Integrating care and climate adaptation into a holistic fiscal framework at the country level

Introduction

Countries and international institutions are increasingly focused on adaptation to climate change in light of rising temperatures, longer-term droughts, severe flooding, and other impacts. Currently, however, financing for adaptation activities is insufficient to meet needs.¹ Moreover, analysis of climate finance indicates that an important system of services and infrastructure is overlooked in almost all national and global assessments of climate adaptation finance: care. In a climate adaptation context, investing in comprehensive care services infrastructure,² entailing childcare and education, healthcare, and long-term care, can strengthen preparedness and response efforts to various climate hazards. Universal coverage through affordable, accessible, and high-quality services and decent jobs for the care workforce can help build the resilience of families and communities. While some initiatives include education and healthcare in climate adaptation planning, sectors such as Early Childhood Care and Education (ECCE) and Long-Term Care (LTC) remain largely overlooked or absent. This paper aims to address this gap by proposing a methodological framework for integrating ECCE and LTC into climate adaptation planning and finance, recognizing their critical role in building inclusive and resilient communities.

In many low- and middle-income, and even in some high-income countries, deficits in paid care services are widespread. This became glaringly evident during COVID-19. But even before the COVID-19 pandemic, institutions like the International Labor Organization (ILO) (2018), UN Women (2018), UNDP (2015), and the World Bank (2015) highlighted a global care crisis.³ An estimated 23% of children globally need childcare but do not have any access to it, with nearly 80% of those 350 million children living in low- and middle-income countries.⁴ ILO (2018) estimated that 2.3 billion people will require care by 2030, driven by both aging populations and growing numbers of children.⁵

There is an inextricable link between the global care crisis and the climate crisis, both of which constitute compounding, interlocking emergencies. This chapter, based on a forthcoming working paper by Grown, De Henau, Ilkkaracan, and Martinez, explores the linkages and suggests an approach to estimate the costs of incorporating comprehensive care services infrastructure in climate adaptation planning and finance. The objective is to support policymakers, urban planners, the climate adaptation finance community, and care advocates with practical steps to inform planning, decisionmaking, and investment strategies. Recognizing that there is no one-size-fits-all design, the approach is intended to be adaptable to diverse local conditions and varying climate hazards.

Our argument can be summarized as follows: Comprehensive care services infrastructure—a policy objective independent of climate crises—contributes to building resilience to climate change as it supports the well-being and functioning of individuals and communities before, during, and after climate shocks. Care-centered adaptation strategies enable those who provide care—paid and unpaid—to anticipate and plan for climate disruptions, which can potentially minimize the adverse effects on households and communities. When care services are in place, vulnerable groups, including children, older persons, people with disabilities, and individuals with chronic illnesses or long-term health conditions, may face reduced exposure to health risks. Families, in turn, can rely on structured support rather than bearing the burden alone. Moreover, investing in public care provision can relieve those who provide unpaid care, allowing them to engage in paid work and improve their financial resilience. Paid care workers, in turn, benefit from better working conditions and training to respond to emergencies, further strengthening social preparedness.⁶ In short, well-functioning, formal care services infrastructure can be viewed as a climate adaptation strategy—one that builds long-term resilience by protecting health, reducing social vulnerabilities, and strengthening communities’ capacity to face and recover from climate hazards.

Conceptual approach and methodology

Our approach identifies the adaptation activities and needs for care resilience in the context of climate change. It can be incorporated into any country’s National Adaptation Plans (NAPs) or into local disaster risk response plans. NAPs aim to estimate countries’ adaptation finance needs and planning instruments to identify sectoral priorities and interventions based on the national context and climate vulnerabilities. Disaster risk response plans, developed by localities, identify actions to be taken before, during, and after a disaster, but they do not always contain the costs of specified actions.⁷

Climate change disproportionately affects young children, older persons, and individuals with disabilities, among others, because of heightened susceptibility to disease and temperature extremes, limited mobility, and a decreased capacity to independently fulfill essential life-sustaining needs.⁸ Climate-related hazards such as severe flooding, hurricanes, and cyclones impair care facilities (e.g., hospitals, clinics, daycare centers, nursing homes, and schools) and stop or disrupt their operations.⁹ Moreover, climate change-related events often reduce access to essential inputs for care, such as water and food, and complementary infrastructure such as safe shelter.

