of inquiry during interview data analysis that comprises a process of linking codes (categories and concepts) to one another via a combination of inductive and deductive reasoning. 9, 10 These categories were then coded to identify regularities. Categories that are grouped together became themes and subthemes, which have been captured in this article by way of headings and sub-headings. Data saturation was reached when the ability to obtain additional new categories from the raw data ceased, making further coding no longer feasible. To validate interpretations, study conclusions were taken back to a subset of the participants, as well as the key stakeholders as identified by the NDoH, South Africa (in consultation with UNISA and the CSIR) during a workshop held in January 2021, for the enrichment and substantiation of analyses. 9,10 Two international experts in climate change and health: one based at IDEES laboratory at Le Havre University, France and the other at the Maastricht Sustainability Institute of Maastricht University, the Netherlands, also provided overall quality assurance in terms of the data analysis and findings.

The interview probes were developed based on the climate change and health expertise of the Unisa and CSIR researchers. After the initial drafting of the probes, the involved national departments and the funder, as well as the two international experts, provided further commentary and refinement. Broad interview questions and probes included, but were not limited to, the following: 

Seven participants have a public health background, six have an environmental health background and four are in the field of both climate change and health. Six participants are from public universities, three from research councils, whilst another three participants work for the government. Table 1 indicates the industry, role and field of experience of each expert participant. It was also generally felt that lay knowledge in terms of climate change exists, but not necessarily in terms of the correct terminology or context. The youth were generally considered to have more understanding with regard to climate change and relevant contexts. Social media also played a significant role in individual climate change knowledge acquisition and overall attitudes.

Another key theme to arise from the data analyses is that of psychological and physical vulnerability. The impact of climate change on mental health and individual brain physiology was mentioned in particular, for example, mental health services will also need to factor in climate-change impacts on their clinical care strategies The existing health status or some inherent traits, such as albinism, may also affect people's vulnerability; this includes both physical (which could also be related to ultraviolet ultroviolet radiation and ozone depletion, air pollution and the impact of heat) and mental health aspects, as suggested by the given quotes:

'So, it's not only that we look at issues of albinism, for those who are having the condition the sun is so hot, and it affects them as they go out into the sun because of the nature of their pigmentation.' (Participant 5, government official, provincial department)

'Those who are working at farming areas, so when the heat strikes, like climate change itself on its own, it affects your mental capacity … I'll tell you cases of suicide -we were told that people are getting depressed in a way that they take organophosphate poisoning.' (Participant 5, government official, provincial department)

Geographic areas of concern raised by participants in terms of vulnerability included specific provinces in South Africa and rural areas in particular -this included areas in Limpopo, Mpumalanga, KwaZulu-Natal and the Northern, Eastern and Western Cape.

The impact of climate change on the health of vulnerable communities was highlighted by most participants, notably on the poorest of households, those already terminally ill, lacking food security and livelihoods.

One participant referred to the impact of climate change on the air quality and how this has an impact on several diseases that people often experience. The potential change in disease occurrences because of climate change, such as the change in malaria vector patterns, heightened diarrhoeal disease and plague, was also mentioned. These disease occurrences will be intensified because of a potential lack of services. Furthermore, within the context of food security and healthcare, poverty constrains household livelihoods:

'I think some of the people who will be most affected are people from previously disadvantaged areas, the marginalised areas, where there is already high prevalence of other diseases that can actually be augmented by changes in climate.' (Participant 14, researcher, weather services)

The impact of climate change was found to be problematic given that most of the poor communities are lacking resources to effectively cope with the crises, and intervention was equally lacking in terms of addressing the problem. This was found to have a spiralling effect, often to the detriment of vulnerable communities. The interconnectedness of vulnerable communities, adaptation or "safety-net" strategies, including social networks, was also highlighted, as indicated by the quote here:

'It highlights the importance of the climate impacts and climate change within a broader social and ecological context in terms of thinking about adaptation… that's what our work pointed to as climate change certainly potentially has impacts for food security of households, but the sort of safety nets could be quite diverse be they social or environmental and of course other types of social networks would be government social grants types of safety nets.' (Participant 12, academic, public university)

