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Building Global Health System Climate Resilience��Dr James Bevan

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Learning Outcomes

Define health system resilience and its core components.

Explain how environmental degradation undermines health system functions and population health outcomes.

Identify strategies to strengthen health system resilience in the context of environmental change.

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What is a health system?

“Health systems consist of the people and actions whose primary purpose is to improve health” - WHO

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Health System

Leadership and Governance

Health Financing

Health Workforce

Health Information

Medicines, medical products etc

Service delivery

WHO (2007)

Leading medical education to meet the challenges of climate change

Lecturer Notes

The WHO definition is deliberately broad – people and actions – not just hospitals and clinics
A health system is essentially everything and everyone involved in keeping people healthy
It includes:

Primary, secondary and tertiary care
Doctors, nurses, pharmacists and allied health professionals.
Public health organisations and activities
Suppliers who provide equipment, medications and infrastructure
Organisations that pay for healthcare
Governments that regulate

A health system is the complex interactions between all these actors, items and infrastructure.

References

World Health Organization. Everybody's business: strengthening health systems to improve health outcomes: WHO's framework for action [Internet]. Geneva: WHO; 2007 [cited 2026 May 29]. Available from: https://www.who.int/publications/i/item/everybody-s-business----strengthening-health-systems-to-improve-health-outcomes

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Defining Climate Resilience

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WHO Definition:

A climate resilient and low carbon health system as able to anticipate, respond to, cope with, recover from and adapt to climate-related shocks and stress,

While reducing greenhouse gas (GHG) emissions and other negative environmental impacts in their operations,

To bring sustained improvements in population health, despite an unstable climate.

WHO (2023)

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Developing climate resilience

Assess Vulnerability

System-specific vulnerability, capacity, and risk

Engage & Design

Co-design with key stakeholders, communities, and health workers

Implement

Plan and deliver intervention

Monitor and learn

Track outcomes, feed learning back into the cycle

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Assessing Health System Vulnerability

Each health system has unique vulnerabilities.

Understanding these vulnerabilities is the first step in designing effective solutions for resilience.

Environmental Degradation can exacerbate these factors

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WHO (2021)

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Environmental change threatens health systems

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Increased need for health services

Reduced access to health services for patients and staff

Direct damage to health infrastructure

Supply chain disruption

Financial burden of repairs

Strain to governance and surveillance

Leading medical education to meet the challenges of climate change

Lecture Notes

Environmental degradation (climate change, biodiversity loss and pollution) threatens health systems and can expose, exacerbate or cause vulnerabilities.

This can occur through several mechanisms:

Increased need for health services - Environmental degradation drives ill health, increases outbreak risk, and shifts disease epidemiology, increasing demand on health systems. Climate migration can increase the burden on health systems.
Reduced access to health care: Extreme weather events reduce access to services for both patients and staff (e.g. flooded roads), meaning patients present later with more complex conditions.
Damage to health Infrastructure: Healthcare facilities and be directly damaged or destroyed from flooding, server overheating, and wildfires.
Supply chain disruption: Extreme weather events and resource exploitation can threaten supply chains, from raw material extraction (helium for MRI scanners) to cold chain failure for vaccines.
Financial Burden: Repeated shocks create significant financial burden through repair and emergency response costs, crowding out investment in routine services and long-term system development.
Governance: Climate emergencies strain governance and surveillance mechanisms, especially when compounded with conflict or displacement. This is often when strong governance is most required.

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Health System Vulnerability – Case Studies

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Health System Vulnerability – Madagascar

Biological

High burden of Malaria, TB with increasing chronic disease burden

Demographic

Young population (average age ~14), rapidly growing: high fertility rate (4-5 births per woman).
Large rural population with poor infrastructure and access to healthcare

Geographical

Vulnerable to large tropical cyclones, causing damage and destruction to infrastructure, including health facilities

Socio-economic

High rates of poverty, an aid-dependent health system. 75% occupation in work in agriculture

Socio-political

Recurring political instability

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Environmental Shock - 2022 cyclones

Setting: Rural Madagascar, high poverty rates, poor transport infrastructure and low access to healthcare

Shock: Four large cyclones within a few weeks, Batsirai the largest with windspeeds of 230km/h

Health Impact:

93 health facilities impacted
204 deaths
~304,000 without access to healthcare
~61,000 people displaced
>90% Crops destroyed in some areas, Severe malnutrition tripled in affected areas.

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WHO Regional Office for Africa (2022).

Evans MV (2025 )

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Lecture Notes

Four cyclones in weeks , not a single shock but a sequence overwhelming recovery capacity
The country already had poor infrastructure and access to healthcare.
The cyclones

Had a direct impact on health – 204 deaths
Reduced the capacity to manage health crisis – 93 health facilities impacted
Caused long term economic and food supply issues - >90% crops destroyed – malnutrition.