Both unpaid and paid care work, predominantly provided by women and girls, act as a hidden but essential “shock absorber” to climate change, especially in the context of insufficient public funding for care.¹⁰ Deficits in care services and infrastructure force women to take on more unpaid caregiving responsibilities, diminishing their economic productivity and extending their workdays. Globally, women already perform more than 76% of unpaid care work, leaving them with limited time, reduced access to paid employment, and fewer resources to adapt to climate impacts.¹¹ The demands on paid care services also increase in the context of climate disasters, requiring additional work time of paid care workers under substantially more constrained conditions, such as coping with facility damage. Climate disasters place immediate stress on emergency rooms, paramedics, nursing staff, childcare, and LTC workers. A review of literature on health workers’ ability to respond to climate change identifies gaps in knowledge and training, understaffing, and time constraints as significant challenges.¹² The failure to invest in care services infrastructure not only entrenches gender inequality but also undermines community resilience in the face of escalating climate risks.

Adaptation costs can be described as the expenses involved in planning, preparing for, enabling, and executing adaptation actions aimed at reducing damage or taking advantage of favorable opportunities presented by climate.¹³ Tracking adaptation investment in planning and financing is challenging because there is no standardized taxonomy or clear definitions regarding what qualifies as adaptation activities and needs.¹⁴ While most NAPs include health care, education, and (to a lesser extent) social protection, they generally ignore ECCE and LTC. Nor do they cost interventions to support paid care workers and unpaid caregivers. For instance, although the NAPs of Bangladesh, Mozambique, Tonga and Grenada note investment in some climate-resilient healthcare facilities (hospitals and clinics) and education systems (schools), they are silent about increasing the number and training of teachers, health workers, and caregivers who enable these systems to function and ignore some of the spaces where such activities are carried out (e.g., daycare centers, LTC homes).¹⁵

​​​While NAPs can be improved in various ways, including costing the increases in the number and capacity of teachers and health workers important for coping with climate change, our focus is on the overlooked sectors of ECCE and LTC. We estimate the costs of adapting: 1) the services provided by paid care workers and their coordination with unpaid caregivers and care receivers for preparedness, and 2) the built environment where care provisioning takes place, prioritizing nature-based solutions (e.g., urban gardens, tree cover, greenways).¹⁶

To identify the investment requirements for care, the approach builds on the ILO care policy investment simulator.¹⁷ This tool simulates the investment needed for countries to provide universal care services. With some flexibility determined by the user, the ILO tool was primarily designed to simulate a comprehensive care services infrastructure with the following characteristics: universal, free at the point of use (or with very small user contributions), high-quality, and locally managed with public funds distributed by the national treasury to local authorities. High-quality care entails well-trained and paid staff with clear career progression pathways and low user/staff ratios. ECCE and LTC needs are both estimated using demographic projections and health indicators.¹⁸

However, the ILO tool needs adapting to account for climate change impacts. This can be done by projecting care needs and workforce requirements using a baseline climate scenario that is country-specific. Consider the example of Bangladesh. Its NAP uses a projection based on a downscaled multi-model ensemble:¹⁹ a warming of 0.44°C to 0.69°C in the near term (2030s) compared to the 1981-2010 period. It also posits rainfall variation due to climate change, ranging between 0.1-1.4% until 2030, and sea level rise projected to be between 0.11-0.12 meters (m) in the near term.²⁰

Under each of these conditions, it is possible to calculate some health impacts using sex- and age-disaggregated data from the Global Burden of Disease dataset, which combines United Nations population projection scenarios with Disability Adjusted Life Years (DALYs) linked to environmental risk factors that may increase the need for care.²¹ Estimates of the direction of impacts are mixed. Morbidity might increase, but mortality might also increase, which implies counteracting effects on care needs. Sensitivity analysis of central estimates to deal with these variations can be used to determine the direction of effects.

Once the impacts of climate change on the needs for care can be plausibly determined or simulated, the costing estimation requires applying markups of adaptation costs to each type of ECCE and LTC services infrastructure. The markup would apply to activities like training and capacity-building of caregivers, whether early childhood teachers, nurses, in-home aides, community health workers, or unpaid caregivers. This is to respond to climate-induced disruptions and to illustrate behavioral adaptation, e.g., disseminating life-saving information and modeling adaptive practices within households and communities. Training care workers and caregivers does not necessarily incur significant additional costs beyond their initial training, as already outlined in the baseline exercise according to the ILO tool. Instead, it may involve adapting the learning to include climate awareness sessions.

