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Analysis
Opportunities and challenges for financing women’s, children’s and adolescents’ health in the context of climate change
  1. Blanca Anton1,
  2. Soledad Cuevas2,
  3. Mark Hanson3,
  4. Zulfiqar Ahmed Bhutta4,5,
  5. Etienne V Langlois6,
  6. Domenico Gerardo Iaia6,
  7. Giulia Gasparri6,
  8. Josephine Borghi7
  1. 1Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
  2. 2Instituto de Economía, Geografía y Demografía, Consejo Superior de Investigaciones Científicas, Madrid, Spain
  3. 3Institute of Developmental Sciences, University of Southampton, Southampton, UK
  4. 4Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
  5. 5Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
  6. 6Partnership for Maternal, Newborn and Child Health, World Health Organization, Geneve, Switzerland
  7. 7Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
  1. Correspondence to Ms Blanca Anton; Blanca.anton{at}lshtm.ac.uk

Abstract

Women, children and adolescents (WCA), especially in low-income and middle-income countries (LMICs), will bear the worst consequences of climate change during their lifetimes, despite contributing the least to global greenhouse gas emissions. Investing in WCA can address these inequities in climate risk, as well as generating large health, economic, social and environmental gains. However, women’s, children’s and adolescents’ health (WCAH) is currently not mainstreamed in climate policies and financing. There is also a need to consider new and innovative financing arrangements that support WCAH alongside climate goals.

We provide an overview of the threats climate change represents for WCA, including the most vulnerable communities, and where health and climate investments should focus. We draw on evidence to explore the opportunities and challenges for health financing, climate finance and co-financing schemes to enhance equity and protect WCAH while supporting climate goals.

WCA face threats from the rising burden of ill-health and healthcare demand, coupled with constraints to healthcare provision, impacting access to essential WCAH services and rising out-of-pocket payments for healthcare. Climate change also impacts on the economic context and livelihoods of WCA, increasing the risk of displacement and migration. These impacts require additional resources to support WCAH service delivery, to ensure continuity of care and protect households from the costs of care and enhance resilience. We identify a range of financing solutions, including leveraging climate finance for WCAH, adaptive social protection for health and adaptations to purchasing to promote climate action and support WCAH care needs.

  • health economics
  • environmental health
  • global health
  • health policies and all other topics
  • health insurance

Data availability statement

There are no data in this work.

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This is an open access article distributed under the terms of the Creative Commons Attribution IGO License (CC BY NC 3.0 IGO), which permits use, distribution,and reproduction in any medium, provided the original work is properly cited. In any reproduction of this article there should not be any suggestion that WHO or this article endorse any specific organization or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article’s original URL.

https://doi.org/10.1136/bmjgh-2023-014596

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    Summary box

    • Women, children and adolescents (WCA), especially in low-income and middle-income countries, are disproportionately affected by the impacts of climate change due to systemic gender inequalities and their unique stages in the life course.

    • Investing in WCA can address these inequities in climate risk, and generate large health, economic, social and environmental gains in both the short-term and long-term.

    • Climate adaptation is currently rarely integrated within women’s, children’s and adolescents’ health (WCAH) programmes, and WCAH and well-being is not mainstreamed in climate policies and financing.

    • Initiatives to promote co-financing of WCAH and climate resilience would therefore yield large and sustained returns.

    • For climate finance to be effective, it is crucial to increase equity and gender and age responsiveness of climate mitigation and adaptation plans.

    • There is also a need for investments in new or adapted health financing mechanisms to support WCA climate-related needs.

