CLIMATE AND HEALTH COUNTRY PROFILE – 2015 MALAYSIA
OVERVIEW Malaysia, with a population of 29 milliona, has had steady recent economic growth and succeeded in nearly eradicating poverty [World Bank, Country Overview, 2015]. In international climate discussions (COP21, Copenhagen), Malaysia announced a conditional voluntary target of up to 40% reduction in carbon intensity of GDP by 2020 compared to 2005 levels. Malaysia has also had a strong focus on the development of sustainable energy policies (see section 5). Malaysia faces numerous potential threats to population health and development due to climate change. Communities living in coastal regions could be at risk of flooding due to sea-level rise. Climate sensitive diseases such as malaria, cholera and dengue as well as heat-stress are likely to rise with increased temperatures and changes in precipitation patterns.
and 1990. A rapid reduction in emissions could limit heat-related deaths in the elderly to just over 6 deaths per 100,000 in 2080.
OPPORTUNITIES FOR ACTION Malaysia has adopted a National Policy on Climate Change which incorporates health perspectives. Currently Malaysia has a number of policies and plans which are responsive to climate change such as flood mitigation plans, fire suppression plans, etc. Malaysia is taking steps to address the potential health impacts of climate change by managing the aspects of climate change that may affect public health. From time to time, response measures are also being established to avoid situations that will affect or worsen public health due to climate change impacts. Malaysia is currently implementing projects on health adaptation to climate change, building institutional and technical capacities to work on climate change and health, and has conducted a national assessment of climate change impacts, vulnerability and adaptation for health. Country reported data (see section 6) indicate further opportunities for action in the following areas:
SUMMARY OF KEY FINDINGS • Under a high emissions scenario, mean annual temperature is projected to rise by about 4°C on average from 1990 to 2100. If emissions decrease rapidly, the temperature rise is limited to about 1.1°C. • Under a high emissions scenario, and without large investments in adaptation, an annual average of 234,500 people are projected to be affected by flooding due to sea level rise between 2070 and 2100. If emissions decrease rapidly and there is a major scale up in protection (i.e. continued construction/raising of dikes) the annual affected population could be limited to about 300 people. Adaptation alone will not offer sufficient protection, as sea level rise is a long-term process, with high emissions scenarios bringing increasing impacts well beyond the end of the century. • Under a high emissions scenario heat-related deaths in the elderly (65+ years) are projected to increase to almost 45 deaths per 100,000 by 2080 compared to the estimated baseline of under one death per 100,000 annually between 1961
1) Adaptation • Estimate costs to implement health resilience to climate change.
2) Mitigation • Develop an Integrated Disease Surveillance and Response (IDSR) system with early warning for climate-sensitive health risks. • Conduct valuation of co-benefits to health of climate change mitigation activities.
3) National policy implementation • Formulate action plans and work programmes to support the implementation of policies related to climate change and health.
DEMOGRAPHIC ESTIMATES Population (2013)a Population growth rate (2013)a Population living in urban areas (2013)b Population under five (2013)a Population aged 65 or older (2013)a 29 million 1.5% 73.3% 8.0% 5.4% 10,628 USD 4% 4.54% 0.773 74 years 7.5 e United Nations Development Programme, Human Development Reports (2014) f Global Health Observatory, WHO [2014] g Levels & Trends in Child Mortality Report 2015, UN Inter-agency Group for Child Mortality Estimation [2015]
ECONOMIC AND DEVELOPMENT INDICATORS GDP per capita (current US$, 2013)c Total expenditure on health as % of GDP (2013)d Percentage share of income for lowest 20% of population (2009)c HDI (2013, +/- 0.01 change from 2005 is indicated with arrow)e
HEALTH ESTIMATES Life expectancy at birth (2013)f Under-5 mortality per 1000 live births (2013)g a b c d World Population Prospects: The 2015 Revision, UNDESA (2015) World Urbanization Prospects: The 2014 Revision, UNDESA (2014) World Development Indicators, World Bank (2015) Global Health Expenditure Database, WHO (2014)
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CURRENT AND FUTURE CLIMATE HAZARDS
Due to climate change, many climate hazards and extreme weather events, such as heat waves, heavy rainfall and droughts, could become more frequent and more intense in many parts of the world. Outlined here are country–specific projections up to the year 2100 for climate hazards under a ‘business as usual’ high emissions scenario compared to projections under a ‘two-degree’ scenario with rapidly decreasing global emissions. Most hazards caused by climate change will persist for many centuries.