References

WHO Regional Office for Africa. Mobilizing health assistance after deadly cyclones devastate Madagascar [Internet]. Brazzaville: WHO AFRO; 2022 [cited 2026 May 29] https://www.afro.who.int/photo-story/mobilizing-health-assistance-after-deadly-cyclones-devastate-Madagascar
Evans MV, Rajaonarifara E, Garchitorena A, Ralaivavikoa FA, Rahajatiana PE, Finnegan KE, et al. Designing and evaluating a health system resilient to extreme weather events in rural Madagascar. Ann Glob Health. 2025;91(1):33. doi:10.5334/aogh.4759

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Health System Vulnerability - UK

Biological

High burden of chronic disease – obesity, diabetes, heart disease etc.

Demographic

Ageing population with increasingly complex and costly care needs.

Geographical

Increasing flooding and extreme heat events
Health infrastructure not designed for extreme heat

Socio-economic

High GDP per capita but rising inequality.
Publicly funded NHS under economic strain.

Socio-political

Unstable political leadership since Brexit.

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Environmental Shock London, UK – Heatwave July 2022

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Setting: Major urban NHS teaching hospital, London; ageing IT infrastructure with known cooling vulnerabilities

Shock: Record UK temperatures of 40°C on 19 July 2022 the hottest day ever recorded in Britain

Health impact:

Both hospital data centres failed simultaneously
Staff lost access to patient records, blood results, and CT/MRI scans
Operations cancelled; hospitals reverted to full paper-based systems
Patient safety incidents, including near-medication errors
Six weeks to full restoration; cost £1.4m

Guy's and St Thomas' NHS Foundation Trust, 2022

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An unequal threat to universal healthcare

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Salas R N, (2019)

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Lecture notes

Comparing the two case studies – which had the greater impact on local health systems

UK: shock disrupted services at one hospital, serious, but within a high-baseline system with strong recovery capacity
Madagascar: cyclone left 304,000 without any healthcare access, in a system already stretched before the cyclones hit. The cyclone was also a much more violent event.

The core pattern:

the most climate-vulnerable populations tend to live in countries with the weakest health systems, greater exposure to extreme weather and reduced capacity to respond
Within countries, the same repeats: marginalised communities face higher environmental exposures and greater barriers to care simultaneously

Reading the maps:

left chart - lighter red = higher climate vulnerability;
right chart - lighter red = lower UHC coverage.
The geographic overlap is the point - these are largely the same regions

References:

Salas RN, Jha AK. Climate change threatens the achievement of effective universal healthcare. BMJ. 2019;366:l5302. doi:10.1136/bmj.l5302

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Building Climate Resilience

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WHO Framework

Ten building blocks of health systems resilience.

Designed to highlight areas for resilience interventions across a healthcare system.

Targets resilience and sustainability

WHO (2023)

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Engage and Co-design

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Why it's important

Top-down interventions frequently fail
Engagement builds ownership, improves uptake and sustainability

Key Principles

Inclusive - involve those most exposed, actively reach marginalised groups
Early - engage before solutions are designed, not to validate decisions already made
Local knowledge as evidence - lived experience of risk is data, not anecdote
Iterative - feeds back into reassessment as conditions change

Leading medical education to meet the challenges of climate change

Lecture Notes

Top-down interventions without local knowledge often fail because they lack insight into issues on the ground
Co-design is a participatory approach in which those affected by a problem are actively involved in designing the solution, rather than being passive recipients of decisions made on their behalf.
This is critical for building climate resilience interventions, in every context both in local and global health solutions.

Figure: Arnstein's Ladder of Citizen Participation (1969) is a framework describing the spectrum of public involvement in decision-making, from tokenism to genuine power-sharing.

The ladder has eight rungs grouped into three broad levels:

Non-participation (bottom): Manipulation and Therapy - authorities shape opinion rather than seek it
Tokenism (middle): Informing, Consultation, Placation - communities are heard but have no guarantee their input changes anything
Citizen power (top): Partnership, Delegated Power, Citizen Control - communities have real influence or outright control over decisions

References

Arnstein SR. A ladder of citizen participation. J Am Inst Plann. 1969;35(4):216–24. doi:10.1080/01944366908977225

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Case Study: Bangladesh Cyclone Preparedness Programme

Intervention

A community-centred early warning and evacuation system, now supported by Nationally broadcast warnings are disseminated locally via flag systems, mosque loudspeakers, megaphones, and door-to-door outreach.
Vulnerable residents are assisted to evacuate to 4,000+ cyclone-resistant shelters, many doubling as schools and community centres.

Impact

76,000+ trained volunteers across coastal communities.
~50% of volunteers are women, strengthening reach through female social networks and improving safe evacuation for women and girls.
A widely cited model of climate-resilient risk reduction, credited with contributing to a sustained fall in cyclone fatalities over 50 years.

