Ensuring Greater Sustainability in Health Care
Collaborative Actions to Strengthen Health Systems in the Face of Climate Change
An FP Analytics issue brief, with support from
Amidst the ongoing COVID-19 pandemic, which has claimed more than 6.5 million lives worldwide, the World Health Organization (WHO) has declared that climate change is the greatest threat to global health. A growing body of evidence shows that climate change compounds risks such as malnutrition and disease transmission. For example, global warming is contributing to the rise, rapid spread, and resurgence of a variety of communicable diseases such as Zika, dengue, and malaria. The United Nations (UN) has warned that by 2050, malaria transmission could rise by as much as 50 percent due to global warming as malarial mosquitoes spread to areas that were previously unexposed to the disease. Meanwhile, the WHO warns that climate change is also worsening psychological well-being. The impacts of these and other risks will be felt disproportionately in under-resourced countries and in marginalized communities across the world that are already contending with rising sea levels, extreme weather events such as prolonged droughts, and other factors, which could lead to the displacement of an estimated 1.2 billion people by 2050. Beyond health impacts, climate change will also create and exacerbate challenges for health systems, which are likely to be far reaching and vary from one place to another. For example, more than 90 percent of hospital wards in the UK could face overheating, while 10 percent, if not more, will have to contend with significant flooding. Impacts of weather events such as these on health infrastructure, along with additional strain on services due to climate impacts such as increased respiratory illness and heat-related hospitalization, are putting significant strain on health systems and undermining the delivery of high-quality, equitable care. This stark reality warrants a rethinking of health care systems worldwide to make them fit for their purpose not only to meet the health challenges stemming from climate change, but also to ensure that those systems do not exacerbate environmental degradation.
In anticipation of the Conference of Parties (COP) 27 conference in Sharm El Sheikh, taking place November 2022, and with support from Sanofi, FP Analytics presents this timely issue brief centering on the deep interconnection among public health, climate change, and sustainability. Health has featured on recent COP agendas, with growing recognition of the interdependence and mutual benefits between medical and ecological well-being. Indeed, the WHO expects that health benefits from compliance with the 2015 Paris Agreement will amount to more than twice the costs of implementation. However, policies and programs to mitigate the environmental impacts of the health care industry and to mainstream sustainability into health systems for better health and environmental outcomes warrant further attention in order to overcome what some experts have classified as “a dangerous delusion” stemming from “the separation of health and environmental policy.” The role of the health care sector in addressing the climate crisis by advancing environmentally sound and equitable solutions remains likewise underexplored.
To elevate these issues on the COP 27 agenda and by drawing on a range of evidence, the following analysis illuminates how health care systems contribute to environmental degradation and identifies opportunities for collaboration and public-private partnership across the health care, development, and environmental sectors to strategically channel resources and strengthen global health resilience.
Establishing data-driven awareness of the health care sector’s environmental impacts is key to improving climate and health outcomes
The extent to and ways in which the global health care industry impacts climate change is yet to be fully understood, and there is an increasing need for baseline assessments to bridge knowledge gaps. Some estimates suggest that the health care industry contributes approximately 4.4 percent of global net emissions, over half of which come from the US, China and the EU. If the global industry were a country, this would make it “the fifth-largest emitter on the planet.” The environmental effects of the health care sector operations, including water and air pollution, carbon emissions, hazardous waste, and other pollutants, can in turn negatively affect health outcomes. At COP 26 in Glasgow, in 2021, the WHO called for greater tracking and understanding of global greenhouse gas emissions caused by health systems, including health supply chains. While data remains limited, estimates suggest that 17 percent of the global health care sector’s emissions are produced directly, whereas the vast majority of emissions stem from indirect sources, including purchased energy (12 percent) and the supply chain (by far the largest share, at 71 percent). The health care supply chain includes production of pharmaceuticals, transportation, and use and provision of goods and services, making the sector a nexus for different industries and stakeholders. As such, while the health care sector has a significant carbon and environmental footprint, it is also well positioned to act as a leader, collaborator, and connector in broader climate mitigation and adaptation efforts.