    Introduction

    Climate change impacts everyone, but not equally. Due to systemic gender inequalities and their unique stages in the life course, women, children and adolescents (WCA), especially in low-income and middle-income countries (LMICs), will be forced to bear the worst consequences during their lifetimes, despite contributing the least to global greenhouse gas emissions.1 Figure 1 depicts the impacts of climate change across the different life stages. Climate change is an intergenerational injustice. Under current emission reduction pledges, children born in 2020 will experience a twofold to sevenfold increase in extreme weather events during their lifetime compared with a person born in the 1960s.2

    Figure 1
    Figure 1

    Impacts of climate change across the life stages.50

    Investing in WCA can address these inequities in climate risk, as well as generating large health, economic, social and environmental gains.3 However, women’s, children’s and adolescents’ health (WCAH) and well-being are still not mainstreamed in climate policies and financing. For instance, only 2.4% of multilateral climate financing incorporate child-related activities.4 Moreover, climate adaptation is rarely integrated within WCAH programmes, and WCAH financing does not adequately promote climate consciousness or resilience-building, with very limited health-related aid supporting climate mitigation or adaptation.5 There is, therefore, a need to also consider new financing arrangements that support WCAH alongside climate goals, including by exploiting synergies between WCAH financing and climate finance, and considering the potential for co-financing (the use of funding from one sector to support the goals of the other), generating a win-win scenario. Adaptations to financing arrangements can be considered across the three health financing functions, including revenue generation, pooling and purchasing.

    We provide an overview of the threats climate change represents for WCA, including the most vulnerable communities, and where health and climate investments should focus. We draw on evidence to explore the opportunities and challenges for health financing and climate finance to enhance equity and protect WCAH while supporting climate goals. Table 1 provides an overview of the threats of climate change to WCA and the challenges and opportunities for health financing, climate finance and intersectoral financing.

    View this table:
    Table 1

    Overview of WCA threats from climate change, and the challenges and opportunities for financing

    Increasing burden of ill-health and healthcare demand

    Climate change increases the burden of ill-health among WCA. Research suggests that natural disasters disproportionately kill more females at a younger age than males.6 Due to cultural barriers, women are often not able to make independent decisions on whether to evacuate or not, depending on the male household head. This divide will only be exacerbated by increasing and more severe weather events caused by climate change. This disparity is, however, reduced when the social status of women improves.6

    WCA are further vulnerable to the rise in climate-sensitive conditions and chronic effects, such as infectious diseases and respiratory conditions linked to pollution.7 Half a million children under the age of 5 die from air pollution-related causes every year. Newborns and younger children are particularly vulnerable to the impacts of air pollution as they breathe faster, have higher metabolic rates and their immune systems are still developing.8 Climate-related emergencies also cause major disruptions in sexual and reproductive health service delivery, including commodity supply chains for family planning, which can affect the healthcare burden in the population.9 Furthermore, there is an increased risk of adverse birth outcomes, such as miscarriage, preterm birth, stillbirth and low birth weight among pregnant women exposed to extreme heat.9 Climate events also aggravate violence against women and girls and increase the risk of human trafficking10 and child, early and forced marriage.9 Adolescents are further particularly susceptible to mental health impacts and eco-anxiety.11 Thus, climate-related effects on health occur across the lifecourse and can cast a shadow across generations.

    Challenges: rising demand and increased out-of-pocket payments

    The additional ill-health and disease burden, together with supply-side constraints and access barriers to healthcare, impact private health spending.12 In low-income settings, households bear the majority of healthcare costs of climate conditions. Thus, research across African countries showed that a 1% increase in the level of CO2 emissions can increase out-of-pocket health expenditures by 0.42%.12 The rise in health expenditures can compromise the financial protection goal of universal health coverage, as well as limit access to needed care.

    Opportunity: adaptive social protection schemes, and inclusion of climate-related WCAH service needs

    There is potential to link adaptive social protection schemes for climate hazards to health insurance, providing access to healthcare for those most likely to be impacted by a hazard.13 In addition, unconditional cash transfers can improve access to health services and improve health outcomes among mothers and children.14 During drought in Kenya, for example, cash transfers were distributed to children and orphans to ensure access to health check-ups.15 A study from food insecure and drought-prone areas in Ethiopia showed that the participation of female-headed households in a social safety-net programme increased the enrolment in a community-based health insurance scheme by 16.3 percentage points.14 Although maternal and child health services are often free in public facilities in LMICs, waivers of fees or copayments may also be considered for any fee-paying WCAH services.16 Benefit packages can also be revisited to ensure climate-related WCAH service needs are covered.

