MONSOONS are a recurring feature and come as no surprise. And yet, astonishingly, the most predictable health threats associated with the season are routinely neglected. The most common monsoon health hazards include: acute watery diarrhoea and cholera, especially in Sindh and southern Punjab, where flooding contaminates drinking water; dengue and malaria outbreaks, common in urban lowlands like Karachi, Lahore and Peshawar due to standing water and poor drainage; skin infections, scabies and leptospirosis in displaced populations; maternal and child health crises, particularly in hard-to-reach floodaffected areas where routine services collapse.

The Met Department issues repeated advisories aboutmonsoons anditsintensity,butresponse prioritisation at the national level remains inconsistent. In theory, the NDMA coordinates with the Ministry of National Health Services and provincial health departments to preposition stockpiles (for example, cholera and antimalarial kits). In practice, response remains post-disaster, not anticipatory. Some glaring examples can be traced back to the 2022 floods. Response teams arrived after major outbreaks had begun and did not anticipate preventive action. The National Institute of Health (NIH) maintains an Emergency Operations Centre and disease surveillance unit, but real-time district-level health risk analysis is rarely available to front-line responders in advance. There`s no standardised health risk heat map integrated into the Provincial Disaster Management Authority (PDMA) monsoon preparedness plans, and health supplies are rarely pre-deployed based on forecasted risk.

In Pakistan, trigger-based health action is limited to `simplified early action protocols` by the Pakistan Red Crescent Society for floods (for example, in the Kabul River basin) focused on WASH and cash; no health kit pre-deployments have been activated as yet. By contrast, Bangladesh established early action protocols across sectors, including health, WASH and cash triggered by riverine flooding forecasts, and Nepal has been piloting anticipatory health responses in recent years, mainly around floods and food security. Where finance-based forecasting is concerned, Pakistan mainly uses pilots through PRC plus the International Federation of Red Cross for heatwaves, droughts and floods that remain small in scale, whereas Bangladesh has institutional-ised FbF at the national level with pre-approved finance and scenario-based triggers. In Nepal, active plots are embedded in DRR strategies, often tied into food security anticipatory schemes.

Integration into local health programmes is weak in Pakistan, with ad hoc coordination between PDMA and the health department. Nepal has integrated community clinics into a pre-activation mechanism viz the FbF task force.

The government buy-in for anticipatory health remains siloed. The monsoon contingency is led by NDMA and not integrated into health planning. Bangladesh launched an early action protocol in 2019 under its disaster management & relief ministry that targets multiple sectors, including health, and Nepal is taking steps towards formally including health in DRR and climate planning via federal initiatives and donor programmes.While Bangladesh has institutionalised anticipatory health action, particularly in cyclone and flood-prone districts, linking it to national health supply chains and forecast-based triggers, Pakistan remains reliant on post-disaster surge capacity, with no formal anticipatory health activation system at the provincial level. Some of the challenges in provincial disaster systems are: Fragmented governance: In most provinces, health and disaster management departments do not share real-time risk or stockpile information.

Thereisno unifiedlogisticsplatform(forinstance, digital inventory dashboards or GIS-based heatmaps) integrating forecasted flood zones with vulnerable health infrastructure.

Weak institutional mandates: PDMA planning documents (like monsoon contingency plans) often mention disease risk in general terms, without assigning clear anticipatory roles to district health officers or logistics focal person.

Operational capacity gaps; For example, in Balochistan and KP, flood-prone areas like Dera Allah Yar or D.I. Khan lack cold-chain storage ormobile health capacity that can be pre-positioned or activated based on risk forecasts.

Finance and procurement lags: Even when forecasts allow for seven-to-10-day early warning, emergency health funding is rarely unlocked in time due to central-level approval bottlenecks and procurement delays.

Lack of coordination with non-state actors: INGOs and UN agencies often run parallel anticipatory pilots, but these are not integrated into government SOPs, creating duplication or misalignment in logistics planning.

However, despite long-standing structural gaps, there are important signs of progress in aligning health and disaster preparedness in Pakistan. In 2023, the NDMA piloted a joint monsoon simulation exercise with the NIH and provincial stakeholders, marking a first step toward unified early planning; the country`s National Adaptation Plan now explicitly references climate-sensitive disease surveillance and heathealth action plans, signalling a growing awareness of health risks in a changing climate; donorsupported systems such as the WHO and Early Warning Alert and Response Network are slowly improving post-disaster disease tracking and analysis in flood-affected regions.

However, progress remains piecemeal and project-based. Without sustained provincial ownership, cross-sector coordination, and dedicated domestic financing, anticipatory health logistics will continue to be the exception not the norm.

With rising temperatures, more intense monsoons, and the shifting geography of disease vectors, climate change is no longer a distant threat.

It is a health emergency unfolding in real time.

Pakistan needs to: formally embed anticipatory health action into disaster risk management protocols; ensure such efforts are resourced through health sector budgets, rather than relying solely on donor-driven projects; build systems that are backed by real time data, integrated early warning and multisector planning.

Pakistan needs a `Climate and Health Resilience Policy` that bridges institutions, anticipates climate-driven disease threats, and enables action before and not after the next outbreak. • The wnter is chief executive of the Civil Society CoaliNon for Climate Change.

aisha@csccc.org.pk