Climate change as a risk to the health system: The impact of climate change on vulnerable public healthcare infrastructures was also indicated as a concerning factor. All participants agreed that climate change will impact health and the health system in South Africa, particularly for those in underserviced areas, with many indicating that the impacts are already being felt:

'If you have a clinic that doesn't have adequate air conditioning, or even fans, and you have long waiting times and queues, it's either going to dissuade people from accessing the health services or it's just going to result in a greater burden in terms of fainting in the queues, demoralising staff working under really unpleasant conditions, stifling conditions ... I think that climate change is also going to directly impact the actual access of the health services that are available or the effectiveness and suitability and desirability of those services.' (Participant 12, academic, public university)

The impact of climate change in terms of supply chain issues, as well as multiple other domains such as employee wellness, food control, clinic infrastructure and medical services, was highlighted.

Adaptation measures: The interviewees recommended various adaptation strategies that should be considered in terms of climate change and health. These include clinics being fitted with cooling systems (e.g. with fans), keeping clinics open for longer and making transport available for the community to clinics. Consideration regarding implementing tax rebates and other economic incentives was also highlighted by one participant. Participants also emphasised the need to focus on mitigation and that not enough was being performed in this regard, although no mention was made of specific mitigation strategies that should be implemented. The importance of a collaborative approach to adaptation amongst national departments, as well as the need to link adaptation to local and indigenous knowledge, was also highlighted.

Participants also associated adaptation with the availability of information and data, and indicated that it should be implemented at a grassroots level. Agribusiness and its recursive effect on health and resilience were also highlighted: The need for trans-and inter-disciplinarity in research and academia, policymaking and practitioner practice was mentioned, together with the training of school and postgraduate students, as well as advocacy in general. This included government officials across spheres and levels, implementation agencies, emergency medical services, the medical community, as well as the public and students.

One participant pointed out that long-term behaviour change in the health sector was not achievable through education only -but that people did change their behaviours after a crisis (e.g. in San Francisco, during the early years of the HIV/AIDS epidemic and more recently with the COVID-19 pandemic). Participants highlighted the importance of getting climate change and health into the curriculum for doctors and nurses and in continuing education and training. However, it was observed that it is very difficult to change the curriculum. One suggestion was to allow medical students, during their public health electives, to rotate through research councils and other institutions working on climate change and health.

Highlighting climate change and health through local professional bodies via conferences and academic journals was also suggested to increase visibility and increase awareness of the issues. Private-public partnerships were highlighted as important. These can be helpful to provide funding, to increase awareness and to bring a key stakeholder (i.e. private companies) to the 'It is about addressing some of the softer side of research, which are covered most even in the ethics. That, you speak to people's values and ensure that people feel they need to take part, because this is not only important now to you but also to them.' The urgency for localised robust scientific research within the fields of climate change and health was indicated by numerous participants, with credible research being more likely to be considered by policymakers. Proposed research focal points include climate change-related: population and community displacement, water scarcity and quality, conflict, food security, spread of disease, indirect and direct impacts and the impact on mental health. One participant also mentioned the need for scientific results to be communicated in easy-to-understand language for the general public.

It was acknowledged that there are still research gaps in terms of impacts, risks and vulnerabilities. The need for strong baseline data was highlighted, as was investigating currently available data sets that are underutilised. Key components of determining the usefulness of climate information included the clarity and timing of the message, the audience and lead times. For example, it was observed that the seasonal diseases such as malaria requires, a lot of planning (such as buying chemicals, hiring seasonal workers) for those potentially impacted and needs longer lead times in order to prepare and take the necessary precautions. In addition, research outcomes and information should be used at a higher level within the government to guide planning.

The need for further research on the food/energy/water nexus was also highlighted, as well as the deployability of mobile clinics and that research should be practice driven, multidisciplinary and evidence and micro-based. It was further emphasised that researchers should have a more activist or action-orientated approach.