    Healthcare provision and cost

    With an increase in the frequency and impact of extreme weather events, climate change can cause an unprecedented disruption to health services,9 17 which can persist beyond normal recovery cycles of 3–5 years. Bangladeshi women, for example, showed lower usage of maternal healthcare beyond the normal recovery period after the floods between 2011 and 2014.18 Furthermore, in the USA after hurricane Harvey, healthcare access was particularly hindered for people who lost their job after the disaster.19 Impacts are particularly experienced by women in poverty, as they are often more negatively affected.20

    Challenges: health budget constraints, and pro-rich allocation of funds

    The increased demand for healthcare services among WCA associated with climate change, and changing disease and risk profile among this population has implications for health financing in terms of the level of financial resources and its allocation, including which services are purchased.

    Despite the need for more financial and health support after climate hazards, evidence suggests that extreme weather events reduce growth and tax revenues,21 through damage to infrastructure, production and productivity, leading to a reduction in government resources for health.22 Extreme weather events have macro-economic impacts and impact subnational allocation of funding, including for health.23 Funding allocations often favour wealthier localities and better educated and informed individuals who are better able to access funding and thus respond to a disaster, further exacerbating inequalities.23

    Opportunity: carbon pricing and climate adaptation funds to support WCAH, and agile public finance management

    Climate hazards, however, can also drive additional funding for climate adaptation and mitigation, yielding health co-benefits for WCA. For example, following the devastating wildfires in California, the 2022 state budget proposed funding to increase surveillance of climate-sensitive conditions and for local health departments to develop health resilience plans.24 There is also an opportunity for climate adaptation funds and carbon tax and credits and micro-levies to provide additional revenues to support WCAH goals.25 Experience from COVID-19 highlights the benefits of agile public financial management systems which provide greater flexibility in budget allocation and deployment in the aftermath of a disaster.26 Adaptations to routine provider payment mechanisms (transfer of funds from healthcare purchasers to healthcare facilities and health workers) can also be considered to encourage climate-conscious behaviour within health facilities, supporting sustainability goals and adaptation strategies linked to the delivery of WCAH services.

    Livelihoods, economics and farming

    Following an extreme weather event, women experience the direct impacts on health more severely than men, and suffer economic hardship. Women are often much more vulnerable because they lack power and access to assets, hindering their ability to adapt. Women tend to work more and take on more caring responsibilities during disasters in order to secure livelihoods, which leaves less time for education and developing new skills.7 In India, for example, women reported taking out loans to cope with the effects of increased care responsibilities and lost income due to extreme weather events.27 These livelihood effects coupled with increased out-of-pocket payments for health, risk increasing catastrophic health expenditure and impoverishment.

    Loss of income and lack of access to credit among WCA

    There is also evidence from high-income countries of gendered livelihood impacts of extreme weather events. After hurricane Katrina in the USA, for example, women were more likely to drop out of their current employment than men due to caregiving roles. In New Orleans, women experienced on average a 7% loss in earnings (a 14% loss among African-American women), whereas males experienced on average a 23% gain due to the increased importance of the construction and sales industries which are dominated by males.20

    For women to adapt better to extreme weather events, it is vital to incorporate sustainable farming practices, however, access to tools, knowledge and technology is often gendered and women may not possess the financial means or knowledge that is required to adopt sustainable farming practices. Women tend to have less access to seeds, fertilisers or tools, spend more time collecting water and often manually till fields, rather than using agricultural machinery.28 One of the main reasons for this is that women tend to have less access to credit and cash and are limited in their decision-making in male-headed households.20 27 As a result, climate change often reduces household income and forces a shift to lower income activities. In order to search for alternative work, males often migrate to rural areas, increasing the economic vulnerability of women.20

