District-level HIV and TB health system vulnerability to climate and weather hazards in South Africa: a composite index approach
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Background
Climate change and extreme weather events (EWEs) threaten health systems, disrupt continuity of HIV and TB services, amplify communicable disease burdens, and exacerbate health inequities in South Africa. Yet few empirical studies have quantified district-level vulnerability, where HIV and TB service delivery and climate adaptation are operationalised.
Methods
We developed a district-level composite HIV/TB Vulnerability Index, integrating indicators of HIV & tuberculosis burden (sensitivity), health system capacity, and socio-economic vulnerability. We also developed a Hazard Index which when combined with the HIV/TB vulnerability Index, identifies districts where underlying vulnerability coincides with higher likelihood of EWEs. Indicators were drawn from national surveys, routine health information systems, and international hazard datasets, normalised using a min-max scaling, and aggregated with equal weighting. Sensitivity analysis were conducted to assess the robustness of the composite indices.
Findings
The most vulnerable districts were located in the Northern Cape, Eastern Cape and KwaZulu Natal provinces where high HIV/TB burden and socio-economic sensitivity coincided with limited health system adaptive capacity. In contrast, the least vulnerable districts, were concentrated in Gauteng and Western Cape, reflecting stronger health system capacity and more favourable socio-economic conditions. Hazard exposure exhibited a clear spatial division with western districts experiencing greater heat stress and eastern districts facing higher flood and heavy-rainfall hazards. When hazard exposure was combined with the HIV/TB vulnerability Index, districts with both high vulnerability and hazard scores clustered predominantly along the east coast (Ugu, uMkhanyakude, and Harry Gwala in KwaZulu-Natal, and O.R. Tambo and Alfred Nzo in the Eastern Cape).
Interpretation
South Africa’s district-level vulnerability to climate and weather hazards is driven by the convergence of high HIV/TB burden, constrained health system capacity, and socio-economic disadvantage. Where this vulnerability intersects with increased hazard risk, it creates a compound susceptibility that needs attention. Our findings provide evidence for geographically targeted adaptation, prioritising continuity of HIV/TB services, health system resilience, and hazard-specific preparedness.
Funding
National Institute for Health and Care Research (NIHR).
Research in context
Evidence before this study
We searched PubMed and Google Scholar using terms combining “health vulnerability”, “climate and health”, “composite indicator”, “district level”, “South Africa”, “HIV mortality”, and “TB mortality”, and reviewed reference lists in relevant IPCC and WHO reports on climate and health vulnerability assessments. No prior district-level vulnerability index for South Africa incorporating HIV/TB health outcomes and health systems was identified.
Added value of this study
We developed the first district-level HIV/TB Vulnerability Index for South Africa, integrating 27 indicators of HIV and TB outcomes, health system capacity, and socio-economic sensitivity and adaptation. We also developed a companion HIV/TB Vulnerability and Hazard Index (HVHI) which combines vulnerability with exposure to climate and weather hazards to identify districts facing the greatest compound risks. The analysis results revealed marked geographical disparities: the highest vulnerability was concentrated in KwaZulu-Natal, Eastern Cape, and Northern Cape, whereas districts in Gauteng and Western Cape exhibited greater adaptive capacity. The Hazard Index revealed a distinct east-west gradient with western districts experiencing greater heat stress and eastern districts facing higher flood and heavy rainfall hazards.
Implications of all the available evidence
Districts where climate and weather hazards coincide with high HIV/TB burden and constrained health system capacity face compounded risks, and should be prioritised for climate adaptation. Strengthening health system resilience including workforce capacity, hospital bed availability, primary health care access, and continuity of HIV/TB services, should be complemented by hazard-specific preparedness with heat-health planning prioritised in western districts and flood resilience in eastern districts. Investments in socio-economic enablers, including access to piped water, paved roads, and information are also essential. These findings provide an evidence base for geographically targeted climate-health adaptation planning in South Africa.