COUNTRY-SPECIFIC CLIMATE HAZARD PROJECTIONS The model projections below present climate hazards under a high emissions scenario, Representative Concentration Pathway 8.5 [RCP8.5] (in orange) and a low emissions scenario, [RCP2.6] (in green).a The text boxes describe the projected changes averaged across about 20 models (thick line). The figures also show each model individually as well as the 90% model range (shaded) as a measure of uncertainty and, where available, the annual and smoothed observed record (in blue).b,c
MEAN ANNUAL TEMPERATURE
DAYS OF WARM SPELL (‘HEAT WAVES’)
30
300
°C
28 30 26
Days
200 300 100
°C
28 24 26 1900 1950 2000 2050 2100
Days Year
200 0 100 1900 1950 2000 2050 2100
Year
24 emissions scenario, mean annual temperature is Under a high projected to rise by about 4°C on average from 1990 to 2100. If 1900 rapidly, 1950 the 2000 2050 rise 2100 emissions decrease temperature is limited to about 1.1°C. 60 50
Year
Under a high 0 emissions scenario, the number of days of warm spelld is projected to increase from about 10 days in 1990 to 1900on average 1950 in2000 2050 2100 about 300 days 2100. If emissions decrease rapidly, the days of warm spell are limited to about 100 Year on average. 40 30 CONSECUTIVE DRY DAYS (‘DROUGHT’)
DAYS WITH EXTREME RAINFALL (‘FLOOD RISK’) 40
Days
60 30 50 20 40 10
Days
20 40 10 30
Days
30 0 20 1900 10 0 1900 1950 2000 2050 2100 1950 2000 2050 2100
Days Year
0 20 10 0 1900 1950 2000 2050 2100 1900 1950 2000 2050 2100
Year
Year Under a high emissions scenario, the number of days with very heavy precipitation (20 mm or more) could increase by about 7 days on average from 1990 to 2100, increasing the risk of floods. A few models indicate increases well outside the range of historical variability, implying even greater risk. If emissions decrease rapidly, the increase in risk is much reduced.
Year Under both high and low emissions scenarios, the longest dry spell may increase by 2 or 3 days from an average of just under 20 days, with continuing large year-to-year variability.
a b c d
Model projections are from CMIP5 for RCP8.5 (high emissions) and RCP2.6 (low emissions). Model anomalies are added to the historical mean and smoothed. Observed historical record of mean temperature is from CRU-TSv.3.22; observed historical records of extremes are from HadEX2. Analysis by the Climatic Research Unit and Tyndall Centre for Climate Change Research, University of East Anglia, 2015. A ‘warm spell’ day is a day when maximum temperature, together with that of at least the 6 consecutive previous days, exceeds the 90th percentile threshold for that time of the year. 2
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CURRENT AND FUTURE HEALTH RISKS DUE TO CLIMATE CHANGE
Human health is profoundly affected by weather and climate. Climate change threatens to exacerbate today’s health problems – deaths from extreme weather events, cardiovascular and respiratory diseases, infectious diseases and malnutrition – whilst undermining water and food supplies, infrastructure, health systems and social protection systems.
EXPOSURE TO FLOODING DUE TO SEA LEVEL RISE Severity of climate change scenario RCP2.6 Without Adaptation 27,100 234,500 With Adaptation 300 600
KEY IMPLICATIONS FOR HEALTH Malaysia also faces inland river flood risk due to climate change. Under a high emissions scenario, it is projected that by 2030, 85,800 additional people may be at risk of river floods annually due to climate change and 89,300 due to socio-economic change above the estimated annual affected population of 307,700 in 2010.a In addition to deaths from drowning, flooding causes extensive indirect health effects, including impacts on food production, water provision, ecosystem disruption, infectious disease outbreak and vector distribution. Longer term effects of flooding may include post-traumatic stress and population displacement.