    Enhancing access to economic and social resources for women

    Enhancing access to economic and social resources for women is a crucial step to promote WCAH in the wake of climate change. Health is considered a key ‘non-economic loss and damage’,29 which would enable the loss and damage fund to address WCAH impacts of climate hazards, including for displaced populations. Insurance mechanisms, as part of loss and damage finance specifically targeting farmers, can be leveraged to improve resilience and food security. This can include government-backed insurance, potentially combining micro-insurance and macro-level contingency funds as part of a broader social protection programme.30 Index-based weather insurance, for example, can improve food security among farmers, however insurance on its own, and in particular market-based insurance, has limited potential to address non-economic loss and damage such as health.31 Moreover, barriers to accessing finance persist due to high illiteracy rates among women and complicated application processes, as well as prejudices towards marginalised groups.32 Financing also favours male-dominated sectors, including energy and transport, whereas female-dominated sectors such as agriculture or textile manufacturing are rarely acknowledged.33 For this reason, social protection support for alternative income sources, including skill development, training and household asset management, should be promoted for women,34 as well as expanding access to formal credit with reduced interest rates.35

    Moreover, UN agencies and multilateral development banks are relevant actors in providing dedicated funds for deforestation (Reducing Emissions from Deforestation and Forest Degradation, REDD+), or smallholder agriculture (Adaptation for Smallholder Agriculture Programme, ASAP) which have important linkages with women’s rights, livelihoods and health. These funds can be leveraged to provide support for sustainable farming practices with an equity lens.36 An evolving number of multilateral dedicated funds exist that provide financial support for climate mitigation and adaptation. The United Nations Framework Convention on Climate Change (UNFCCC) funds and its associated funds, further play a significant role in leveraging national sector and private finance.

    Displacement and migration

    Climate change has significantly disrupted displacement and migration patterns and drivers. It is also a threat multiplier, and may exacerbate conflict over depleted resources, leading to further movement.37 It is estimated that, by 2050, >216 million people will be internally displaced because of changing climatic conditions.38 Studies also show that women and children are particularly vulnerable as they have a higher likelihood to become trapped due to sociocultural gender norms,6 and are at greater risk of exploitation and human trafficking.10 Displacement can further have detrimental impacts on children as they can become separated from their families following a disaster, their access to education and healthcare can be disrupted, increasing the risk of malnutrition, inadequate immunisation and disease.8 Studies further found post-traumatic stress disorder, separation anxiety and depression among children who were exposed to disasters.11

    Increase in host health system resource needs, and health financing gaps for migrants

    Migration can, in exceptional cases, improve health and provide better access to healthcare. In reality, however, host regions or communities often lack adequate hygiene standards and public health resources, and the health of climate-migrants is becoming a key issue.37 Mental health issues arising from climate-driven migration can further trigger a feeling of solastalgia, which is understood as emotional and existential distress caused by climate change.39 Equally, migrants may not be covered by health financing arrangements when they move within their countries or to neighbouring countries.

    There is a pressing need to fund climate migration-related projects, both to develop adaptive measures that prevent displacement and to support people migrating. Funding for migrants comes primarily from high-income countries, and the current modalities to support fragile settings are not sustainable.40 A lack of in-depth understanding regarding which approaches are most successful, and the politicised nature of migration, currently pose barriers to intersectoral collaboration. There is an urgent need for more context-specific data and collaboration between migration experts and climate donors.41

    Innovative health financing for migrants, funding for host health systems and impacted communities to prevent migration

    Common financial challenges among refugees in humanitarian settings include high out-of-pocket payments, fragmented financial support and limited funding.42 Sources of innovative humanitarian health financing for refugees and migrants, such as health insurance schemes,42 multipurpose cash transfers43 or remittances, are needed to strengthen adaptive capacity and resilience among households.44

    The Global Cities Fund for Migrants and Refugees supports host communities to be better prepared for climate migration.45 The fund supports cities with technical and financial resources to address the needs of migrant communities affected by climate change. An additional fund was initiated specifically for migrant and displaced children and their care-givers, which supports their health and well-being.45 Evidence from India’s Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA) further suggests the relevance of social protection to climate resilience among the rural poor. MGNREGA guarantees labour and cash payments to the rural poor in India, which has contributed to female empowerment and protected children during droughts and decreased child labour. However, barriers to accessing the programme exist for individuals under working age, the disabled and women with childcare responsibilities.46

    Discussion

    WCA are disproportionately affected by the impacts of climate change. Gender-responsive climate finance and funding allocation are therefore needed to avoid an exacerbation of existing inequalities.47 Investing in WCA can also generate health, economic, social and environmental gains.3 Enhancing access to economic and social resources for women is a crucial step to promoting WCAH in the wake of climate change.

