Building Climate-Resilient Health Systems in LMICs: A Pragmatic One Health Approach

The New Operational Baseline: Climate Change as a Health Systems Shock

For decades, global health security discourses framed climate change as a looming, horizon-level threat. Today, as a public health practitioner who has managed municipal health departments and disease surveillance systems in Nepal, I can state unequivocally that the horizon has arrived. Climate change is no longer an abstract modeling exercise; it is the daily operational baseline fundamentally altering the epidemiology of low- and middle-income countries (LMICs).

My training in Global Health Security at Yonsei University emphasized the theoretical frameworks of pandemic preparedness. However, ten years inside Nepal's government health service taught me that preparedness is meaningless if it cannot be executed at the primary care level. We are witnessing an unprecedented intersection of environmental degradation, shifting climatic zones, and health system vulnerabilities. From the expansion of vector-borne diseases into the high Himalayas to the silent, compounding lethality of extreme heat on non-communicable diseases (NCDs), our health architecture is being stress-tested in ways it was never designed to withstand.

Building climate-resilient health systems in LMICs requires more than high-level declarations at global conferences. It demands rigorous implementation science, the pragmatic operationalization of the One Health approach, and the modernization of routine health information systems like DHIS2 to generate actionable epidemic intelligence.

The Epidemiological Shift: Vector-Borne Diseases at High Altitudes

Perhaps the most visible indicator of climate-induced health shocks in South Asia is the shifting geography of vector-borne diseases. Historically, diseases like dengue, chikungunya, and malaria were confined to the tropical and subtropical plains. The Aedes aegypti and Aedes albopictus mosquitoes were not supposed to thrive in the temperate mid-hills of the Himalayas.

Yet, recent years have shattered these ecological boundaries. In Nepal, we have recorded massive dengue outbreaks sweeping through Kathmandu and reaching mountainous districts previously considered non-endemic, sometimes at altitudes exceeding 2,000 meters. The World Health Organization and the Lancet Countdown on Health and Climate Change have extensively documented this expansion, noting that the environmental suitability for transmission by Aedes mosquitoes is increasing globally.

For a municipal health chief, this epidemiological shift presents an immediate crisis in clinical capacity and supply chain management. When a disease emerges in a naive population where clinical suspicion is historically low, misdiagnosis is rampant. Patients presenting with dengue fever in highland primary healthcare centers are often initially treated for typhoid or seasonal influenza.

Implementation strategies must focus on rapid decentralization of diagnostics and the urgent retraining of the primary health workforce. We must update national standard treatment guidelines to reflect shifting endemicity and ensure that rapid diagnostic tests (RDTs) for expanding vector-borne diseases are pushed down to the lowest tiers of the health system.

Extreme Heat: The Silent Multiplier of NCD Mortality

While vector-borne disease outbreaks command media attention, extreme heat remains a poorly quantified, silent killer in LMICs. Having served as an NCD and mental health focal officer, I have observed firsthand how heatwaves act as a severe threat multiplier for chronic diseases.

During prolonged periods of extreme heat, which are becoming longer and more intense across South Asia, primary care facilities see spikes in acute exacerbations of cardiovascular diseases, chronic kidney disease (often linked to occupational heat stress in agricultural and construction workers), and respiratory distress. Furthermore, the mental health toll of extreme heat—ranging from heat-induced agitation and sleep deprivation to the psychological trauma of climate-driven displacement—is vastly under-reported.

Health system resilience against extreme heat must be addressed on two fronts: clinical management and infrastructure survival.

Clinically, heat action plans must be integrated into routine NCD management. Community health workers should be trained to identify heat exhaustion and educate vulnerable populations—such as the elderly, pregnant women, and those on specific antihypertensive medications—on heat mitigation.

Infrastructurally, extreme heat threatens the core functioning of healthcare facilities. Heatwaves often trigger rolling power blackouts, compromising vaccine cold chains and disrupting essential medical equipment. Resilient health systems must prioritize the integration of renewable energy, specifically solar-hybrid power backups, to ensure that life-saving cold chains and emergency trauma care capacities remain intact during climate shocks.

Operationalizing One Health at the Municipal Level

To effectively combat the climate-health nexus, the global health community heavily promotes the 'One Health' approach—a framework recognizing the absolute interconnection between human, animal, and environmental health. However, as an implementation science researcher, I frequently encounter the gap between One Health as a Geneva-level policy and One Health as a municipal reality.