* Medium ice melting scenario
RCP8.5
** Values rounded to nearest ‘00
Under a high emissions scenario, and without large investments in adaptation, an annual average of 234,500 people are projected to be affected by flooding due to sea level rise between 2070 and 2100. If emissions decrease rapidly and there is a major scale up in protection ( i.e. continued construction/raising of dikes) the annual affected population could be limited to about 300 people. Adaptation alone will not offer sufficient protection, as sea level rise is a long-term process, with high emissions scenarios bringing increasing impacts well beyond the end of the century. Source: Human dynamics of climate change, technical report, Met Office, HM Government, UK, 2014.
INFECTIOUS AND VECTOR-BORNE DISEASES Population at risk of malaria in Malaysia (in millions) 50 Population at risk (millions) 45 40 35 30 25 20 15 10 5 0 Baseline 1961–1990 2021–2050 2041–2070 RCP2.6 RCP8.5
KEY IMPLICATIONS FOR HEALTH Some of the worlds most virulent infections are also highly sensitive to climate: temperature, precipitation and humidity have a strong influence on the life-cycles of the vectors and the infectious agents they carry and influence the transmission of water and foodborne diseases.b Socioeconomic development and health interventions are driving down burdens of several infectious diseases, and these projections assume that this will continue. However, climate conditions are projected to become significantly more favourable for transmission, slowing progress in reducing burdens, and increasing the populations at risk if control measures are not maintained or strengthened.c
By 2070, under both emissions scenarios, approximately 43 million people are projected to be at risk of malaria compared to the estimated baseline of 17.6 million. Population growth can also cause increases in the population at risk in areas where malaria presence is static in the future. Source: Rocklöv, J., Quam, M. et al. 2015.d
Mean relative vectorial capacity for dengue fever transmission in Malaysia Mean relative vectorial capacity 1.20 1.00 0.80 0.60 0.40 0.20 0.00 Baseline 1961–1990 RCP2.6 RCP8.5 2021–2050 RCP2.6 RCP8.5 2041–2070
Under both high and low emissions scenarios, the mean relative vectorial capacity for dengue fever transmision is projected to increase from the baseline period towards 2070. Co-factors such as urbanization, development and population movements may modify the disease burdens associated with dengue, and make the disease cross new sub-national borders. Source: Rocklöv, J., Quam, M. et al., 2015.d
a b c d
World Resources Institute, Aqueduct Flood Analyser; Assumes continued current socio-economic development trends (SSP2) and a 10-year flood plan. Atlas of Health and Climate, WHO & WMO 2012. Quantitative risk assessment of the effects of climate change on selected causes of death, 2030s and 2050s. Geneva: World Health Organization, 2014. Country-level analysis, completed in 2015, was based on health models outlined in the Quantitative risk assessment of the effects of climate change on selected causes of death, 2030s and 2050s. Geneva: World Health Organization, 2014. 3
HEAT-RELATED MORTALITY Heat-related mortality in population 65 years or over, Malaysia (deaths / 100,000 population 65+ years) Deaths/100,000 population 65+ years 50 40 30 20 10 0 Baseline 1961–1990 RCP2.6 RCP8.5 RCP2.6 RCP8.5 RCP2.6 RCP8.5 2030 2050 2080
KEY IMPLICATIONS FOR HEALTH Climate change is expected to increase mean annual Text text text text Text text text text Text textof text temperature and the intensity and frequency heat text Text text text text Text number text textof text Text text waves resulting in a greater people at risk text text of heat-related medical conditions. The elderly, children, the chronically ill, the socially isolated and at-risk occupational groups are particularly vulnerable to heat-related conditions.
Under a high emissions scenario heat-related deaths in the elderly (65+ years) are projected to increase to almost 45 deaths per 100,000 by 2080 compared to the estimated baseline of under one death per 100,000 annually between 1961 and 1990. A rapid reduction in emissions could limit heat-related deaths in the elderly to about 6 deaths per 100,000 in 2080. Source: Honda et al., 2015.a
UNDERNUTRITION Climate change, through higher temperatures, land and water scarcity, flooding, drought and displacement, negatively impacts agricultural production and causes breakdown in food systems. These disproportionally affect those most vulnerable to hunger and can lead to food insecurity. Vulnerable groups risk further deterioration into food and nutrition crises if exposed to extreme weather events.b Without considerable efforts made to improve climate resilience, it has been estimated that the risk of hunger and malnutrition globally could increase by up to 20 percent by 2050.b In Malaysia, the prevalence of child malnutrition in children under age 5 is 12.9% (2006).c
a Country-level analysis, completed in 2015, was based on health models outlined in the Quantitative risk assessment of the effects of climate change on selected causes of death, 2030s and 2050s. Geneva: World Health Organization, 2014. b World Food Project 2015 https://www.wfp.org/content/two-minutes-climate-change-and-hunger c World Health Organization, Global Database on Child Growth and Malnutrition [2015 edition]. Child malnutrition estimates are for % underweight, defined as: Percentage of children aged 0–59 months who are below minus two standard deviations from median weight-for-age of the World Health Organization (WHO) Child Growth Standards.
