Health systems response to climate change adaptation: a scoping review of global evidence | BMC Public Health

Findings are presented in themes based on the research questions.

Health system response to climate change

Forty-six (46) included studies with varied designs (cross-sectional surveys, qualitative, mixed-method and document review) presented findings on health system response to climate change. Through thematic content analysis, health system responses to climate change were grouped into 15 themes. Frequency counts were assigned to each theme based on the specific adaptation actions and the number of studies that explored such actions. For instance, there are 23 specific climate adaptation actions under the theme “climate change policy and planning”. Studies that explored each action are then added to give counts to the theme. For example, a study that explored five specific actions under a theme were counted as five. Figure 3 presents the themes generated from the reviewed studies and the assigned counts. Table 3 presents the themes and specific climate actions by health systems highlighted in reviewed studies.

Weights assigned to themes generated from the included studies

Health policy and planning

There are efforts being made especially in developed countries and some developing countries such as Vietnam [23], and some countries in SSA such as Ghana, Nigeria, Ethiopia, Namibia, Kenya and South Africa [45] to refine and establish regulatory frameworks for climate change actions in health policy [8, 22,23,24, 45, 46]. Furthermore, efforts are been made to mainstream climate considerations into all healthcare policies [25] and planning [9, 15, 16, 48, 55, 56, 59] at national and local levels. The importance of integrating hospitals into urban planning [16, 17] and incorporating climate change education into school curricula and graduate studies [16, 25, 26, 45] have also been highlighted. Studies have also emphasised the importance of climate change mitigating measures taken by the health systems, including reducing greenhouse gas (GHG) emissions from anaesthetic gas usage, promoting energy conservation in health facilities [30] and developing policies to improve transportation systems [60]. Moreover, evidence suggest that health systems are implementing essential policies aimed at heat risk adaptation [27], undertaking sea defence projects to protect coastal population and health infrastructures situated along the coastal areas [28, 29], and developing national electronic databases for climate change actions [9, 31, 46, 55] and ensuring universal healthcare access [18, 49] in responses to climate crisis. Policies aimed at facilitating effective climate change mitigation and adaptation within health systems rely on several key elements, including long-term planning [22, 66], collaborative efforts with non-health sectors [9, 10, 27, 28, 33, 35, 38, 39, 43, 47, 51, 52, 55, 58, 60, 61, 65, 69], sufficient funding and resources [18, 26, 33, 46], regular policy evaluation [6, 15, 22, 28, 49, 50, 69] and enforcement of policy regulations [9, 28, 34].

Health promotion

Health systems are making a strong case for investment in health promotion [48], by creating health promoting communities that fosters knowledge sharing on climate change and support health systems in several ways, including empowering local response and support at-risk populations [9, 15,16,17,18,19,20,21]. Health systems are focused on educating communities [8, 15, 17, 19, 20, 22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44] and health professionals [27, 29, 45,46,47] on the impact of climate change on human health and health systems. Promoting climate-informed health programmes [6, 18], facilitating communities’ access to health programmes [18, 26, 29, 46] and communicating co-benefits and actions to protect the health of individuals and communities [10, 18, 49] are among important health promotion interventions adopted by health systems. Co-benefits encompasses additional health benefits derived from implementing climate-informed health programmes [18, 49].

Risk assessment, disaster preparedness and response

Health system response through risk assessment, emergency planning and preparedness were reported in the literature [9, 19, 21, 29, 31, 36, 40, 41, 50,51,52,53]. For instance, vulnerability assessments for health systems [18, 28, 33, 48, 50, 53,54,55], assessment of health impact [15, 54] and the use of an integrated assessment model [54] are adaptation strategies by health systems reported in included studies. Moreover, emergency risk communication, especially for high risk population and communities [9, 29, 50, 53, 55], including health messaging during extreme events [9] and rapid disease-specific emergency response are also essential health system adaptation strategies [29]. However, disaster response actions are more useful when they are well coordinated [38], planned based on reliable information [48] and adequately financed [9, 56].

