There is a clear connection between health care, climate change and environmental issues. Extremes in temperature and weather events, along with air pollution contribute significantly to illness and mortality. The World Health Organization (WHO) underscores the significant health consequences of climate change, forecasting that it will cause an additional 250,000 annual deaths from 2030 to 2050. Beyond climate change, the WHO attributes nearly a quarter of global chronic diseases to environmental factors, disproportionately affecting vulnerable populations and worsening inequalities. Environmental concerns affect public health and global health insurance costs. As climate change accelerates, urgent action is needed to prevent and adapt to the increasing health impacts of climate change.

Health care sector activities significantly affect the environment. This contributes to health problems, somewhat ironically contradicting the sector's primary goal of promoting health. These negative externalities include:

• Greenhouse gas (GHG) emissions: Health care contributes close to 5 per cent of worldwide carbon dioxide emissions (HCWH and ARUP, 2021; The Lancet Digital Health, 2023). Health care facilities emit GHGs directly through energy consumption and transportation. Indirect emissions occur across the supply chain, from goods production to staff and patient travel.
• Water and energy consumption: Health care systems consume substantial amounts of water and energy, driven by heating, cooling, lighting and the use of equipment. Large hospitals particularly exhibit high energy intensity, while the production of health care products may involve significant water usage.
• Medical waste comprises materials discarded from health care facilities, such as used needles, syringes, bandages and chemicals. Globally, the substantial volume of waste generated and the extensive use of disposable products makes waste management challenging, a situation exacerbated by the COVID-19 pandemic (WHO, 2022).

Health systems therefore require a comprehensive approach to climate change and environmental protection. They must reduce emissions and waste, aiming for carbon neutrality, and address inefficiencies. Collaboration across public health, environmental policy, mobility, and urban planning is vital for reducing carbon footprint, consumption, and waste. By integrating energy efficiency, waste management, green building design, transportation, education, and policy advocacy, health care facilities can lessen their environmental impact while advancing public health and sustainability objectives.

Health care practitioners and social security institutions, dedicated to public health, can lead in promoting sustainable health care. They shape policy, promote eco-responsible patient behaviour, and implement eco-awareness campaigns. Establishing sustainable health care systems necessitates financial incentives, regulations, stakeholder collaboration, and transitioning health care practices towards sustainability.

This article further contributes to the International Social Security Association’s (ISSA) work on the relationship between social security and climate change. Previous contributions include an analysis on the role of social security in responding to climate change (ISSA, 2023a) drawing from actions implemented by its member organizations. The ISSA also collaborated with the International Actuarial Association (IAA) on a report examining how climate risks affect social security from an actuarial perspective (IAA and ISSA, 2024), and climate change and environmental concerns have been central themes in numerous ISSA webinars.

Social security organizations are exploring innovative approaches and strategies to ensure sustainable health care. By sharing experiences and best practices, they can effectively contribute to addressing the climate crisis. This article outlines key concerns raised by international organizations and ISSA members, alongside innovative strategies to drive responsive action.

Adopting environmental sustainability policies for health care systems

Initiatives by international organizations

The WHO initiative Alliance for Transformative Action on Climate and Health (ATACH) was set up to achieve COP26 goals of resilient and sustainable health systems. Aimed to drive global shifts on priority issues through collective action by WHO Member States and stakeholders, it includes prioritizing feasible areas, monitoring country-level progress, ensuring quality assurance, identifying financing needs, and facilitating knowledge sharing among participants (WHO, n.d.).

At the 2023 United Nations Climate Change Conference the COP28 Presidency, along with the WHO, introduced the COP28 UAE Declaration on Climate and Health (COP28, 2023) to prioritize health in climate action and accelerate the development of climate-resilient, sustainable and equitable health systems. Supported by 123 countries, this Declaration represents a historic acknowledgment by governments of the increasing health effects of climate change globally. World leaders committed to implementing new strategies for climate action, aiming to transform health systems to be climate-resilient, low-carbon, sustainable, and equitable, while also preparing communities and vulnerable populations for climate change impacts. The objective is to achieve climate-neutral health systems by 2050 by actively engaging in climate mitigation and nature-positive practices, with customized emissions accounting.

In addition, addressing climate change not only reduces health risks but also enhances well-being and protects against climate-related diseases. It is crucial to communicate both the risks of climate change and the health benefits of solutions. Health professionals are essential in educating communities, promoting protective measures, and advocating for climate solutions. To support this, the WHO, in collaboration with partners, has developed a toolkit for health professionals designed to equip health and care workers with the knowledge and confidence to effectively communicate about climate change and health (WHO, 2024).

The Organisation for Economic Co-operation and Development (OECD) prioritizes climate change and supports policymakers and health care systems in addressing this global issue. It champions sustainability in health care, endorsing eco-friendly practices and fostering climate-resilient health care systems.

In the OECD Declaration on Building Better Policies for More Resilient Health Systems (OECD, 2024) health ministers pledged to promote climate-neutral and environmentally sustainable health systems, including supply chains and pharmaceutical manufacturing. This commitment involves regular monitoring to track progress, striving for climate-resilient health systems in the short term and aiming for climate-neutral health systems by 2050, with no adverse impact on patient care.