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CURRENT EXPOSURES AND HEALTH RISKS DUE TO AIR POLLUTION
Many of the drivers of climate change, such as inefficient and polluting forms of energy and transport systems, also contribute to air pollution. Air pollution is now one of the largest global health risks, causing approximately seven million deaths every year. There is an important opportunity to promote policies that both protect the climate at a global level, and also have large and immediate health benefits at a local level.
OUTDOOR AIR POLLUTION EXPOSURE Outdoor air pollution in cities in Malaysia annual mean PM2.5 (μg/m3) 2012* WHO annual mean PM2.5 guideline value (10 μg/m3) 18 16
KEY IMPLICATIONS FOR HEALTH Outdoor air pollution can have direct and sometimes severe consequences for health. Fine particles which penetrate deep into the respiratory tract subsequently increase mortality from respiratory infections and diseases, lung cancer, and cardiovascular disease.
Annual mean PM2.5, μg/m3
14 12 10 8 6 4 2 0 Bayan Lepas Kota Kinabalu Kuantan Kuching Petaling Jaya
In 2012, the five most populated cities for which there was air pollution data available had annual mean PM2.5 levels that were above the WHO guideline value of 10 µg/m3. Please note that the PM2.5 converted values, presented here, are indicative only and are to be taken with care since conversion factors are approximative. As the PM2.5 data is presumptive based on the application of a conversion factor applied as per the WHO Ambient Air Pollution Database methodology, the Government of Malaysia assumes no responsibility for any misunderstanding to readers and these values are not official Government of Malaysia estimates. Source: Ambient Air Pollution Database, WHO, May 2014. * The conversion of PM10 to PM25 values is based on a National conversion factor if available or regional conversion factor otherwise. National conversion factor is a city population-weighted conversion factor. The regional conversion factor is not population weighted.
SHORT LIVED CLIMATE POLLUTANTS
KEY IMPLICATIONS FOR HEALTH Short-lived climate pollutants such as black carbon, methane and tropospheric ozone – released through inefficient use and burning of biomass and fossil fuels for transport, housing, power production, industry, waste disposal (municipal and agricultural) and forest fires – are responsible for a substantial fraction of global warming as well as air-pollution related deaths and diseases. Since short-lived climate pollutants persist in the atmosphere for weeks or months while CO2 emissions persist for years, significant reductions of SLCP emissions could result in immediate health benefits and health cost savingsa, and generate very rapid climate benefits – helping to reduce near-term climate change by as much as 0.5oC before 2050.a In Malaysia, it is estimated that a reduction in SLCPs* could prevent 5,900 premature deaths attributed to outdoor air pollution per year, from 2030 onwards (Shindell, D., et al, Science, 2012). *Through implementation of 14 reduction measures: 7 targeting methane emissions and the rest, emissions from incomplete combustion. See source for further detail.
a United Nations Environment Programme. Reducing Climate-related Air Pollution and Improving Health: Countries can act now and reap immediate benefits. http://www.unep.org/ccac/Media/PressReleases/ReducingClimate-relatedAirPollution/tabid/131802/language/en-US/Default.aspx
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CO-BENEFITS TO HEALTH FROM CLIMATE CHANGE MITIGATION: A GLOBAL PERSPECTIVE
Health co-benefits are local, national and international measures with the potential to simultaneously yield large, immediate public health benefits and reduce the upward trajectory of greenhouse gas emissions. Lower carbon strategies can also be cost-effective investments for individuals and societies. Presented here are examples, from a global perspective, of opportunities for health co-benefits that could be realised by action in important greenhouse gas emitting sectors.a
Transport Transport injuries lead to 1.2 million deaths every year, and land use and transport planning contribute to the 2–3 million deaths from physical inactivity. The transport sector is also responsible for some 14% (7.0 GtCO2e) of global carbon emissions. The IPCC has noted significant opportunities to reduce energy demand in the sector, potentially resulting in a 15%–40% reduction in CO2 emissions, and bringing substantial opportunities for health: A modal shift towards walking and cycling could see reductions in illnesses related to physical inactivity and reduced outdoor air pollution and noise exposure; increased use of public transport is likely to result in reduced GHG emissions; compact urban planning fosters walkable residential neighborhoods, improves accessibility to jobs, schools and services and can encourage physical activity and improve health equity by making urban services more accessible to the elderly and poor.