Actions to improve science-policy linkages: One participant drew from their knowledge of the successes and failures of HIV/AIDS campaigns to suggest ways to improve the linkages between research and policy, thus elevating the profile of these issues in the health sector. This will need to include health economists. In order to improve the science-policy linkages, participants highlighted the need for strong relationships and regular dialogue between researchers and policymakers. Another participant observed the difference between research that is policy relevant and policy-demand driven, and that many researchers do want their work to support policy decisions, but because of a lack of communication or poor timing, it may not have the desired impact. The need for local solutions within the context of meaningful research was emphasised.

Intervention: Participants emphasised that interventions should be evidence based. They highlighted that climate change and health interventions should focus on aspects such as improved infrastructure and energy generation, better utilisation of resources, employment opportunities, further research and mass means of making the general population aware of the need to protect the planet, which includes relevant education at schools and tertiary educational institutions. The importance of prevention being better than cure was emphasised by one participant (getting the basics right). It was mentioned that the NHI should explicitly incorporate interventions related to climate change.

'It should say that climate change is something that is serious and should be addressed by the NHI. It should not be a separate thing … there should be funding and education to the municipalities, government and the national department of health to say, you will use money for climate change adaptation.' (Participant 2, policy and grassroots advocate, environmental health institute)

The need to identify high-risk areas at a finer resolution scale was also highlighted, as well as the advancement of practice initiatives, and it was mentioned that climate change may be a catalyst for improving the healthcare system. The need for (and sometimes lack of) monitoring and tracking interventions was also raised. One participant noticed that interventions can also start small and be practical. The usefulness of cost-benefit analysis of interventions in the absence of climate change was also highlighted.

The importance of political will, good leadership and using common sense for identifying and applying interventions, as well as the need for trust and collaboration in ensuring the success of interventions, was also cited. One participant indicated that communities should be educated in terms of climate change and intervention. Testing the acceptability of interventions within communities was indicated as very important. Interventions can also have unintended consequences if not planned properly and viewed within the bigger picture.

Climate change and health risk and vulnerability assessment framework: Participants shared their thoughts on the fields that a climate change and health RVA framework should cover. Emphasis was placed on the need to involve government and communities at a localised level and adopting a multidisciplinary approach with a group of mandated leaders to drive the process: A health vulnerability assessment tool, applicable to South African towns, is currently being developed by the South African Medical Research Council (SAMRC). 11 It is still preliminary, but the approach to the tool and its implementation can provide input into their project. University of Pretoria's AitaHealth is a tool used by community health workers. Workers visit homes and collect data, after which they do a risk assessment to identify red flags and then follow up on these. 15 Furthermore, it is necessary to understand the distribution of resources in an R&V assessment. The use of technology such as telemedicine should be considered in areas with less access to doctors. However, this type of technology requires connection to other technologies, which are not always available in rural areas.

Overall, there was not much awareness or knowledge of existing climate and health R&Vs internationally or in South Africa, apart from those adopted by NDFFE and the WHO.

What stakeholders should be involved in developing a health risk and vulnerability assessment framework?: It was agreed that stakeholders should be from across disciplines and fields. The main stakeholders observed were (in no specific order): climate scientists, infectious disease experts or epidemiologists who can relate information to understanding how the disease burdens might shift, leadership, technology experts (within the context of implementing the framework), academia, community, NGOs and government (across levels and sectors). Government sectors include health, environment, water, housing and treasury; the medical community, climate adaptation experts and private companies and grass-root community members were also listed as important. In addition, one participant highlighted the need for stakeholders to coordinate these R&V fields.

Who should implement the health risk and vulnerability assessment framework?: The participants highlighted different aspects to be considered for how the framework should be implemented.