    There is potential for greater use of existing climate finance and to leverage additional funding to enhance the resilience of WCA and address the health consequences of climate change. There are an evolving number of multilateral climate funds that support WCAH activities and goals. The Green Climate Fund, for example, suggests various financing instruments that can support health goals, including climate grants, insurance or bonds for climate-sensitive health co-benefits.25 Other funds, such as the Adaptation Fund, have already developed plans to integrate gender in their processes and projects.47 To further facilitate access to multilateral climate finance, it will be important to promote the accreditation of more health organisations, which can apply for climate finance, especially those supporting WCA. A major addition to multilateral climate finance will be the Loss and Damage Fund, where the needs of those who are particularly vulnerable to the effects of climate change are supported. Further research and documentation of real-world practices are needed to support the valuation of WCAH-related loss and damages, especially non-economic loss and damages from climate change, to ensure that the Loss and Damage Fund fully accounts for these and can adequately support WCAH needs.

    In order for climate finance to benefit WCA, it is further crucial to increase the gender and age responsiveness of climate mitigation and adaptation plans.47 WCA are often relevant actors in the implementation of mitigation and adaptation strategies but their needs are usually not explicitly recognised and the health benefits of mitigation and adaptation projects for WCA often depend on community and household dynamics. For carbon credit-funded conservation projects, for example, community governance and impact on ecosystems determined the degree of investments in WCAH priorities.48 Literature further suggests that gender equity is better embedded in adaptation plans compared with mitigation plans. 46% of bilateral official development assistance to adaptation actions targeted gender equality, compared with only 28% for mitigation actions, highlighting the need to recognise the gendered effects of climate change and actively promote WCAH in climate action.49

    Another possible opportunity for donors to increase gender equity is through improving support of predictable finance for civil society organisations in the Global South. Supporting locally led action on climate change and gender is necessary to address the needs of WCA in the wake of climate change and to ensure funds reach the local level. In 2014, only 2% of gender-responsive climate aid supported civil society organisations in the Global South.49

    There is also a need for investments in new or adapted provider payment mechanisms or resource allocation formulae to incentivise ‘climate conscious’ behaviour (eg, initiatives to reduce emissions of the healthcare sector and/or to reduce vulnerability to climate hazards) among health workers and healthcare managers linked to health service delivery for WCA. These will be pertinent to addressing the specific vulnerabilities and needs of WCA in emergency and humanitarian response plans. The Global Financing Facility for Women, Children and Adolescents can, for example, be leveraged to support WCAH in the context of climate change by strengthening health systems and improving access to healthcare for WCA. More research is required to better understand the impacts and distributional effects of novel financing arrangements that support WCAH in the context of climate change. A co-financing agenda which addresses the needs of WCA arising from climate change, and builds resilience, while acknowledging their contributions to economic progress and social stability across the life-course, merits urgent consideration.

    Data availability statement

    There are no data in this work.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Not applicable.

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    Footnotes

    • Handling editor Seye Abimbola

    • X @EtienneVincentL

    • Contributors BA, SC and JB contributed to the conception and design of the paper and wrote the first draft of the paper and undertook the review underpinning the paper. MH, ZAB, EVL, DGI and GG contributed to the conception and design of the study and reviewed and contributed to the paper.

    • Funding The research underpinning this article was supported through a grant from the Partnership for Maternal, Newborn and Child Health (PMNCH), hosted by WHO.

    • Disclaimer The author is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the World Health Organization.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.