Electricity Generation Reliable electricity generation is essential for economic growth, with 1.4 billion people living without access to electricity. However, current patterns of electricity generation in many parts of the world, particularly the reliance on coal combustion in highly polluting power plants contributes heavily to poor local air quality, causing cancer, cardiovascular and respiratory disease. Outdoor air pollution is responsible for 3.7 million premature deaths annually, 88% of these deaths occur in low and middle income countries. The health benefits of transitioning from fuels such as coal to lower carbon sources, including ultimately to renewable energy, are clear: Reduced rates of cardiovascular and respiratory disease such as stroke, lung cancer, coronary artery disease, and COPD; cost-savings for health systems; improved economic productivity from a healthier and more productive workforce.
Household Heating, Cooking and Lighting Household air pollution causes over 4.3 million premature deaths annually, predominantly due to stroke, ischaemic heart disease, chronic respiratory disease, and childhood pneumonia. A range of interventions can both improve public health and reduce household emissions: a transition from the inefficient use of solid fuels like wood and charcoal, towards cleaner energy sources like liquefied petroleum gas (LPG), biogas, and electricity could save lives by reducing indoor levels of black carbon and other fine particulate matter; where intermediate steps are necessary, lower emission transition fuels and technologies should be prioritized to obtain respiratory and heart health benefits; women and children are disproportionately affected by household air pollution, meaning that actions to address household air pollution will yield important gains in health equity; replacing kerosene lamps with cleaner energy sources (e.g. electricity, solar) will reduce black carbon emissions and the risk of burns and poisoning.
Healthcare Systems Health care activities are an important source of greenhouse gas emissions. In the US and in EU countries, for example, health care activities account for between 3–8% of greenhouse gas (CO2-eq) emissions. Major sources include procurement and inefficient energy consumption. Modern, on-site, low-carbon energy solutions (e.g. solar, wind, or hybrid solutions) and the development of combined heat and power generation capacity in larger facilities offer significant potential to lower the health sector’s carbon footprint, particularly when coupled with building and equipment energy efficiency measures. Where electricity access is limited and heavily reliant upon diesel generators, or in the case of emergencies when local energy grids are damaged or not operational, such solutions can also improve the quality and reliability of energy services. In this way, low carbon energy for health care could not only mitigate climate change, it could enhance access to essential health services and ensure resilience.
a For a complete list of references used in the health co-benefits text please see the Climate and Health Country Profile Reference Document, http://www.who.int/globalchange/en/
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EMISSIONS AND COMMITMENTS
Global carbon emissions increased by 80% from 1970 to 2010, and continue to rise.a,b Collective action is necessary, but the need and opportunity to reduce greenhouse gas emissions varies between countries. Information on the contribution of different sectors, such as energy, manufacturing, transport and agriculture, can help decision-makers to identify the largest opportunities to work across sectors to protect health, and address climate change.
Malaysia ANNUAL GREENHOUSE GAS EMISSIONS (metric tonnes CO2 equivalent) Malaysia – Key source analysis for greenhouse gas emissions for year 2000, with LULUCF Key Category Energy Industries Transport Manufacturing industries and construction Landfills Forest and grassland conversion (LULUCF) Mineral products Emissions and removals from soils (LULUCF) Metal production Commercial Rice production GHG CO2 CO2 CO2 CH4 CO2 CO2 CO2 CO2 CO2 CH4 Emissions (Gg CO2 eq) 58,486 35,587 26,104 24,541 24,111 21,987 9,776 4,638 2,797 2,122 1,861 Level Assessment (%)1 26.2 16.0 11.7 11.0 10.8 9.9 4.4 2.1 1.3 1.0 0.8
A 2ºC upper limit of temperature increase relative to pre-industrial levels has been internationally agreed in order to prevent severe and potentially catastrophic impacts from climate change. Reductions are necessary across countries and sectors. In order to stay below the 2ºC upper limit it is estimated that global annual CO2-energy emissions, currently at 5.2 tons per capita, need to be reduced to 1.6 tons per capita.c The most recent emissions data available for Malaysia is from 2000. At that time, carbon emissions from energy industries and the transport sector formed the largest contributions. Through intersectoral collaboration, the health community can help to identify the best policy options not only to eventually stabilize greenhouse gas emissions, but also to provide the largest direct benefits to health.