Given the complementarities between paid and unpaid caregiving, a plan to build care resilience in the face of climate disasters would entail investing in joint preparedness and coordination across both types of caregiving. Climate risk preparedness must extend to include unpaid caregivers, who often play the primary role in home-based or community-based care. For example, nursery and preschool disaster preparedness cannot be effective unless parents (guardians) are also trained, informed, and coordinated with childcare staff. In addition to coordinating training between paid care workers and unpaid caregivers, preparedness programs must also engage those on the receiving end of care—especially children and youth, older adults, people with disabilities, and those with chronic illnesses.

Mechanisms for inclusive planning can entail local care councils and participatory workshops to ensure inputs across the care provisioning spectrum. This is often part of the NAP process. Designing such coordinated plans requires investing in the development of a structured framework, methodology, and (digital) tools for planning, evaluation, regular review and updating, as well as trained facilitators and administrative capacity. These costs would need to be factored into country climate adaptation budgets.

The other element of the costing applies to adapting the physical infrastructure where care services take place. For this, metrics should reflect the costs of adapting buildings and facilities (shelters) that house carers and their recipients, including private homes. For instance, in Bangladesh, some adaptation studies include estimates for retrofitting or construction of new facilities.²² Although sparse and context-specific, relevant costings can be derived for care facilities and homes. Examples include climate-resilient coastal villages or floating communities in low-income urban areas (see LIFT for coastal projects and Munich Re for bamboo villages).²³ Such studies, which involve nature-based solutions, local knowledge and materials, as well as autonomous provision of food, energy, and waste management, do not seem to suggest significantly different costs of building resilient structures than traditional low-cost structures. Therefore, the markup may be minimal. Other studies, such as retrofitting schools in Mozambique, indicated a 20% markup, which can provide an upper bound.²⁴ Determining the size of the markup will depend on the local context.

For more formal and higher-income urban neighborhoods, some techniques of retrofitting, still focusing on nature-based solutions, may be appropriate but will constitute a small part of the care adaptation investment, given their share of the population. Various pilot initiatives in high-income countries can serve as references for elements that can be included. For example, in Queensland, Australia, the “Guidelines for Preparing Heat Adaptation Plans for Aged Care Facilities” recommends using shade trees, bioswales, climbing plants, permeable surfaces, and reflective roofs as effective climate adaptation strategies.²⁵ Similarly, Austria’s GREEN: Cool & Care project promotes co-designed interventions, such as living walls and open green spaces, which benefit both elderly residents and care staff.²⁶ For flood-proofing houses (as a 2m-high elevation), markups of 15-20% could be derived from Aerts et al. (2018) and de Ruig et al. (2020), using a study for Los Angeles.²⁷

The main challenge of this costing exercise is, of course, existing data gaps. Applying the steps described above to any particular country context requires adequate geospatial and socioeconomic data, including granular information on various parameters, such as the type of settings, staff qualifications, wages, and infrastructure costs, as well as geospatial coverage of temperature, rainfall, and sea-level rise, which countries at different levels of development do not systematically collect. An important future task is collecting such data and curating them for public dissemination and use, especially at the local level, where climate and care needs intersect.

Conclusion

This brief makes the case for a comprehensive climate-adapted care services infrastructure and proposes a conceptual approach to guide policymakers and urban planners on how to identify the adaptation activities and needs. The approach also suggests how to calculate and integrate the costs of these activities into climate adaptation plans and financing strategies to improve resilience. Building on ​​the ILO care services cost calculator, the approach emphasizes assessing investment care needs by analyzing morbidity linked to climate-related environmental risk factors, incorporating climate resilience infrastructure interventions into physical care settings, and enhancing targeted paid worker and unpaid caregiver training and capacity-building. To strengthen this methodology, further efforts should be directed toward collecting more detailed, disaggregated data regarding the provision of care services, the types of settings, workforce qualifications and wages, as well as the costs of broader care infrastructure. Better data would be important both to refine the methodology and to improve the efficacy of interventions. Building partnerships with national statistical agencies and planning units within local governments will help ensure that the approach is based on context-specific realities. Additionally, improving climate health projections should involve considering the increased caregiving burdens on households that result from the lack of universal, climate-adapted, and high-quality health systems.