Surveillance and monitoring of climate-sensitive diseases

Routine epidemiologic surveillance [9, 15, 18,19,20, 22, 24, 25, 28, 29, 34, 36, 37, 39, 41, 52, 55, 57], which enhances existing surveillance programmes to include climate-sensitive diseases [18, 32, 45, 56, 58], and the implementation of early warning systems [6, 8,9,10, 13, 16,17,18, 21, 22, 26, 29, 31,32,33, 36, 38, 40, 41, 45, 59,60,61] including innovative technologies like remote sensing [54] have been identified as valuable approaches. Many developed nations also emphasise disease-centric approaches, technological advancements, and are integrating climate change events into public health policies and planning [19, 20, 39]. Evidence emphasises particular disease and vector programmes [58, 62, 63], such as vaccination [25, 28, 36, 40], mosquito control [9, 55], and screening of pathogens at border or entry points [8], as effective actions within health systems which address climate change vulnerability. Immunisation programmes for at-risk communities and children, especially under-5 children, have been reported [64]. The importance of targeting at-risk communities and high risk populations through initiatives such as enhanced testing and diagnosis of climate-sensitive diseases [44], the utilisation of mobile devices for surveillance purposes [30], and the implementation of robust diagnostic methods for food and waterborne diseases [27, 40] have also been reported.

Furthermore, both developed and developing countries recognise the urgency of surveillance, research, and monitoring efforts in tackling climate-related health challenges. Developed nations are leveraging on advanced technology and resources for these purposes [39, 68], the developing countries are emphasisng capacity building and resource optimisation for effective surveillance and monitoring [25, 33, 64]. While these approaches differ based on resources and priorities, the common goal remains the adaptation and resilience of healthcare systems to address the impacts of climate change on public health.

Health service delivery and mental health

Improving health service capacity to deliver quality care [18, 33, 34, 44, 49], strengthening healthcare delivery in climate hotspots [8, 53] and preparing health services for emergencies [27, 64, 66] are effective ways to respond to the changing climate. Facilitating healthcare access [22, 49, 58, 64],including outreach that target at risk populations [19, 39, 44, 58, 63], telemedicine [30], and strategic allocation of health resources [66] are some essential climate change adaptation actions. Providing culturally appropriate [34, 41, 49, 64], community-oriented [34, 47] and patient-centred care [17, 34, 49] are effective means the health system deals with climate crisis. Also, developing community-based models for the management of children with acute malnutrition [52], improvement in the management of climate-sensitive diseases [23] and early treatment of infections [58] have been reported by included studies. In addition, providing resources and information for mental health adaptation [65], including monitoring of psychosocial resources and skills [44, 65] and creating awareness about the impact of climate on mental health, especially in high risk communities and healthcare workers [67] are essential to reduce the effects of changing climate on health systems.

Health infrastructure and supply chains

Across developed countries like the UK, USA, Australia, Poland, Canada, Germany, Japan, etc. notable similarities in health system responses to climate change emerged. These nations prioritise sophisticated infrastructure development and improvements, such as implementing early warning systems [15, 17, 21, 24, 27, 29, 55, 60, 70], developing comprehensive healthcare facility plans [68], and integrating the climate crisis into various healthcare programmes [17, 24]. Conversely, in developing nations like India, countries in SSA, and Southeast Asian, including Indonesia and Vietnam, the focus revolves around community-oriented approaches [19, 23]. These countries prioritize public education, access to clean water, sanitation, and collaboration across sectors [25, 33, 45, 57, 58]. Their adaptation strategies often revolve around building resilience in public health infrastructure, addressing poverty, and enhancing traditional healthcare systems [25, 33, 51, 58, 64]. Additionally, they highlight the importance of localised solutions and training healthcare workers to adapt to climate change impacts.

Health system response to climate change includes improving health infrastructure and facilities such as upgrading emergency response units, ensuring the resilience of medical equipment to extreme weather conditions, and establishing backup power sources for uninterrupted healthcare delivery during climate-related events [8, 10, 14, 45, 26, 28, 29, 60, 18, 67, 61, 21, 38, 43, 53, 54]. Others include modernisation of laboratories for early diagnosis [9, 20], building social infrastructures such as community health centers, support groups for at-risk populations, mental health hotlines, neighborhood networks that promote health education, and community-based organisations that support care systems [21] and supporting off-the-grid solutions for hospitals [31, 33, 47]. Ensuring thermal comfort [17] through improved ventilation [10, 17, 20, 30] is vital in healthcare facilities in rising temperatures. Health systems are prioritising improvement in health supply chains [29] that are less pollutant through rapid assessment to identify needed supplies [19] and stockpile medical supplies and pharmaceuticals [20, 27].

