Resilient health systems can reduce the negative health and social effects of climate change. However, health systems are themselves threatened by climate change through climate hazards increasing the demand for services, threatening health infrastructure and supply chains, and stressing the workforce. While there is significant research on the environmental sustainability of health facilities in high-income countries, less attention has been paid to building climate resilience (sustainably), especially in low- and middle-income countries (LMICs). This scoping review aims to connect top-down guidelines with concrete bottom-up activities to accelerate transformational change in the health sector. We systematically and comprehensively searched the academic and grey literature to identify case studies of climate-resilient health facilities in LMICs and describe the activities that build resilience to climate-related health risks. We used scoping review methodology (Arksey and O’Malley 2005 Int. J. Soc. Res. Methodol. 8 19–32; Levac et al 2010 Implement. Sci. 5 69) and employed a two-phase, double-blinded, screening approach to search the academic and grey literature (from 2015 to 2022). We searched four academic databases (Scopus, PubMed, CINAHL, Lilacs), Google Scholar and key websites from the World Health Organisation (WHO), Green Climate Fund, Global Adaptation Mapping Initiative, Health Care Without Harm, and the Global Environmental Facility. A coding framework guided data extraction and data were analysed quantitatively and qualitatively. We identified 26 case studies in 46 countries outlining planned and implemented activities to develop the climate resilience of health facilities in LMICs. We focussed on activities targeting health care facilities rather than broader health systems level planning and present a narrative synthesis of these activities using the WHO Operational Framework for Climate-Resilient and Low Carbon Health Systems. As a result, we developed a conceptual theory of change model that can be applied to various health settings to guide vulnerability assessments and improvement plans to build climate resilience. The research sought to identify successful efforts to build climate resilience at the facility level in LMICs, yet we found very little evidence of actual implementation and no evaluations. Of the case studies that were identified, the activities mapped neatly onto the WHO Operational Framework with some novelties and nuances. Key enablers to building climate resilience include supportive policies, strong information systems, stakeholder coordination, adequate funding, and technical expertise. Community engagement emerges as an important consideration and is recommended for inclusion in climate resilience frameworks, action plans, and strategies. Bridging the knowledge-action gap can be helped by collating experiences, standardized reporting of initiatives, and increased investment in implementation science. Lessons learned and good practices should be shared among health decision-makers within and between countries, allowing for mutual learning. There is also an urgent need to ensure climate finance reaches the health facilities and populations most at risk.

Objective Physical and mental well-being are threatened by climate change. Since hospitals in high-income countries contribute significantly to climate change through their greenhouse gas (GHG) emissions, the medical ethics imperative of ‘do no harm’ imposes a responsibility on hospitals to decarbonise. We investigated hospital stakeholders’ perceptions of hospitals’ GHG emissions sources and the sense of responsibility for reducing GHG emissions in a hospital. Methods We conducted 29 semistructured qualitative expert interviews at one of Germany’s largest hospitals, Heidelberg University Hospital. Five patients, 12 clinical and 12 administrative employees on different levels were selected using purposive maximum variation sampling. Interviews were transcribed verbatim and analysed using the framework approach. Results Concerning GHG emissions, hospital stakeholders perceived energy and waste as most relevant emission sources followed by mobility. Climate change mitigation in general was considered as important. However, in their role as patients or employees, hospital stakeholders felt less responsible for climate change mitigation. They saw providing best possible medical care to be the top priority in hospitals and were often concerned that patients’ health could be jeopardised by climate change mitigation measures. Conclusion Perceptions of most important emission sources did not coincide with those in literature, highlighting the need to inform stakeholders, for instance, about pharmaceuticals as important emission source. A frequently perceived conflict between reducing emissions and providing high-quality medical care could be eased, if reducing emissions would not only be justified as a contribution to mitigation, but also as a contribution to preventing ill health—a basic principle of medical ethics.