An urgent green transformation within the health care sector encompasses a range of critical measures designed to mitigate the environmental impact of health care services (Colombo, 2022; Sherman et al., 2021):

• Waste reduction: Health care providers are urged to adopt sustainable practices for managing non-hazardous and general domestic waste.
• Transitioning to reusable products: Exploring approaches towards refurbishing and circularity in medical equipment.
• Carbon-neutral care pathways: Designing care pathways with environmental considerations to reduce wasteful care and emissions.
• Evaluation of low-value care: Assessing the environmental impact of medical interventions to reconsider appropriateness.
• Out-of-hospitals health care services: Encouraging health care services outside hospitals to reduce emissions.
• Accreditation mechanisms: Governments can mandate accreditation to assess greenhouse gas efforts.
• Financial incentives: Governments can use financing to motivate health care providers to reduce emissions.
• Training and awareness: Increasing awareness among health care providers and patients about health care carbon footprint and reduction strategies.

Figure 1. The green transformation of health care

Source: Colombo (2022).

The International Labour Organization (ILO) emphasizes the critical role of social protection in reducing inequalities and enhancing resilience against climate risks, advocating for integrated approaches across health and social policies to address climate change impacts effectively (ILO, 2024). Environmental improvements in health care and social services are essential, focusing on reducing the ecological footprint, adopting climate-sensitive designs, and expanding social protection coverage, particularly in low and middle-income countries. Universal social protection ensures equitable access to resources for climate adaptation and mitigating environmental threats, with targeted efforts needed for vulnerable communities disproportionately affected by climate-related health risks.

Embracing participatory governance and involving social partners in policy implementation enhances trust and effectiveness in achieving sustainable social health protection systems, which are increasingly focused on minimizing their carbon footprint, reducing greenhouse gas emissions, and enhancing accessibility through streamlined administrative processes and digital innovations. Aligning purchasing strategies with low-emission technologies and sustainable practices further supports global efforts towards a net zero health sector, highlighting the importance of cohesive policy frameworks and investments in health care infrastructure and sustainable practices worldwide (ILO, 2024).

National experiences

Countries and social security organizations are developing tailored strategies for sustainable health care. Collaboratively sharing national responses, methods, and funding approaches can enhance the identification and implementation of effective solutions. Leveraging social security systems for environmental protection in health care is forward-thinking, reducing environmental footprints while advancing public health and ecological well-being. This integrated approach aligns with broader sustainability goals, emphasizing responsible resource management and the welfare of current and future generations.

France. The WHO identifies environmental factors as significant contributors to chronic diseases, with France noting a high prevalence among its insured population. Responding to this, France introduced the 4th National Environmental Health Plan: "One Environment, One Health" (2021–2025) (France, 2024), recognizing the link between climate change and public health and advocating for a multifaceted approach to controlling environmental risk factors.

France's National Health Insurance Fund (Caisse nationale de l'assurance maladie – CNAM) spearheads the country's health care system's ecological transition, aiming to reduce the carbon footprint of health care products, improve patient care efficiency and bolster prevention efforts. Collaborating with global partners further amplifies these endeavours to develop an eco-friendly health insurance model (ISSA, 2023b).

For example, France is addressing endocrine disruptors through a national strategy, complemented by regional and local initiatives to mitigate associated illnesses. Primary health insurance funds (Caisses primaires d’assurance – CPAM) in Indre and Aisne have initiated an environmental health prevention campaign, focusing on averting exposure to endocrine disruptors, particularly phthalates (National Sickness Insurance Fund – France, 2024).

Germany. The National Association of Statutory Health Insurance Funds (GKV Spitzenverband) in Germany is committed to establishing a sustainable and climate-neutral health care system, in line with global agreements such as the Paris Agreement and the European Union’s (EU) Green Deal. Their efforts are supported by initiatives like the federal Health Climate Pact, launched in 2022, which mobilizes stakeholders in health care to promote both health and climate protection. To enhance sustainability, health insurance funds monitor emissions, reassess procurement practices, and prioritize green energy and products. Mitigating climate change in health care involves comprehensive monitoring of greenhouse gas emissions, a coordinated approach and implementing a "Health-in-all-policies" strategy.

Recently, the GKV-Spitzenverband has adopted the policy paper Sustainable and Climate-Neutral Development of Health care and Long-Term Care (GKV-Spitzenverband, 2024). The goal is to achieve a climate-resilient, climate-neutral, and sustainable health care and long-term care system by 2045. This initiative involves collaborating with stakeholders across the health care sector to meet concrete targets. The federal and state governments are called upon to fulfil their responsibilities in funding and supporting these efforts.

Key strategies include reducing health care service overuse and misuse, advancing digitalization, and promoting responsible medicine use. Addressing climate-related health risks is crucial, particularly for vulnerable insured persons, emphasizing the need for tailored prevention and treatment measures.