Social support systems and equity

Developing poverty alleviation programmes [18, 41], provision of alternative employment opportunities [8] and improving housing systems for lower-income families [25, 29, 41] are relevant social interventions that aid health system adaptations. Moreover, evacuation of high risk populations [19], including timely relocation of displaced people and migrants [29, 57] and provision of temporary shelter for displaced people [19] are actions needed for the protection of vulnerable people for improved health outcomes. Extreme weather events necessitate neighbourhood support schemes [36, 39], improved social networks [10] as well as relief programmes for the population at risk of climate change events [10, 38], including people living in hard-to-reach areas. Efforts are being made to preserve social structures for populations facing forced migration [29], to enhance legal and effective migration [8, 32], facilitate organised relocation [8] and provide migrants with adequate nutrition and access to healthcare [8]. Health system adaptation to climate change may help reduce issues of inequity and ensures equitable access to healthcare [44] through equitable distribution of health resources [8].

Research, training and development

Health system adaptation to climate crisis includes improving scientific research [22, 23, 25, 33, 34, 48], provision of funding for quality research [16, 20] and vaccines [40] and the translation of research into practice [18, 69] for quality health services. Besides, policy-oriented research is essential in supporting effective health system adaptation to climate change [64]. Nations are training and building the capacity of their health workforce on climate change and its impact on health [6, 8, 9, 18, 20, 22, 23, 28, 33, 36, 45, 47, 50, 55, 57], preparing frontline health workers to manage heat stress [44] and strengthening network and capacity of experts and institutions [18, 27, 28, 53, 68].

Sanitation, water and food

Efforts are being directed towards improving sanitation through improving waste management [9, 25, 30] and hygiene infrastructure [10, 28, 52, 56, 61, 63], as well as promoting community clean-up campaigns [9]. Increasing access to clean food and water [41, 56] through maintaining and improving water systems and sources [9, 24, 28, 30, 52, 61, 63]. Others are investing in clean water technologies [25] and enforcing proper food handling regulations systems [9, 24].

One Health

One health refers to an interdisciplinary approach that recognises the interconnectedness of human health, animal health, and the environment [8]. Thus, one health emphasises the interdependencies between the health of humans, animals, and ecosystems and recognises that their well-being is closely intertwined. The importance of health system adaptation to climate change through one health has been emphasised [8, 66]. One Health emphasises the interconnectedness of human, animal, and environmental health, advocating for collaborative approaches to address the impacts of climate change on health systems [66].

Occupational health and safety (OHS)

The importance of incorporating climate change effects into OHS assessment [31] and increased research on OHS implications of climate change [27] are paramount to health system adaptation to climate change. Ensuring safety and well-being of healthcare workers involve implementing measures that protect workers from heat stress [20, 31, 60], optimising workplace ergonomics [17], enhancing staffing levels [17] increasing staff insurance policies [31], and adopting work processes that are adapted to the challenges posed by climate change [17].

Our findings encompass a broader spectrum of strategies implemented by health systems in response to climate change. While the WHO framework primarily focuses on specific categories like governance, leadership, health workforce, service delivery, information systems, essential medicines, financing, and research, our research delves deeper into additional areas such as social support systems, One Health strategies, and OHS. These expansions transcend the defined categories of the WHO framework, showcasing a more comprehensive understanding and implementation of health system responses to climate change across various interconnected domains.

Barriers to health system response to climate change

Twenty-nine included studies reported on barriers to effective adaptation to climate change by health systems. The thematic analysis of the included studies yielded nine distinct themes on the barriers to health system adaptation to climate crisis. These themes include inadequate climate policies and disaster preparedness, resources constraints, poor policy implementation and evaluation, low-risk perception, lack of expertise and evidence, inequity and problems in healthcare delivery. These themes are presented in Table 4 and Fig. 4.