The role of national government as coordinator: It was suggested that NDFFE or the Technical Committee on Climate Change should implement the framework, as this is 'the only way that you're going to have any kind of coordination between what's going on in the different sectors … they're the common denominator'. (Participant 11, advocacy, non-governmental organisation)

Phased implementation and flexible tool: Participants recommended that implementation should be at a provincial, municipal and district level and one tool will not fit all. They recommended a pilot study to assess the framework before it is implemented. In addition, they suggested the framework should be applied regularly and continuously (i.e. for monitoring and evaluation purposes) and will evolve as the situation, state and questions evolve, and as more useful, detailed data are generated (such as moving towards a higher tier of assessment as per the Intergovernmental Panel on Climate Change (IPCC) methods by starting with defaults and moving towards detailed local data).

Local government should be able to implement: It was recommended that after the development of the climate change and health R&V tool, a local government official should be able to implement it without the need for a consultant. The tool should align questions with data from the Integrated Development Plan (IDP), so that any official would have the information at hand.

The participants appeared to not have a clear idea on how the NHI planning and roll-out should address climate change impacts on health. There was, however, an indication that medication, mental health and other morbidity and mortality issues would need to be factored into the NHI:

'NHI will have to address other issues highlighted earlier, such as pharmaceutical issues, mental health problems, higher morbidity and mortality, etc.' (Participant 3, government official, national department)

Some participants had reservations about the NHI because of the failures in the current primary health care (PHC) system: ' But the fact that we haven't been very successful in getting our basic PHC system, including referrals to work and it should, provided the same barriers are going to affect that. Anyway, in the health sector we just need to do the same old stuff but do it better. And then we'll probably be quite well equipped for climate change. But as I mentioned, for example, I think there might be some unexpected things such as financing.' (Participant 20, consultant, economics-based consultancy)

The majority of participants observed the need for collaboration between researchers, indigenous knowledge systems, politicians and government departments. In terms of improving collaboration, one participant suggested a model that is shaped around five pillars, which include respect, joint knowledge, currency, building networks and a concerted effort towards helping the community. Whilst indigenous knowledge and frameworks were seen as important by all participants, there was some hesitancy amongst two participants as to how indigenous knowledge should be used. It was observed that many lessons can be learnt from local and indigenous knowledge systems, in dealing with climate variability in the natural environment and combining it with scientific information to improve on the information and accessibility and that this knowledge should be capitalised on more. The concern was that climate change will present problems we have never seen before; in this sense, indigenous knowledge is a start but not the end point for climate change adaptation. In addition, it was suggested that indigenous knowledge varied (i.e. one community's indigenous knowledge is not always applicable elsewhere).

Participants also highlighted the need for local grassroots ownership in terms of climate change and health research and interventions, as well as the importance of early engagement with the community and stakeholders. There was agreement that these aspects are not always performed well during research and climate assessments. Community champions, as well as stakeholder agency, were also identified as needs.

Barriers to climate change and health strategies included the capacity of the government to deal with climate change given the burdens they are already facing. One participant emphasised the need to build trust. A lack of monitoring was also seen as a barrier to the development of an effective public health programme.It was also mentioned that the medical community is not aware of or, if they are, is too overloaded with other stresses to consider the impacts of climate change on health and the health system. In addition, it was questioned whether climate change is a priority in the health sector.

The Presidential Health Summit (2018) report was mentioned as a document that highlights the priorities of the sector; however, neither climate change nor global warming is mentioned in this report at all. 16 The Presidential Health Summit Compact (2019) only mentions climate change once under intersectoral collaborations. 17

Furthermore, climate change was not regarded to be a priority or core function of national and provincial departments. The aspect of corruption in government departments was mentioned as a potential barrier, and the need for clear governance, transparency and accountability was highlighted -with potential oversight by international organisations.

Other barriers included clinical aspects being highlighted above environmental issues and environmental health and practitioner practice: 

Participants indicate that public health funding at the local level is not prioritised. Participants also highlighted the silos that government departments tend to work in, and the resultant gaps that ensue regarding climate change because of this shortfall. One participant working in a provincial government department indicated the need to form a dedicated 'National Department of Climate Change', which should report directly to the president and parliament, so that there could be a consolidated approach from government's side in dealing with climate change:

'Climate change should not be just a portion of the responsibilities of various departments in South Africa. There should be one dedicated "Climate Change Department", fully funded and driven by experts, to coordinate all the "loose ends" as far as climate change is concerned. Reporting should be directly to the president and to parliament.' (Participant 3, governmental official, national department)

The discussion of the results focuses on the subthemes of healthcare; adaptation and mitigation; systemic approaches and innovation; research, indigenous knowledge, intervention and policy development; the NHI; vulnerability, climate change and health risk and the vulnerability framework, as well as governance and concludes with a discussion on the study's strengths and limitations.