Fugitive emissions from oil and gas systems CH4
1 Level assessment refers to the contribution of each key category in relation to the total amount of emissions expressed in percentage. Source: Malaysia Second National Communication to the UNFCCC,Ministry of Natural Resources and Environment Malaysia. http://unfccc.int/resource/docs/natc/malnc2.pdf
NATIONAL RESPONSE d
1994 2002 2009 2009 2011 2011
MALAYSIA RATIFIED THE UNFCCC MALAYSIA RATIFIED THE KYOTO PROTOCOL NATIONAL RENEWABLE ENERGY POLICY AND ACTION PLAN NATIONAL POLICY ON CLIMATE CHANGE RENEWABLE ENERGY ACT SUSTAINABLE ENERGY DEVELOPMENT AUTHORITY ACT
a Boden, T.A., G. Marland, and R.J. Andres (2010). Global, Regional, and National Fossil-Fuel CO2 Emissions. Carbon Dioxide Information Analysis Center, Oak Ridge National Laboratory, U.S. Department of Energy, Oak Ridge, Tenn., U.S.A. doi 10.3334/CDIAC/00001_V2010. b IPCC (2014) Blanco G., R. Gerlagh, S. Suh, J. Barrett, H.C. de Coninck, C.F. Diaz Morejon, R. Mathur, N. Nakicenovic, A. Ofosu Ahenkora, J. Pan, H. Pathak, J. Rice, R. Richels, S.J. Smith, D.I. Stern, F.L. Toth, and P. Zhou, 2014: Drivers, Trends and Mitigation. In: Climate Change 2014: Mitigation of Climate Change. Contribution of Working Group III to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change [Edenhofer, O., R. Pichs-Madruga, Y. Sokona, E. Farahani, S. Kadner, K. Seyboth, A. Adler, I. Baum, S. Brunner, P. Eickemeier, B. Kriemann, J. Savolainen, S. Schlömer, C. von Stechow, T. Zwickel and J.C. Minx (eds.)]. Cambridge University Press, Cambridge, United Kingdom c Pathways to deep decarbonization, Sustainable development Solutions Network, 2014 report. d Columbia Law School, 'Climate Change Laws Of The World'. N.p., 2015.
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NATIONAL POLICY RESPONSE
The following table outlines the status of development or implementation of climate resilient measures, plans or strategies for health adaptation and mitigation of climate change (reported by countries).a
GOVERNANCE AND POLICY Country has identified a national focal point for climate change in the Ministry of Health Country has a national health adaptation strategy approved by relevant government body The National Communication submitted to UNFCCC includes health implications of climate change mitigation policies
HEALTH ADAPTATION IMPLEMENTATION Country is currently implementing projects or programmes on health adaptation to climate change Country has implemented actions to build institutional and technical capacities to work on climate change and health Country has conducted a national assessment of climate change impacts, vulnerability and adaptation for health Country has climate information included in Integrated Disease Surveillance and Response (IDSR) system, including development of early warning and response systems for climate-sensitive health risks Country has implemented activities to increase climate resilience of health infrastructure
FINANCING AND COSTING MECHANISMS Estimated costs to implement health resilience to climate change included in planned allocations from domestic funds in the last financial biennium Estimated costs to implement health resilience to climate change included in planned allocations from international funds in the last financial biennium
HEALTH BENEFITS FROM CLIMATE CHANGE MITIGATION The national strategy for climate change mitigation includes consideration of the health implications (health risks or co-benefits) of climate change mitigation actions Country has conducted valuation of co-benefits of health implications of climate mitigation policies
a Supporting monitoring efforts on health adaptation and mitigation of climate change: a systematic approach for tracking progress at the global level. WHO survey, 2015.
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