1. Introduction
There is a growing body of evidence that Earth is warming at an unprecedented rate as a result of anthropogenic activities, such as deforestation, urbanization, population growth, industrialization and the release of greenhouse gases [
1]. The Intergovernmental Panel on Climate Change (IPCC) predicts an increase of 1.5–5.8
C in global average temperature by 2100 as a result of greenhouse emissions [
2]. Despite the fact that the wealthiest countries are disproportionately responsible for more emissions than developing countries, the consequences of climate change are more severe in the poorest countries, particularly in sub-Saharan Africa. In fact, developing countries have the least adaptive capacity justified by limited access to climate information, financial, human, natural resources, and armed conflicts [
3]. As a consequence of climate change, it is estimated that more than 30 million people in sub-Saharan Africa will fall into poverty if no substantial climate and development action is taken by 2050 [
4]. Furthermore, it is expected that the gross domestic product to decrease by 3%, a scenario that poses a significant challenge to climate adaptation and resilience efforts, as it will lead to an increase in the number of people affected [
5].
The effects of CC on disease prevalence and human health are multifaceted. Studies show that CC is behind the unprecedented increase in a myriad of non-communicable and communicable diseases, such as vector and waterborne diseases, respiratory, and cardiovascular diseases [
6,
7]. For instance, rainfall affects water-borne diseases, and a large number of diarrhea pathogens are water-borne and will therefore be affected by CC through water availability and temperature. Moreover, CC can potentially trigger heat waves, floods, droughts, and storms, leading to high fatalities and injuries and altering disease scenarios [
8]. Additionally, these events have other negative health consequences, such as depriving the health facilities of water, sanitation systems and electricity (thus interrupting the cold chain of vaccines, reagents and some drugs), blocking access routes to health facilities, destroying warehouses and stores of sanitary consumables, causing delays and absences in health personnel, etc.
Mozambique is considered to be at a high risk of being influenced by climate change due to its geographical position, along the coastline and downstream of main rivers in southern Africa. As a matter of fact, among the most vulnerable countries to natural disasters, the country ranks third [
9]. In the last 42 years, the country has registered 15 droughts, 20 floods and 26 tropical cyclones [
10]. In March 2019, the country was hit by the deadliest tropical cyclone to ever hit Africa (cyclone Idai), ranked as the second-deadliest on record [
11,
12]. The tropical cyclone caused significant flooding in Madagascar, Mozambique, Malawi, and Zimbabwe, killing more than 1500 people. In Mozambique, the cyclone affected mainly the provinces of Inhambane, Manica, Sofala and Zambézia, leading to 1.85 million people in need of humanitarian assistance and protection [
13]. In The province of Sofala, which was the most affected, the cyclone prompted a cholera outbreak, with more than two thousand cholera cases [
13]. Subsequently, in less than two months, the country was again struck by another intense tropical cyclone, named Cyclone Kenneth. Tropical cyclone Kenneth affected the northern provinces of the country, Cabo Delgado and Nampula, displacing more than 18 thousand people and causing 45 deaths [
14,
15].
Amid increased vulnerability, it is worth stressing that the impact of CC can be mitigated through preparedness, adaptation and strengthening of the health system. Therefore, this calls for the creation of policies that will strengthen the health system and other social sectors. Nevertheless, the creation of conducive policies is somehow dependent on the vulnerability and adaptation assessment of the health sector. With these grounds, the present study aims at assessing the vulnerability and adaptation needs of the health sector to climate change in Mozambique. To the best of our knowledge, this is the first study in Mozambique, as for the first time an assessment of the vulnerability of the health sector to climate change on a national scale is carried out in the country.
4. Discussion
The present study, which is the first of its kind in the country, sought to derive a health vulnerability index for assessing the vulnerability and adaptation needs of the health sector to climate change in Mozambique at the district level. The health vulnerability index was operationalized following the IPCC definition of vulnerability, generating measures for exposure, sensitivity and adaptive capacity at the district level. This allowed us to assess how the vulnerability and its dimensions vary within the country. Our results pointed out that exposure to climate change is substantially high in the southern region of Mozambique. Additionally, the results showed that coastal districts located in other regions of the country are also highly exposed to climate hazards, emphasizing Nhamatanda, Buzi, Beira and Marromeu districts in Sofala province. The elevated exposure index among districts located in the coastal area can be justified because this region of the country is exposed to several coastal hazards, including tropical cyclones, storm surges, and sea level rise [
42]. In fact, Mozambique has a vast coastline of about 2,500 km in an area highly prone to tropical depressions and typhoons. In the last 40 years, Mozambique has been hit by about 21 cyclones, most of them affecting coastal districts. These results are consistent with the study by Cabral et al. [
43] on Mozambique’s exposure to coastal climate hazards and erosion. The authors found that districts on the central coast had more than 10% of their coastal areas with higher exposure to climate hazards.