Developing targeted benchmarking and expanding the evidence base will be critical for setting realistic goals and subsequent actions to achieve the net-zero transition. Comprehensive data collection could not only facilitate more precise monitoring of emissions, pollution, and other environmental effects of the health industry, but also help to inform deeper evidence-based analysis to enable health care leaders to constructively engage with policymakers who are at the forefront of developing environmental protection and climate change adaptation frameworks. Governments, development institutions, and the private sector can collaborate on data collection and benchmarking efforts by establishing economy-wide carbon emission accounting expectations, setting goals and expectations regarding other environmental impacts such as pollution reduction, and supporting governments globally to expand data-collection capacities and close information gaps. For example, the International Monetary Fund (IMF)’s Climate Change Indicators Dashboard identifies some of the indicators and metrics that will be beneficial to track and build upon, as does the Organization for Economic Co-operation and Development (OECD), whose membership includes some of the world’s biggest polluters.
Building climate resilience and health care resilience are mutually reinforcing goals
Making health care systems, programs, and approaches more environmentally sound is as much about strengthening the resilience of communities and countries to climate change as it is about fostering equitable and transformative development that uplifts marginalized populations, reduces inequities, and works with nature rather than against it. This is true especially in low-income economies where inequalities remain a persistent challenge. Several of the UN’s Sustainable Development Goals (SDGs) to combat poverty aim to promote better health and a healthy environment, including SDG3, “Good Health and Well-Being,” SDG 6, “Clean Water and Sanitation,” SDG 7, “Affordable and Clean Energy,” and SDG 13, “Climate Action.” Indeed, the health sector is highlighted as the most important sector to the achievement of six out of the total 17 goals and is mentioned as relevant to all of them. Beyond improving health outcomes, the health care sector can be an important driver of both poverty eradication and climate change mitigation.
Sources of Greenhouse Gas Emissions in the U.S. Health Care Industry
Percent of Scope 1, 2, and 3 Greenhouse Gas Emissions in 2018
DATA SOURCE: Health Affairs
Much like the effects of climate change itself, the health care sector—even where locally focused—is not bound by borders, as supply chains often stretch across countries and continents. Health care is thus an industry ripe for greater international collaboration, especially among companies, governments, and development organizations. A study of health carbon footprints in the Organisation for Economic Cooperation and Development (OECD) region plus India and China, from 2000 to 2014, found that, on average, 28 percent of a country’s carbon emissions were occurring in non-OECD countries, largely as part of their supply chains. Public- and private-sector stakeholders that develop and sustain health systems, including those that manufacture pharmaceuticals and equipment, can therefore play a significant role in mitigating the negative climate impacts felt across the health care value chain. This is especially important in low-income countries, where socioeconomic inequality is wide, and susceptibility to climate change heightened, and in poorer communities and regions of high-income countries. Research also demonstrates that general national energy consumption patterns hew closely to the health carbon footprint of a country, suggesting that broad, nationwide changes to energy and emissions policies—such as encouraging the use of renewable energy sources—will have a significant impact on the emissions of the health care industry. This presents an important opportunity for greater alignment across the health care and renewable energy sectors that could be facilitated on a broad scale with government support.
Climate-friendly health systems can be strengthened by cross-sectoral collaboration and public-private partnership
Growing awareness of how health care and climate change intersect and shape each other presents both a challenge and an opportunity for greater cross-sectoral partnership. As health systems are designed, created, and improved upon around the world, including in both advanced and developing economies, integrating climate resilience into those systems while minimizing environmental damage will be key. Such an approach can be facilitated through greater coordination and collaboration among scientists, architects, engineers, health care providers, and development professionals to encourage creative, low-cost, and scalable interventions that improve health and climate outcomes simultaneously. For example, recent research suggests that strengthening and prioritizing preventive care, rather than curative care, and an increase in ambulatory health care could help reduce national carbon footprints. This finding aligns well with ongoing health systems investments and programming in some bilateral and multilateral donor organizations, which promote the prioritization of primary and preventive health care as key to reducing noncommunicable diseases (NCDs), which tend to increase in prevalence as societies become wealthier, and to generally improving the health and well-being of populations.