Climate change may be a catalyst for improving the healthcare system overall and should serve as the conduit to do so. Holistic healthcare and climate adaptation strategies must focus on strengthening healthcare systems in terms of human resources in health, accessibility, networking and referral, infrastructure, equipment, sanitation and medication. These outcomes are supported in the study of Dos Santos, Howard, Kruger, Kornik and Banos (2019), which explores healthcare service sustainability within the context of climate change in the Agincourt subdistrict, Kruger to Canyons Biosphere Region in Mpumalanga, South Africa. 18 Under-capacitated healthcare facilities in terms of human resources in health will benefit from telemedicine and cross-referral networks. However, for telemedicine to be used, the technology for such connections is necessary; this is not always the current case in rural areas. Mental health services will need to factor in climate-change impacts into their clinical care strategies.

Adaptation strategies, which have largely been neglected within the South African context, should also be considered within the context of climate change and health and healthcare structures and services. These include clinics being fitted with cooling systems, keeping clinics open for longer and making transport available for the community to travel to clinics. There needs to be a focus on mitigation as well and not only adaptation. Studies indicate that a wellfunctioning and resourced health system can respond deftly to stresses such as changes in disease patterns and extreme events and be able to provide the necessary services to mitigate the impact of a changing climate on health. However, a health system that is under stress, which is most evident in previously disadvantaged areas within the South African context and unable to respond to a changing climate, may exacerbate the health impacts of the people that the health system serves. 19, 20 Tax rebates and other economic incentives for proenvironmental behaviour should be considered at an individual and institutional levels. Evidence gathered on disasters in recent memory, such as the COVID-19 pandemic, can be used to catalyse interest in adaptation, planning and thinking about the future, including awareness raising and expanding people's horizons on how this information can be used to plan. 21

All role players should be empowered to adopt a holistic and systemic approach through which climate change and health governance and associations are addressed, be it from a grass-root level, public health, research or policy level. These findings concur with that of Capon, Synnott and Holliday 

Research should be practice driven, multidisciplinary, evidence-and micro-based. Quantifying the relationship between health outcomes and climate variables is a key first step in developing an evidence-base on the impact of climate and climate change on health in South Africa. This includes synergistic feedbacks and interactions between the different impacts. There is an urgency for localised, robust scientific research, focusing on population and community displacement, water scarcity and quality, conflict, food security, spread of disease, indirect and direct impacts of climate change and health, the food/energy/water nexus, and the impact of climate change on mental health. Furthermore, interdisciplinary/transdisciplinary training of students at the postgraduate level can assist in bringing together these different disciplines. Medical students, in their public health electives, could be allowed to rotate through research councils and others working on climate change and health. These disciplines should also be addressed by the school curriculum. 

It is critical that the health and health system impacts from climate change are well understood, especially in light of the plans to implement the NHI scheme. The increased stress on the health sector from climate change may undermine the implementation and expansion of the NHI. 25 Implementation of the NHI may be a catalyst for improving primary health care services and infrastructure. 26 The NHI should be framed in a way that deals with all primary health care problems: prevention, health promotion aspect (health literacy), and should not just be curative for it to be climate resilient. Furthermore, environmental health practitioners need to be capacitated within the forthcoming NHI structure, findings of which are supported in the work of Mathee and Wright (2013). 27 One way of structuring a health system is to start with a minimum basket of essential products that people have access to, irrespective of where they live, followed by more expensive products. Once such a system is in place, resource allocation can then be made to ensure that care is available in high-risk areas.