The results also revealed that the southern region of Mozambique is highly exposed to climatic hazards. In fact, it is worth noting that this part of the country locates in one of the largest river basins of the Southern African development community (SADC). This Limpopo River basin has been subject to several floods of great magnitude. In the last 70 years, in 1955, 1967, 1972, 1975, 1977, 1981, 2000, and 2013, severe floods have affected the Limpopo river basin, caused mainly by heavy localized rainfall, tropical cyclones and inadequate management of upstream dams and wetlands [
44,
45]. The analysis also showed that contrary to other regions that only experience one time of climatic hazard, the southern region experiences all the climatic hazards, which could be behind the elevated exposure index in this part of the country. The results also indicated that the districts along the Zambezi River basins (the second largest river basin in the African continent) in Zambézia and Nampula province are also susceptible to extreme weather events, mainly to floods.
With regard to the sensitivity of the country’s population to climate change, the results suggested that despite the country being highly exposed to extreme weather events, the country is vastly characterized by districts with either low or moderate sensitivity. The reasons behind the generalized low sensitivity index nationwide are not evident. Nevertheless, a more in-depth analysis (not shown herein) suggested that although the country is prone to extreme weather events, the country experiences few cholera outbreaks. Districts located in Mozambique’s central and northern regions, such as Beira, Caia, Tete, Nampula Melucu, and Mecufi, which have frequent cholera outbreaks, are the ones that stood out with high sensitivity. In fact, Mozambique’s central and northern regions are more prone to floods than the southern region, which often cause people to move and settle into overcrowded places with poor sanitation conditions, increasing the risk of cholera outbreaks. For instance, in 2019, an intense tropical cyclone hit the central region of Mozambique, leaving the region entirely devastated, causing a cholera outbreak with more than six thousand cases [
46,
47]. Additionally, it is worth emphasizing that districts with high sensitivity also had a high risk of food insecurity between 2016 and 2019. With the northern region being prone to floods as a result of climate change, it is expected that there is a destruction of food crops, storehouses and livestock, and as a result, a decline in food availability and an increase in the risk of food insecurity, which in turn would increase nutritional problems among children under five [
48,
49]. According to the Mozambique Technical Secretariat for Food Security and Nutrition (SETSAN), chronic food insecurity is most prominent in the central and northern regions of the country [
50].
The results further revealed that Mozambique generally has a low adaptive capacity, being more pronounced in the central and northern regions of the country. Poverty, limited investments in advanced technology, and the fragility of infrastructure and social services, particularly health and sanitation, may explain the country’s poor adaptive capacity to climate change [
51]. As a matter of fact, it is expected that regions or districts with well-developed institutions coupled with higher levels of capital and stores of human knowledge are considered to have higher adaptive capacity [
52]. For instance, data on the fourth national evaluation on poverty and wellness in Mozambique indicate that the northern region has the highest poverty rates, with the province of Niassa standing out with rates around 60%. Hence, the expected low adaptive capacity among districts from this province. Additionally, a critical examination of the results revealed that the central and northern regions have poor sanitation conditions, which is more evident in rural districts. Add to that, the prevalence of water-borne diseases among children under five is more pronounced in the central and northern regions of Mozambique, varying between 4.1% and 14.5% [
53].
Among the determinants contributing to high adaptive capacity, we also found that access to health services is still deficient in Mozambique, mainly in Niassa (northern region) and the provinces of Gaza and Inhambane (southern region). Nevertheless, it is worth emphasizing that the identified provinces have the least population density with sparse households, which at some point hinders the provision of health services and access to them. These findings align with a study by dos Anjos Luis and Cabral [
54]. The authors analyzed the geographic accessibility to primary healthcare centres in Mozambique. They found that the provinces of Nampula (northern region), Zambézia and Tete (central region), and Inhambane (southern region) have the highest number of villages outside 60 min of a health facility. The results also indicated that access to healthcare is urban-biased. The inequalities in the distribution of health facilities can be justified by the fact that many infrastructures in the rural area were destroyed during the civil war, which makes many of the rural districts much more vulnerable to the impact of climate change [
55]. The lack of access to healthcare not only puts the districts into an increased vulnerability but also affects the abilities of districts to cope with the effects of climate change, such as the rise of cases of cholera, diarrhea, malaria and food insecurity, after the country has experienced an extreme weather event.