To that end, international financial institutions, including multilateral development banks such as the World Bank and regional counterparts, have a critical role to play in enabling partnership across the public health and environmental sectors to support sustainability and overcome inequity. Such work aligns clearly with their shared mandate to end poverty and improve living standards: The World Bank predicts that unchecked climate change will push as many as 130 million people into poverty in the coming decade. As a result, multilateral institutions are expanding their climate funding, but only a few initiatives are deliberately targeting the health industry. The Asian Development Bank (ADB) is funding projects that increase resilience of health infrastructure to climate change impacts, which is key across much of South and Southeast Asia where rapid-onset extreme weather events have increased in frequency and duration against the backdrop of slower-onset climatic changes. Meanwhile, the African Development Bank (AfDB) Strategy for quality health infrastructure in Africa 2021-2030 briefly mentions climate change and climate-friendly systems, affirming the link between the health infrastructure strategy and the climate change strategy.
Still, there is opportunity for far greater synergy between health and climate programming and strategic policy development with member countries. In 2020, for example, Argentina became the first country in the world to incorporate targets and plans for its health care sector into its Nationally Determined Contribution (NDC) plan—as part of the Paris Agreements—yet few other countries have followed its example. In emerging markets and under-resourced countries, which may still be developing their health infrastructure, or where the COVID-19 pandemic has precipitated a reassessment of existing health care systems, blended financing and cross-sectoral projects may be highly effective. For example, new hospitals and health care centers can be designed using climate-friendly materials and approaches, consistent with green building standards such as the LEED rating system, and can be strategically decentralized to be located in not only urban but also peri-urban and rural areas, and connected with public transit links to reduce travel times and distances, thereby increasing community accessibility while lowering environmental impact. In an effort to be carbon-neutral and climate-positive, health care centers also can also strive to reduce unnecessary in-person visits and prevent over-prescriptions while expanding access to, and availability of, telehealth resources.
The International Financial Corporation (IFC) estimates that the climate change commitments made by just 21 developing emerging markets will require $23 trillion in investment before 2030, an amount that will require partnership among development finance institutions, philanthropic foundations, private companies, and governments. Across the private sector, much more can be done to identify and address operational and supply chain risks that enable the functioning of health systems and to bolster health care infrastructure to withstand impacts of climate change. In the long run, strategic adjustments and adaptation are predicted to have a positive return on investment, presenting a clear argument for why private companies and investors need to take part in developing solutions to deliver climate financing process. According to the IFC, such interventions could generate more than $10.2 trillion in future investment opportunities, create 213.4 million new jobs worldwide, and help reduce future greenhouse gas emissions across the board by four billion tons. In the wake of the COVID-19 pandemic and the disruptions it has caused to both the global economy and health systems, the public and private sectors—crucially, including the health care industry—have an opportunity to enhance investments in low-carbon, climate-friendly innovations and infrastructure as part of broader efforts to bolster health care capacities and better prepare for future crises.
Governments, development finance institutions, and the private sector can unlock investments and better integrate climate adaptation and mitigation strategies into global health care systems
Examples of innovative adaptation strategies that link effective climate action to improved health care access are beginning to proliferate. The Sustainable Healthcare Coalition, for example, brings together public and private health organizations to research and implement sustainable practices in health care, including waste reduction and social and environmental standards in supply chain procurement. The coalition includes pharmaceutical companies, which will be key to private-sector reduction of health emissions: evidence presented to the UK parliament in 2019 found that the global pharmaceutical industry has a larger carbon footprint than the automotive industry, at 48.55 tons per million dollars, compared to 31.4 tons per million dollars, based on Scope 1 and 2 emissions (see Figure 2). Research also points to a clear incentive for pharmaceutical companies and others in the health sector to address carbon emissions. Research over 2017 and 2018 on 12 major pharmaceutical companies found that almost all were able to significantly reduce carbon emissions while maintaining or increasing profitability. As private companies begin to implement net-zero or carbon-neutrality targets, governments can help catalyze and incentivize action through conducive policies and partnerships.