Evidence on the health benefits of spending time in nature has highlighted the importance of provision of blue and green spaces where people live. The potential for health benefits offered by nature exposure, however, extends beyond health promotion to health treatment. Social prescribing links people with health or social care needs to community-based, non-clinical health and social care interventions to improve health and wellbeing. Nature-based social prescribing (NBSP) is a variant that uses the health-promoting benefits of activities carried out in natural environments, such as gardening and walking. Much current NBSP practice has been developed in the UK, and there is increasing global interest in its implementation. This requires interventions to be adapted for different contexts, considering the needs of populations and the structure of healthcare systems. This paper presents results from an expert group participatory workshop involving 29 practitioners, researchers, and policymakers from the UK and Germany's health and environmental sectors. Using the UK and Germany, two countries with different healthcare systems and in different developmental stages of NBSP practice, as case studies, we analysed opportunities, challenges, and facilitators for the development and implementation of NBSP. We identified five overarching themes for developing, implementing, and evaluating NBSP: Capacity Building; Accessibility and Acceptability; Networks and Collaborations; Standardised Implementation and Evaluation; and Sustainability. We also discuss key strengths, weaknesses, opportunities, and threats for each overarching theme to understand how they could be developed to support NBSP implementation. NBSP could offer significant public health benefits using available blue and green spaces. We offer guidance on how NBSP implementation, from wider policy support to the design and evaluation of individual programmes, could be adapted to different contexts. This research could help inform the development and evaluation of NBSP programmes to support planetary health from local and global scales.

Climate change is the greatest threat to global health in the twenty first century, yet combating it entails substantial health co-benefits. Physicians and other health professionals have not yet fully embraced their responsibilities in the climate crisis, especially about their communication with patients. While medical associations are calling on physicians to integrate climate change into health counselling, there is little empirical evidence about corresponding perceptions of patients. This study aimed to explore primary care patients' perceptions of climate-sensitive health counselling. From July to December 2021, 27 qualitative interviews with patients were conducted and analysed using thematic analysis. A purposive sampling technique was applied to identify patients who had already experienced climate-sensitive health counselling in Germany. Patients' perceptions of climate-sensitive health counselling were characterised by a high level of acceptance, which was enhanced by stressing the link between climate change and health, being credible concerning physician's own climate-friendly lifestyle, building upon good therapeutic relationships, creating a sense of solidarity, and working in a patient centred manner. Challenges and risks for acceptance were patients' disinterest or surprise, time constraints, feared politicisation of consultations, and evoking feelings of guilt and shame. These findings suggest that primary care patients can accept climate-sensitive health counselling, if it follows certain principles of communication, including patient-centredness. Our findings can be useful for developing communication guidelines, respective policies as well as well-designed intervention studies, which are needed to test the health and environmental effects of climate-sensitive health counselling.

To mitigate the negative (health) consequences of climate change, the Paris Agreement demands a radical reduction of greenhouse gas (GHG) emissions. The health sector contributes considerably to climate change worldwide. In Germany it is responsible for 6.7% of national GHG emissions. The transition to low-carbon hospitals requires detailed knowledge of the amount and sources of GHG emissions. This study aimed at capturing the status quo of GHG emission reporting by German hospitals and at examining characteristics of the reports. Therefore, we performed a grey literature review with pre-defined inclusion and exclusion criteria. The search strategy comprised hand-searching specific databases, targeted websites and web search engines via a standardized set of search terms. We found 232 German hospitals reporting their GHG emissions, representing 12% of all hospitals. Yet, only 62 hospitals (3%) met the inclusion criteria for further analysis. These reports do not comprise all energy-related GHG emissions, omit GHG emissions occurring up- and downstream of hospitals and mainly include CO₂, but leave out other GHG. Consequently, there are severe gaps regarding GHG emissions reports of German hospitals. If Germany wants to comply with the Paris Agreement, hospitals need to be obliged to follow a standardized methodology to report and reduce GHG emissions.