Although the study clarifies the spatial trend of the HVI in Mozambique, there are some limitations. Due to a lack of data on some indicators for some of the districts, proxy indicators were used to assess the exposure, sensitivity and adaptive capacity. Therefore, one should consider the limitations associated with using proxies: under-representation or over-representation. Another major limitation was the lack of weather stations for all the country districts, which made it impossible to obtain in-situ data. Additionally, for several reasons, the historical series of climatic data collected by the operational weather stations present numerous gaps, making it even more difficult to obtain complete and consistent databases to conduct an analysis of this nature. To overcome this situation, the study used reanalysis data. Nevertheless, climate data from reanalysis can be over- or under-estimated in specific periods and zones of the country [
56]. For some indicators, it was not possible to obtain recent data. For instance, for health determinants and water and sanitation data, we had to rely on 2007 census data, despite the 2017 census having been carried out, as by the time of VAA the 2017 census data was not publicly available. Therefore, it is possible that the adaptive capacity index is somehow underestimated, as indicators for these components might have improved over the last 12 years.
5. Conclusion
Overall, the results suggested that the country is highly vulnerable to climate change, except for the main capital cities, which can be explained by the fact that the country is situated in the zone of inter-tropical convergence and downstream of shared watersheds, and frequently endure severe weather-related natural disasters [
57]. The country’s high exposure to tropical cyclones, floods and droughts is particularly significant. It is worth emphasizing that most people in Mozambique fully depend on subsistence farming. Thus, climate variations have to potential to influence the livelihood and the economy of such areas, which in most cases lead to the destruction of crops, livestock and wildlife, loss of human lives, damage to social and economic infrastructure, harm to human health and the environment, etc. For instance, more recently, the cyclones Idai and Kenneth have caused tens of thousands of families, leaving many needing basic supplies such as water and food. The storms also destroyed about 780,000 hectares of agricultural crops, which triggered a nutritional crisis that affected about one million people, including 160,000 children under five [
58]. The natural disasters not only destroyed crops but also schools, hospitals and other infrastructures were destroyed, leaving the country more fragile. Knowing that it is not possible to modify the country’s exposure to climate change or its sensitivity in the short term, it is important to develop policies, strategies, plans and activities that reinforce the ability of the system, communities and individuals to better adapt to climate changes and deal with the changes they bring.
The results provided in this study within the vulnerability analysis framework give a baseline for developing strategies and adaptation actions. Nevertheless, it is essential to consider the multi-sectoral nature of the country’s vulnerability. As we have seen in previous chapters, the HVI on which this analysis is based includes indicators relating to water and sanitation, nutritional status and food security, education, development, etc., which are outside the direct control of the health sector. While each sector must develop its own analyses, strategies and plans, a coordinated multisectoral approach is essential to be able to mitigate the effects of climate changes, implement effective measures to improve adaptive capacity and optimize the limited existing resources. Furthermore, the current study will allow competent authorities to design targeted district-specific policies to mitigate the effect of climate change in the communities. The results showed that coastal districts are highly vulnerable to tropical cyclones. Therefore, the health authorities must ensure the construction of resilient infrastructure to minimize the impacts of climate change. Another point that is worth being emphasized is women’s empowerment. Worldwide, women dominate poverty; in urban areas, about 40% of poor households are headed by women. Additionally, women represent the largest share that is dependent on natural resources (which are often affected by climate change) for livelihood [
59]. Therefore, it is essential to build strategies and policies that promote women’s empowerment in the communities, assuring gender equality in many sectors of the country, mainly among adolescents and youth.
Author Contributions
Conceptualization, R.M, G.M, and W.K; methodology, R.M., G.M., T.M., and L.K.; software, R.M.; validation, R.M., A.J., S.T and G.M.; formal analysis, R.M. G.M., A.J., P.M., I.A., M.K., S.T., W.K., O.I., T.M. and L.K.; investigation, R.M. and G.M; data curation, R.M. I.A., M.K. and G.M; writing—original draft preparation, R.M.; writing—review and editing, T.M., G.M, I.A., M.K., A.J., P.M., O.I., S.T, W.K. and L.K. .; visualization, R.M.; supervision, G.M., T.M., W.K. and L.K. All authors have read and agreed to the published version of the manuscript.