This study was conducted to investigate the role of the health system in relation to two major pillars of the Paris Agreement, namely adaptation and mitigation. The health system is not the custodian for the mitigation measures; hence, its contribution to mitigation is very low compared to other sectors such as energy, industry, environment, and agriculture. Nevertheless, through its advocacy role, the health system can take advantage of the mitigation measures. Our research showed that the health system in Iran can play a role in mitigation measures, i.e. through active participation of the MoHME in the formulation of strategies and programs, as well as taking measures with respect to the mitigation, establishment of green hospitals, increasing the efficiency of energy carriers in healthcare facilities, using renewable energy, reducing waste production in health centers and all health-related manufacturing units in the areas of cosmetics, health, and pharmaceuticals.
Although limited data exists on tracking the health sector’s carbon footprint, The health sector has been estimated to be responsible for about 3–8% of all GHG emissions in some industrialized countries , while the figure is expected to be lower in the less-industrialized countries. Some studies indicate that for the period of 2003–2013, the US health sector has also been estimated to be responsible for a significant contribution to air pollution and its effects including acid rain (12%), greenhouse gas emissions (10%), air pollutants (9%), ozone depletion of the stratosphere (1%), and carcinogenic and non-carcinogenic toxins (1–2%). A previous study stated that, the concerted efforts to improve the environmental performance of health care centers by reducing the waste and energy production, and the burden of pollution are effective . There is very little information on GHG emissions from health systems in low and middle-income countries, which highlights the need for more research in this area . Carbon reduction measures are not only excellent opportunities for financial management in the health sector, but also might help improve the healthcare resilient infrastructures . Previous studies showed that these measures including access to green and renewable energy [39, 40], green health centers , using low-consumption heating and cooling and ventilation systems, reducing distance to health facilities for patients in order to reduce the consumption of transportation energy, and management of procurements, materials, and wastes can contribute to lowering GHG emission .
Adaptation is the second main strategy that set out in Paris Agreement on climate change to tackle the effects of climate change. Considering the inevitability of the climate change phenomenon, adapting to it is crucial now more than ever. Our findings identified capacity building as one of the obvious examples of adaptation in the health system of Iran. Accordingly, capacity building is important in the form of resiliency strategies and adaptation plans for the health and climate change issues, increasing the capacity of healthcare infrastructures to cover full services in extreme climate events, developing health insurance to improve the adaptation; formulation of preparedness plans for health sector at the national, local, regional, and international levels, and integrating a comprehensive risk assessment plan into the health service delivery system to reduce mortality and injury in extreme climate events. It also helps identify the vulnerable groups of the health system in order to increase the capacity and provide the services in vulnerable geographical locations.
The use of indigenous and local capacities to create the adaptation is a strategic decision. In the same vein, the participation of local public and private institutions aimed at adapting to the climate change and inter-departmental and international partnership in terms of health adaptation policies are among the important issues supporting other organizations to achieve healthcare-related goals. In 2015, WHO reported the health and climate policies, human capital development, information infrastructure, and development of health-related services to strengthen the resiliency and increase the capacity of health systems in a variety of climatic conditions as necessary .
With regard to the technologies, the use of new technologies in the area of consumption management plays a significant role, especially, in relation to reduction of waste production and processes related to the enhancement of energy efficiency. The use of these technologies to increase the adaptation can play an effective role in monitoring, outbreak prediction, prevention, and control of diseases that are sensitive to climate change. A study investigated the roles of telemedicine and health information technology in reducing the carbon footprint in the health sector [36, 38]. Some scholars introduce eHealth as an adaptive strategy to reduce social vulnerability to climate change and a promising technology for mitigation in the health sector .
Financial issues related to the health sector and climate change are important and challenging mitigation initiatives and their costs should be calculated for budgeting the MoHME and other relevant organizations.
Evaluation and monitoring health information has always been considered as one of the important processes in the health system management. Our findings revealed the measures required in this regard including the vulnerability assessment of the affected population; continuous and systematic monitoring and evaluation of the effectiveness of adaptive interventions; use of Early Warning Systems to warn against the health effects of climate change and climatic anomalies; collecting health data related to these effects and using them in simulation models.
There are some evidence-based evaluation methods available for policymakers to increase the resiliency against the health effects of climate change including the assessment of burden of diseases related to climate change, evaluation of the adaptation interventions, and estimation of the potential health effects, and using future climate change scenarios .
In terms of reporting and information sharing, complementary to the efforts by the National Climate Change Workgroup at the DoE, which acts as the national authority of the climate change, the health system can also play an important role in formulating health-related appendices to all national and international reports. Relevant stakeholders are expected to contribute to the systematic and periodic reporting of health system achievements and interventions to control the health effects of climate change, and share the reports of relevant interventions with the international organizations. The MoHME needs to join the DoE in learning the lessons from international conventions and related scientific assemblies, while providing feedback to them and their participation in such meetings will be crucial.
The MoHME in Iran is responsible for both provision of public health services as well as enhancing health standards through an educational approach. Our study showed that production of scientific evidence related to climate variables for health interventions, as well as increasing the knowledge and skills of health system staff about the direct and indirect effects of climate change on the health system, are two essential function of Iran’s health system. We advocate a greater collaboration between the health system and other educational institutions in Iran, i.e. the Ministry of Science, Research, and Technology, and the Ministry of Education to strengthen knowledge transfer related to health and climate change. This could be conducted through scholarly meetings, conducting applied research, research collaborations with national and international organizations, and strengthening the educational curricula. Education can be discussed in both specialized and general areas. In particular, the MoHME needs to collaborate with, through the ministry of education, schools for fostering the use of modern knowledge to increase pupils’ awareness about the health effects of climate change. This may create in turn higher adaptation in the form of self-care programs and through educational packages such as films and educational pamphlets, which are important means to understand the relationship between the environment and health. This can also help the next generation create a healthier and more secure future , through integrating the subject of climate change into medical curricula via the best innovations made in medicine .
Our findings are also consistent with those presented in the WHO report of 2015, which offered an operational framework, comprising of 10 key functions to create a resilient health system against climate change. These include health governance and policy, human resources for health, supplying human resources, integrated risk monitoring and early warning systems, vulnerability, capacity and adaptation assessment, essential products and technologies, risk monitoring and early warning system, climate-informed health programs, emergency preparedness and disaster risk management, and management of the environmental determinants of health, research, and financing . In addition, in 2014, the US Center for Disease Control and Prevention (CDC) put forward operational priorities for protecting health against climate change. These priorities include tracking the environmental information and the prevalence of the diseases related to the climate change, modeling and predicting the health effects of the climate change, identifying the locations and populations at risk, developing and implementing the preparedness and response plans for extreme climate events, providing counseling services to public and local health sectors, and providing the workforce responding to the health threats of climate change .
Our study was conducted based on the Paris Agreement on climate change, which is the most up-to-date global policy on adaptation and mitigations measures. Since this agreement observes the “right to health” in its approach, and because of WHO’s emphasis on the development and implementation of adaption strategies, our findings provided an evidence-based basis for future policy-making in the health system of Iran, and perhaps similar middle-income countries, towards a meaningful adaptation to climate change.