Barriers to health system adaptation to climate change

Inadequate climate policies and disaster preparedness

Lack of a supportive policy environment [19], inadequate prioritisation of climate change adaptation actions [71], and limited integration of climate and health issues into planning [22] were policy issues that make health system adaptation to the changing climate difficult. Furthermore, there were limited plans and programmes to address health risks associated with climate change [59], and existing adaptation initiatives often did not target these risks [59, 72]. For instance, a lack of adaptation policies for mental health [59] was reported. Evidence indicates that uncertainty surrounding climate projections and the best adaptation options [9, 48, 54], along with fragmented policies and contradictions [72, 73], present further challenges to health system adaptation. Moreover, the indication is that unclear long-term planning [64], and national adaptation plans do not prioritise health [72]. Few adaptation policies were found concerning OHS [62], but climate change was not integrated into the mainstream curricula of medical schools [62], indicating a narrow framework of climate policies [26] that may affect climate action implementation and evaluation. Furthermore, lack of preparedness for the burden of climate migration [64] and insufficient surveillance and assessment of vulnerabilities associated with climate change impacts [59] are challenging health system attempt to adapt effectively to the climate crisis.

Resources constraints

Insufficient financial resources [9, 26, 35, 48, 54, 61, 71,72,73] coupled with the challenge of securing long-term funding [15] hinder health system adaptation to climate change. Moreover, slow disaster preparedness in health facilities [30], lack of resource planning for disaster response [59], and limited efforts in preparing for extreme weather events were also reported [62]. Inadequate political will or support [35, 62, 64] further exacerbates this situation, which limits the allocation of resources and impedes the implementation of effective strategies. The difficulty in mobilising resources [6, 15] and the dearth of investments in the health system [64] amplify the constraints faced in responding to climate-related health risks. Additionally, the presence of poor infrastructure [59] and the introduction of underdeveloped and expensive new technologies [30, 54, 68, 73] pose significant barriers, that hinder the ability of health systems to effectively adapt to the challenges posed by climate change.

Poor policy implementation and evaluation

The effectiveness of health system adaptation programmes and policies is significantly hindered by inadequate coordination mechanisms among stakeholders [6], resulting in a lack of synchronised efforts to address climate-related health challenges. This lack of harmonisation does not only constrain the smooth execution of adaptation initiatives, it also leads to fragmented and disjointed actions that limit the overall impact of these programmes [6]. Furthermore, the absence of robust monitoring and evaluation systems creates a substantial barrier [6, 72], impeding the ability to comprehensively assess the efficacy of implemented strategies and make informed decisions based on reliable data. This deficit in evaluation mechanisms undermines the adaptive capacity of health systems and constrains their ability to respond effectively to emerging climate risks. Moreover, limitations in organisational capacities within healthcare structures pose additional challenges to the successful implementation of health system adaptation strategies [54, 61, 73]. The inadequate infrastructure and organisational frameworks within these systems contribute to inefficiencies, hindering the prompt deployment of adaptive measures which impedes their effectiveness. Additionally, insufficient collaborative efforts across regions exacerbate these constraints [64], limiting the exchange of critical knowledge, resources, and sharing of best practices needed to bolster adaptation efforts. This lack of cohesive regional collaboration restricts collective ability to address climate-induced health risks comprehensively and compromises the overall resilience efforts of the health systems in the face of evolving challenges associated with climate change.

Low-risk perception and lack of expertise and evidence

Low-risk perception and lack of expertise are also barriers to health system response to climate adaptation. Low climate risk perception [15, 26, 35, 73], lack of knowledge and awareness about health risks from climate change [9, 26, 74], wrong perceptions about the health impacts of climate change [15, 54, 58], and a lack of awareness about heat stress among healthcare workers [59]affect perceived urgency for climate actions. Perceived lack of urgency [15], as well as expertise [39, 64, 71], and education make health system adaptation challenging, especially in developing countries [30]. Insufficient research [51], training [9], and access to climate data and models further hinder effective climate change response efforts of health systems [48]. Limited institutional capacity [48], gaps in reporting [6] and information [33, 68], and a lack of guidelines for reporting the health impacts of climate change [69, 72] present further challenges for health system adaptation.

Inequity and problems in healthcare delivery

Social inequality [58], maldistribution of adaptive capacity [54], and socio-political inequality [68] exacerbate existing health disparities. Besides, fragmented services for migrants [64], and socio-economic challenges [54, 73] contribute to further inequities which compromise the health systems’ response to the changing climate. Marginalised and hard-to-reach populations, especially in global south receive little consideration in climate change adaptation efforts [62, 72]. Moreover, lack of treatment protocols for illnesses related to extreme events [59] presents challenges for health system delivery. Shortages of staff [6, 59], difficulties in integrating evidence-based practices into healthcare [6], and a strained health system [62], especially in developing countries, impede effective health system adaptation to climate change.