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By R. T. Edwards & S. Roberts

2024 was the first year above 1.5°C increase on the earth’s surface since pre-industrial times (World Meteorological Organization, 2025). Health systems produce approximately 5% of greenhouse gas (GHG) emissions globally per year (Pichler et al., 2019). This is double the GHG emissions of the aviation industry. Climate change will impact on the kinds of illness and disease that health systems will need to respond to, and on the places and spaces where healthcare is provided. As we think about our health, well-being and well-becoming (Edwards, 2022; Edwards & Lawrence, 2024), nothing is more important than thinking about climate change (Lawrance et al., 2022; The Lancet Public Health, 2021). It is not just a matter of greening the health system, it is about reducing the demand for health care through prevention of avoidable ill-health, disability, and premature death. 

We have just completed a 10-week online international course on European Climate Resilient Health Systems offered collaboratively and at no cost by the  and . The course focused on decarbonising health systems, integrating sustainability into health technology assessment, strengthening climate resilience, climate surveillance, and health communication and education in a changing climate.

As health economists at the (CHEME) at Â鶹Íø, we have recently been asked by to look at approaches to capturing and valuing health co-benefits of actions to mitigate climate change by the seven health boards across Wales. This course was timely and expanded our knowledge of the links between climate change threats and threats to population health, the potential role of health systems (along with other critical systems) to deal with climate shocks and stressors, and opportunities to adapt in the face of a further changing climate. On the course we learnt that climate change risks are a product of hazards, exposure and vulnerability. Some groups in the population, such as older people, children and those with underlying chronic disease, are most vulnerable to exposure to, for example, floods, excess heat, wild fires, sea level rise, and climate sensitive disease outbreaks. We learnt about co-exposures to health risks such as excess heat and air pollution, which can have a multiplier impact. We entered this course building on a foundation of over 30 years of experience as a research team in public health economics and the economics of prevention at Â鶹Íø (Edwards & Lawrence, 2024; Edwards & McIntosh, 2019). 

With respect to health care systems, we learnt about direct impacts on healthcare systems such as damaged and disrupted facilities, increased demand on healthcare, impacts on the health care workforce, impacts on patients, water and food contamination, environmental contamination, and supply chain disruptions. We were very surprised to learn the large relative impact of health systems on greenhouse gas emissions through, for example, theatre gases (Pichler et al., 2019). We learnt about the global carbon footprint of healthcare systems, described as three categories: scope 1 or direct emissions secondary to energy use; scope 2 or indirect emissions secondary to purchased electricity; and scope 3 for the rest of indirect emissions (Rodríguez-Jiménez et al., 2023). Plastics, part of scope 3 healthcare GHG, account for around 30% of health care waste (Rasheed & Walraven, 2023). Global demand for plastics doubled between 2005 and 2020, in particular during the COVID-19 pandemic.

On the course we learnt that we need to work towards designing and developing climate resilient healthcare systems (World Health Organization [WHO], 2023). Climate resilient health systems can anticipate, respond to, recover from, and adapt to climate-related shocks and stressors. Over time they can redesign themselves to promote better population health even in the face of climate change (WHO, 2024a). 

We learnt about the 26th United Nations Climate Change Conference of the Parties (COP26) commitment to climate resilient health systems and movement towards sustainable low carbon health systems (WHO, 2024a). We learnt about the suite of WHO resources for developing climate resilient health care systems (WHO, 2020, 2021a, 2021b, 2022, 2023, 2024b).

The course emphasised the need for cross-sectoral approaches to creating climate resilient health care systems and that adaptive capacities require cooperation across sectors. It was stressed that at times of climate change shocks to healthcare systems, hospitals and other health care facilities are dependent on other sectors for supply change, energy and waste disposal. 

The course stressed the need for a systems approach to exploring how climate threats impact health care systems. Health care systems are only one critical system and can be affected indirectly by other shocks to systems affected by climate change. For example, migration following climate shocks to a particular area of the globe can impact the health care system of the destination of migrants. The course distinguished between short-term climate shocks (wildfires and floods) and long-term climate stressors (extended droughts and melting glaciers). 

We learnt about stress tests which aim to find out the extent to which health systems are resilient to climate shocks and climate stressors. Again, resilience relies on system-level interaction between multiple stakeholders including health care providers, social care providers, local authorities, key suppliers, utilities companies, and funders.

The course emphasised that a movement away from a secondary care health care system towards a primary care focused health care system is good for the planet by reducing carbon footprint and unnecessary care. In other words, improving health system performance contributes to environmental sustainability. We learnt about the importance of early warning systems which can trigger early action and response to health threats, thereby reducing morbidity, mortality, and economic losses associated with climate risks.

From a health economics perspective, we were particularly interested to learn about parallel incremental cost-effectiveness ratios (ICERs) which could be used in health technology assessment. Conventionally, the ICER (i.e. cost per incremental unit of benefit) does not take account of environmental factors. New thinking puts forward the idea of parallel calculations, for example incremental carbon footprint effectiveness ratios (ICFER) and incremental carbon footprint cost ratios (ICFCR) (Williams et al., 2024). We are engaging nationally with debate over the best way for bodies such as the (NICE) to either internalise carbon reduction considerations into existing methods of health technology assessment, and/or consider the above parallel calculations. In health prioritisation exercises, approaches such as programme budgeting and marginal analysis (PBMA) and multi-criteria decision analysis (MCDA) can introduce consideration of changes in carbon footprint as criteria in option appraisal. 