The latest IPCC definitions of climate vulnerability characterise vulnerability as a function of sensitivity and adaptive capacity (also sometimes referred to as resilience) to stresses and shocks. 28 In combination with exposure to climate hazards and impacts, it indicates risk. Climate change may hamper poverty alleviation strategies and sustainable agriculture in South Africa as the country still relies heavily on large-scale farmers for food products. 29 Furthermore, AIDS, which has a significant impact on structures of healthcare systems, has taken a minimum of 1 million lives each year in sub-Saharan Africa since 1998. 30 Because of its rapid transmission and effect on the immune system, HIV/ AIDS reduces the ability of the human body to recover from the shock. People living with AIDS are thus more at risk when they are exposed to climate-related hazards such as rising temperatures, water scarcity, air pollution, potential water-borne and vector-borne disease outbreaks and habitat redistributions. 30 Risk factors for HIV transmission in southern Africa that may be aggravated by climate change include population displacement, poverty and dislocated communities, gender violence, transactional sex, commercial sex work, increased partner numbers and increased risktaking behaviours. 28, 31 Findings of this study indicate that a coordinating body must be instituted at the national level to ensure that climate change and health RVA assessments use similar methods and input data and thus can be combined and compared. National government should coordinate the implementation of the climate change and health RVAs. The framework should be flexible and undergo a phased implementation, starting with a pilot study to assess the framework before it is implemented nationally. Once the climate change and health RVA is finalised, the local government should implement the tool. The framework should talk to other initiatives such as CSIR's Green Book (https://greenbook.co.za) and the National Climate Change RVA Framework. 32, 33 There needs to be robust oversight, monitoring and evaluation of governmental resource utilisation, which should be undertaken by international organisations. Consideration should be given to forming a coordinating body between the various national departments. There should also be a stronger link between national and local government because provinces don't act in terms of issues related to local municipalities. The development of a tool that can strengthen the IDP by assimilating issues and solutions from different municipalities and across sectors should also be considered.

Qualitative studies are subject to more researcher bias than quantitative studies; however, transcripts and analysed texts were sent to a subset of participants and key stakeholders for their commentary on accuracy and possible enrichment. Peer review of the analyses by all authors also strengthened confidence in the interpretations yielded by the study. Also, the relatively small cohort of 20 expert participants infers representativity limitations, for example, only one community grassroots representative was included in the study. Future research agendas that make use of mixed designs with more representative samples may go a long way in improving recommendations for service delivery and policy advancement.

Interview findings indicate that South Africa, as a country and people, will be particularly vulnerable to climate change and its consequential health effects, food security and overall impact on livelihoods, particularly affecting the poor. Overall, participants held the view that the predicament in access to healthcare is set to overwhelm present and prospective generations within the South African context. Responses to climate change, whether by mitigation of its effects or adaptation to them, will require strong and effective intersectoral organisation efforts within government at all levels, along with interdisciplinary research. A proposal to centralise climate change action within the national departments or to form a South African National Department of Climate Change, which reports directly to the president and parliament, has been made. As the aspect of climate change and public health intersects with virtually all other facets of government, such an initiative may go a long way to increase collaboration across borders.

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National Climate Risk and Vulnerability (CRV) Assessment Framework summary document

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses or interpretation of data; in the writing of the manuscript or in the decision to publish the results. 

Approval to conduct the study was received form the College of Human Sciences Research Ethics Review Committee, University of South Africa (reference: 2019-CHS-CREC-90191714).

The study was funded by the Deutsche Gesellschaft für Internationale Zusammenarbeit, tender number: 83296969

Data sharing is not applicable to this article as no new data were created or analysed in this study.

The views expressed are solely the responsibility of the authors and do not necessarily express the views of the University of South Africa, the Council for Scientific and Industrial Research, the National Department of Health, the National Department of Forestry, Fisheries and the Environment, the Centre National de la Recherche Scientifique: CNRS, France, IDEES laboratory: le Havre University, Maastricht Sustainability Institute, Maastricht University, and the Deutsche Gesellschaft für Internationale Zusammenarbeit.