At the local government tier in LMICs, human health, animal health (veterinary services), and environmental health (water, sanitation, and forestry) operate in strict bureaucratic silos. They possess separate budgets, separate reporting lines, and separate data systems. When a zoonotic spillover event occurs—whether it is scrub typhus, an anthrax outbreak, or rising rabies cases—the lack of joint investigation protocols leads to delayed responses and preventable mortality.

Operationalizing One Health requires structural reform at the local level. Implementation strategies must include:

1. 01Establishing Joint Rapid Response Teams (RRTs): Municipalities must legally mandate and fund cross-sectoral RRTs comprising medical officers, veterinarians, and environmental engineers who deploy jointly during suspected zoonotic or environmental health emergencies.
2. 02Coordinated Budgeting: Local governments must be incentivized to create pooled funding mechanisms specifically dedicated to One Health interventions, breaking the cycle of vertical, disease-specific financing.
3. 03Shared Risk Communication: When climate hazards emerge, such as heavy monsoons risking both cholera outbreaks and livestock diseases, risk communication to the public must be unified rather than contradictory messages from different departments.

Leveraging DHIS2 for Climate-Sensitive Epidemic Intelligence

No health system can be climate-resilient without robust, real-time data. In many LMICs, including Nepal, the District Health Information Software 2 (DHIS2) serves as the backbone of the Health Management Information System (HMIS). However, these systems have traditionally been used for retrospective reporting—counting cases weeks after an outbreak has peaked.

To build climate resilience, we must transform routine HMIS from a passive reporting tool into an active Epidemic Intelligence system. This requires addressing fundamental data quality issues and integrating new data streams.

First, data quality is paramount. If facility-level reporting is delayed, incomplete, or inaccurate, early warning mechanisms will fail. Implementation efforts must focus on reducing the administrative burden on frontline workers, utilizing DHIS2 Tracker for longitudinal patient data, and institutionalizing routine data quality assessments (RDQA).

Second, we must integrate meteorological and environmental data into DHIS2. By overlaying temperature, rainfall, and humidity data with epidemiological trends, health departments can utilize Early Warning and Response Systems (EWARS) to forecast outbreaks. For instance, sustained rainfall coupled with specific temperature ranges can trigger predictive alerts for dengue or malaria surges, allowing local health chiefs to pre-position commodities and mobilize vector-control teams weeks before the clinical caseload overwhelms local hospitals.

Implementation Science Framework for Climate Resilience

Moving from policy to practice requires structured implementation. The following matrix outlines how local governments can systematically deploy and measure climate-resilience strategies:

Financing Adaptation and the Global Health Architecture

The reshaping of global health architecture post-pandemic has rightly emphasized equity, but climate-health financing remains heavily bottlenecked. While multilateral institutions like the World Bank and mechanisms emerging from recent COP summits pledge substantial funds for climate adaptation, these resources rarely reach the sub-national levels where they are most desperately needed.

For a municipal health chief in a resource-constrained setting, navigating the complex accreditation requirements to access global climate funds is nearly impossible. Global health financing must be decentralized. National governments in LMICs must design mechanisms that funnel climate-health adaptation funds directly to local governments in the form of conditional grants for health system strengthening.

Furthermore, donors must move away from funding fragmented, vertical disease programs. A dollar spent on resilient infrastructure—such as solarizing a primary healthcare center or building an interoperable HMIS—yields dividends across pandemic preparedness, maternal health, NCD management, and climate adaptation simultaneously.

Conclusion: Moving from Reactive to Predictive Systems

The intersection of climate change and public health is not a distant scenario to be modeled; it is the current reality being managed by frontline health workers every day. In LMICs, where resources are finite and health systems are already stretched by the dual burden of communicable and non-communicable diseases, we cannot afford to remain reactive.

By leveraging implementation science to operationalize the One Health approach, integrating climate data into routine DHIS2 surveillance for epidemic intelligence, and addressing the silent crisis of extreme heat, we can build health systems that do not merely survive climate shocks, but adapt and protect the most vulnerable. It requires a fundamental shift in mindset from global policy corridors to local municipal chambers: climate resilience is no longer an optional add-on to public health; it is the very foundation upon which future global health security must be built.