Such joint public-private initiatives are well suited to the health care sector, where extensive, international supply chains can be influenced by climate-related targets and purchasing guidelines set by governments or companies. The UK’s National Health Service (NHS) for example, recently published a Sustainable Supplier Framework, setting ambitious targets to reduce the environmental impact of its supply chain, which is responsible for an estimated 62 percent of the service’s total carbon emissions. With a budget of close to £170 billion per year, NHS guidance and restrictions on suppliers is likely to have a far-reaching impact. Public and privately-run health systems could take a similar approach, leveraging the NHS framework as a model for adaptation.
In some countries, governments are taking the lead in establishing clear goals and guidelines for public and private health care and creating dedicated taskforces to address the intersection of climate change and health. In the U.S., for example, the Department of Health and Human Services (HHS) has established the Office of Climate Change and Health Equity (OCCHE), in recognition of the unequal impacts climate change is having within the country—as well as beyond its borders—on poor and ethnic minority communities. As part of its work addressing climate-related health inequality, HHS and the OCCHE, in partnership with the White House, launched the Health Care Sector Climate Pledge in 2022, inviting health care industry stakeholders, including suppliers, pharmaceutical companies, and service providers, to commit to climate-friendly actions. As part of the White House’s wider goal to achieve net-zero emissions in the U.S. by 2050, this Pledge commits supporters to reduce greenhouse gas emissions by 50 percent by 2030, demonstrating how the health care sector can be integrated into wider climate action, while continuing to encourage health sector-specific efforts. The U.S. approach could serve as a model for other countries with pre-existing net-zero or climate-forward commitments that want to reform their health sector to be more environmentally sustainable.
Beyond government-led initiatives, the health care industry can proactively mitigate climate impacts by implementing sustainable supply chain practices, collecting disaggregated data on their own climate impacts, and augmenting transparency about the efficacy of efforts to reduce their environmental footprint. For example, submitting detailed information for environmental, social, and governmental (ESG) ratings assessment can enable external stakeholders in climate mitigation to better understand the environmental impacts of health care companies, and create plans for targeted intervention, as can regularly publishing transparency reports. Health care sector companies can also join public sector-led initiatives and agendas with ambitious yet achievable emissions reduction goals, such as the UN’s Race to Zero campaign, or work with the Science Based Targets initiative. Such campaigns create a shared goal for public- and private-sector action and generate opportunities for networking and knowledge-sharing that can lead to innovative climate-friendly practices. As with the fight against climate change more broadly, reducing the climate impact of the global health care sector will require the collaboration and participation of organizations of all kinds to be successful.
Looking ahead: A greener, healthier future
To date, the multifaceted impact of the health care sector on climate change, and particularly carbon emissions, has been inadequately monitored and addressed. However, as awareness of the climate-health relationship grows, stakeholders that are committed to global health and environmental well-being have an opportunity to catalyze collaborative and complementary action. COP 27 represents a key moment at which to convene relevant parties across the health, environment, and economic development fields to build consensus on next steps not only to reduce the environmental damage wrought by the health care sector, but also to harness ongoing and new partnerships to advance a healthier future for people and the planet.
FP Analytics, the research and advisory division of Foreign Policy, produced this issue brief:
Isabel Schmidt, Senior Policy Analyst
Dr. Mayesha Alam, Vice President of Research
Allison Carlson, Managing Director, FP Analytics & FP Events
Illustration by Adrián Astorgano