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Haque (2022)

Photo Source: BBC

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Case Study: PAHO Smart Hospitals Initiative, Caribbean�

Intervention

Following repeated hurricane-related service disruptions
PAHO retrofitted over 70 health facilities across seven Caribbean countries with structural upgrades, solar power, battery storage, and improved water systems.

Impact

Retrofitted sites saw 30-60% reductions in operational costs.
During Hurricanes Beryl and Melissa, Smart Hospital sites remained operational while surrounding facilities lost power, water, and connectivity
Toolkit available for other administrators, SMART hospitals to be introduced in Latin America

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Harvey et al. (2025) J Clim; PAHO Smart Hospitals Initiative

PAHO, Smart Hospital Initiative

Leading medical education to meet the challenges of climate change

Lecture Notes

77% of Caribbean hospitals sit in high-risk areas, built to outdated codes, repeated hurricane disruptions were the catalyst for action
"Smart" = safe + green + maintained; retrofitting and renewable energy treated as a single package, not separate agendas
The 30-60% cost reduction is the headline - resilience pays for itself, which matters enormously for aid-dependent health systems
Beryl and Melissa provided the real-world stress test, smart sites stayed operational while surrounding facilities went dark
Toolkit is freely available on the PAHO website -students can access it; worth flagging as a practical resource
Intervention is being introduced across Latin America

References

Harvey J, van Alphen D, Jagnarine Azan S, Camacho R, Buter C, Ugarte C, et al. Smart greening initiatives for healthcare facilities: a Caribbean case study on environmental sustainability and disaster resilience. J Clim Chang Health. 2025;100525. doi:10.1016/j.joclim.2025.100525
Pan American Health Organization. Smart hospitals initiative [Internet]. Washington (DC): PAHO; [cited 2026 May 29]. Available from: https://www.paho.org/en/smart-hospitals-initiativeHarvey J, van Alphen D, Jagnarine Azan S, Camacho R, Buter C, Ugarte C, et al. Smart greening initiatives for healthcare facilities: a Caribbean case study on environmental sustainability and disaster resilience. J Clim Chang Health. 2025;100525. doi:10.1016/j.joclim.2025.100525 Pan American Health Organization. Smart hospitals initiative [Internet]. Washington (DC): PAHO; [cited 2026 May 29]. Available from: https://www.paho.org/en/smart-hospitals-initiative

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Monitor and Learn

Critical for funding and understanding impact.

Design evaluation and monitoring with the intervention at the beginning

Use logic models and SMART principles to design indicators

Monitoring and evaluation should be a continual process

Improve the intervention iteratively.

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CDC (2024)

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PRACTICAL

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Setting: Valencia Province, Spain

Population

5 million, with a significant elderly population (>20% over 65)
Large seasonal agricultural workforce including migrant workers.
Reside in both urban and rural areas.

Environmental profile

One of Europe's most climate-exposed regions, extreme heat events, prolonged drought, and flash flooding.
The October 2024 Valencia floods killed over 200 people, displaced 15,000, and limited access to and damaged health infrastructure.

Health System

Publicly funded through the Spanish National Health System.
Primary care is well-developed but under strain.
Rural areas have significant access gaps.

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Lecture Notes

Valencia is a worked example of a high-income region that is nonetheless highly climate-vulnerable a useful counterpoint to the assumption that resilience is only a low-income country problem
October 2024 floods caused both:

Direct health impacts (injury, displacement, deaths)
Indirect impacts (disrupted services, mental health, food and water insecurity)

The region has multiple, overlapping vulnerabilities :

elderly population, seasonal migrant agricultural workers, rural access gaps, flash flood exposure

No single intervention will address this; the practical is designed to make students grapple with prioritisation and trade-offs under a real budget constraint
Overall, a multifaceted approach is of course required, the task asks students to choose a focus area and justify it, which is itself the learning point: resilience planning requires making hard choices about where limited resources will have the greatest impact

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Task

You are part of a team applying for €250k from the EU Climate Adaptation Fund to pilot a project strengthening health system climate resilience in the Valencia region.

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TASK

As a group:

Review the health system vulnerabilities using the WHO framework.
Consider how environmental threats affect both population health and healthcare delivery

Then prepare a 2-minute pitch for the project you would pilot in the region.

In your pitch, explain:

How you would design the intervention
Which local partners you would involve
Which health outcomes you hope to improve
How you will evaluate impact

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Possible Focus Areas

Physical Infrastructure
Digital Infrastructure
Outbreak control
Chronic disease management
Early warning and preparedness
Water, Sanitation and Hygiene
Supply chains
Community outreach

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Task - reflection

What have you learnt from trying to do this task?

Was anything more simple or easier than you thought?

Were there challenges that you did not expect?

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Thank you for listening

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