This course created a vision of health care systems in the future which prioritise prevention, including, patient self-care and remote monitoring (where appropriate), staff well-being, and use of renewable energy. The health care systems require the following building blocks: climate-transformative leadership and governance; a climate-smart workforce; continual assessment and monitoring of climate and health risks and GHG emissions; early warning systems for climate shocks and climate stressors; health and climate research; low carbon supply chains; management of environmental determinants of health, and sustainable climate and health financing. Health system adaptations are likely to be more successful if they are proactive rather than reactive. These adaptations can be structural or non-structural and are best set within whole-system pathways towards transformation to a more climate-resilient health system, yet still remaining locally relevant. 

Previous to this course we had read the work of Naomi Klein, Professor of Climate Justice, University of British Columbia (Klein, 2014). Climate justice means putting equity and human rights at the core of decision-making and action on climate change. Climate justice spans structural inequality, social inequality, and intergenerational equity. Climate justice advocates for a Just Transition to lift up those in poverty. The WHO has set up the Climate Resilient Health Systems Initiative. The initiative aims to ensure that by 2030 all health systems worldwide have strengthened resilience against climate impacts. One of the medium-term goals is the establishment of an International Court for the Environment (ICE). 

What was particularly surprising to us on the international course was the emphasis placed on the need for communication and education of health professionals and those who organise and commission health systems. Communication of the health threats of climate change and the need for action raises awareness, promotes protective behaviours, and encourages system change. It was emphasised that what is needed are trusted voices within health systems and across sectors – health professionals can be effective champions for climate solutions. The advice given was for those working across health systems to communicate through: connecting climate issues directly to local health issues that people care about; using clear language that relates to local experiences and suggest specific actions; presenting solutions alongside problems to avoid overwhelming anxiety; and using narrative and emotional connections rather than just presenting data (Chambaud, 2025). Prevailing barriers to climate action across health systems are known to be: fragmented institutional messages; low investment in communication; limited climate literacy, and inadequate training. Education prepares future professionals to understand risks, lead responses, and influence change. 

In summary, the European Climate Resilient Health Systems course stressed the need for a balanced and inclusive approach to economic development that seeks to meet the needs of present and future generations without compromising natural resources and global ecosystems. This requires us to move away from health in all policies to health for all policies. We both passed the course exam (with flying colours!) and we feel that our understanding and literacy relating to climate change and health systems have greatly improved to the extent that we can effectively partner on grant applications for local and international research and evaluations at health system and intersectoral system level. The first of these opportunities has already come across the threshold, partnering on a Big Lottery shared sustainable community heating bid in North Wales. This bid is opportunity to take what we learnt on the international course and apply it on our doorstep in Eryri.

This blog was funded by Health and Care Economics Cymru (HCEC). HCEC is funded by Welsh Government through Health and Care Research Wales.  

Thanks to  and  for offering the European Climate Resilient Health Systems course and the amazing array of international speakers. Thanks to Dr Vladyslav Kulikov for passing on details of this free online course, and thanks to Dr Catherine Lawrence for blog content support.

References

Chambaud, L. (2025). Health communication and education in a changing climate. [Recorded lecture]. European Climate Resilient Health Systems Course. 8 April 2025.

Edwards, R. T. (2022). Well-being and well-becoming through the life-course in public health economics research and policy: A new infographic. Frontiers in Public Health, 10, 1035260. 

Edwards, R. T., & Lawrence, C. L. (Eds.). (2024). Health economics of well-being and well-becoming across the life-course. Oxford University Press. 

Edwards, R. T., & McIntosh, E. (Eds.). (2019). Applied health economics for public health practice and research. Oxford University Press. 

Klein, N. (2014). This changes everything: Capitalism vs. the climate. Simon and Schuster. 

Lawrance, E. L., Thompson, R., Newberry Le Vay, J., Page, L., & Jennings, N. (2022). The Impact of Climate Change on Mental Health and Emotional Wellbeing: A Narrative Review of Current Evidence, and its Implications. International Review of Psychiatry, 34(5).

Pichler, P. P., Jaccard, I. S., Weisz, U., & Weisz, H. (2019). International comparison of health care carbon footprints. Environmental Research Letters, 14(6), 064004.

The Lancet Public Health. (2021). Mitigating climate change must be a priority for public health. The Lancet Public Health 6(9). 

Rasheed, F. N. & Walraven G. C. (2023). Cleaning up plastics in healthcare waste: the transformative potential of leadership BMJ Innovations; 9. 

Rodrígues-Jiménez, L., Romero-Martín, M., Spruell, T., Steley, Z., & Gómez-Salgado, J. (2023). The carbon footprint of healthcare settings: A systematic review. Journal of advanced nursing, 79(8).

Williams, J. T., Bell, K. J., Morton, R. L., & Dieng, M. (2024). Methods to include environmental impacts in health economic evaluations and health technology assessments: a scoping review. Value in Health, 27(6), 794-804.

World Health Organization. (2020). WHO guidance for climate resilient and environmentally sustainable health care facilities. 

World Health Organization. (2021a). Checklists to assess vulnerabilities in health care facilities in the context of climate change.

World Health Organization. (2021b). Climate change and health: vulnerability and adaptation assessment. 

World Health Organization. (2022). Measuring the climate resilience of health systems. 

World Health Organization. (2023). Operational framework for building climate resilient and low carbon health systems. 

World Health Organization. (2024a). WHO country support on climate change and health. 

World Health Organization. (2024b). Target setting for low carbon sustainable health systems. 

World Meteorological Organization. (2025, January 10). WMO confirms 2024 as warmest year on record at about 1.55°C above pre-industrial level.