The Netherlands is aiming to achieve climate-neutral health care by 2050, aligning with global initiatives. This endeavour is supported by a “Green Deal” (Green Deal – Netherlands, 2022) that fosters public-private partnerships across health care sectors (ISSA, 2023b). The deal establishes clear objectives centred on promoting health, raising awareness about climate impact, reducing emissions, fostering circular practices in health care and promoting eco-friendly medication practices.

This initiative advocates for a holistic approach, combining immediate actions with strategic planning, and emphasizes the importance of long-term commitments and substantial changes to effectively address environmental and climate challenges. International collaboration, particularly in the pharmaceutical sector, is crucial for sharing knowledge, fostering innovation and advancing sustainable health care practices worldwide.

The Republic of Korea has taken significant steps to combat climate change by setting ambitious targets to reduce greenhouse gas emissions. In the health care sector, it has introduced a Green Hospital Certification System to encourage eco-friendly practices. Concretely, Korean hospitals have developed comprehensive waste management practices to handle medical waste efficiently and sustainably, such as Segregation and Classification (Jun ho et al., 2021) and Treatment Methods (Yoon et al., 2022). They also applied green building design practices focused on sustainability, energy efficiency, and creating a healing environment by using sustainable materials and fostering energy efficiency (Park and Lim, 2011).

United Kingdom. The National Health Service (NHS) prioritizes research and awareness to address carbon emissions, aiming for Net-Zero emissions by 2040 under its control and by 2045 across all areas, including supply chains and visitors' travel, through initiatives like the “Greener NHS” programme. Achievements include improvements in NHS-managed buildings, zero-emission vehicles and supplier targets aligning with net-zero goals. Additionally, adopting low-carbon alternatives for products such as inhalers and anaesthetic gases, alongside preventive measures, helps reduce carbon emissions in health care. This approach, aligned with national policies, is supported by local pilot projects and monitored via the Greener NHS dashboard, contributing to progress towards a sustainable, carbon-neutral health care system.

Additional initiatives

Health care providers worldwide are actively addressing pollution and greenhouse gas emissions through a range of initiatives aimed at reducing their carbon footprint and advancing sustainability. These efforts are coordinated at the national level, facilitated by cross-sectoral networks and driven by international federations spearheading the global movement for environmentally responsible health care.

Canada’s CASCADES programme is pivotal in advancing sustainable health care through collaboration among 14 government entities. In the 2021–2022 cycle, it yielded solutions such as sustainable inhaler prescribing, a virtual care carbon savings calculator and sustainable anaesthesia practices. The Canadian Coalition for Green Health Care has been offering resources for the whole Canadian health system over 20 years. Choosing Wisely Canada collaborates with clinical societies to develop national recommendations, identifying overused tests and treatments while considering their carbon footprint (CASCADES, n.d.)

Nordic countries. The Nordic Center for Sustainable Health care (NCSH) is a cross‑sectoral network. Through collaboration with various organizations (companies, hospitals, universities, non-governmental organizations (NGO) and regions), the NCSH aims to raise awareness and integrate new technologies and information and communication technology (ICT) to enhance environmental practices. Hospitals are leading this effort, establishing the benchmark for eco-conscious health care and inspiring the worldwide adoption of sustainable initiatives.

Switzerland. The Geneva Sustainability Centre (GSC), powered by the International Hospital Federation (IHF), was established in 2022 to drive net zero, climate resilient and sustainable health care. The GSC aims to provide hospital leaders with the tools and expertise needed to make sustainability a core part of their operations and promote better health for all. According to its work, investing in renewable energy and creating carbon-neutral facilities to achieve net-zero emissions, involves shifting from a traditional illness‑focused model to nurturing the environment and fostering healthier communities, led by health care leaders committed to proactive climate action.

Global. Health Care Without Harm (HCWH and ARUP, 2019 and 2021) was launched in the USA in 1996 with an initial focus on the problem of medical waste incineration. It has since grown to become a global body that brings together organizations in all regions, leading the global movement for environmentally responsible health care. It calls for urgent action to reduce the sector's carbon footprint and advocates for integrating climate and health policies. Governments, health care institutions, and social security bodies are urged to collaborate, innovate and invest in research to accelerate the transition to a sustainable health care system.

Final remarks

Health care systems significantly impact the environment, consuming vast amounts of energy, water, food, and raw materials, resulting in substantial waste generation. In addition, the disposal of excess medicines exacerbates environmental concerns, contributing to health issues.

Environmental protection and climate change mitigation are crucial responsibilities for health care systems, requiring a transition to sustainable practices

Social security health care institutions are important actors in the health system and good practices indicate several initiatives that to contribute to national efforts. These relate in particular to environmental preservation by safeguarding health care access, promoting preventive measures and supporting sustainable practices. These national case studies also highlight the need for international collaboration and the sharing of best practices to find effective solutions.

National health care systems can be guided by the principles outlined by international organizations, that address climate change. International organizations such as the ILO, WHO, OECD and ISSA play a vital role in facilitating this transformation.

Achieving environmental preservation and climate neutrality is imperative for all sectors, including social security and health care. The ISSA is committed to exploring these critical aspects through webinars and articles to facilitate knowledge exchange and best practices dissemination.

References