Potential of urban health systems in climate response is being overlooked

Cities and climate

Cities have a crucial role in climate action. Countries participate in the United Nations Framework Convention on Climate Change, but cities are on the frontline. Globally cities emit 68% of carbon dioxide and 72% of methane emissions.4 As cities continue to grow urban emissions are projected to double by the middle of the century.4 Cities contribute 60% of gross domestic product (GDP) and consume 60% of resources.4 On the other hand, cities have resources and influence over local policies affecting climate and health, including those related to transport, housing, waste management, and access to food and energy.5

Climate impacts also fall disproportionally on urban communities. People living in smaller and middle sized urban centres in low and middle income countries are particularly affected. One third of urban residents live in unplanned, informal settlements (56% in sub-Saharan Africa). They lack the household resources, social protection systems, infrastructure, and services needed to respond to the climate risks.1 These urban communities already experience poor health and low capacity to respond to the rising climate induced burden of disease.

Missing links between climate and urban health

Ill health is a driver of climate induced urban vulnerability, compounding the multidimensional poverty, inequality, and exclusion that together make urban households more vulnerable to climate risks. For example, people with asthma or chronic obstructive pulmonary disease are more sensitive to air pollution. Those with risk factors for heart disease are more susceptible to die in heat waves. Ill health also compromises people’s ability to engage in transformations to address climate change and to obtain wellbeing co-benefits.67

It is also important that climate strategies recognise measures to improve health that enhance mitigation. These include, for example, tackling food deserts through community gardens, or adopting low sugar, low fat, or plant based diets and active mobility for the prevention of non-communicable diseases.8 However, these health links are overlooked in the IPCC chapter on cities.

Another important consideration is the health co-benefits or harms of climate related strategies.8 These are also given little attention in the IPCC chapter, even when there is a strong case for integrated responses. For example, introducing electric cars to mitigate climate change reduces air and noise pollution but overlooks continued traffic injuries and barriers to health promoting cycling and walking. Prioritising public transport and safe cycling and walking reduces pollution, traffic injuries, and noise, and enhances physical activity.9 One sixth of urban households worldwide still use polluting fuels for heating or cooking, over 60% in many sub-Saharan countries.10 Renewable energy interventions for climate can reduce indoor and outdoor air pollution, respiratory disease, and burns in these households.11 Targeting local access by low income communities to green areas and water bodies can enhance equity in reducing exposure to urban heat, mental health, physical activity, and social connections.12 Most housing in low income and informal settlements lacks insulation, leading to respiratory disease in cold weather and deaths during heatwaves. Better insulation saves energy and greenhouse gases while improving health.13

The IPCC chapter focuses on resilient healthcare services to deal with health damage caused by climate change and to help mitigation. While important, this fails to consider health system influences and levers beyond curative care, linking health and non-health sectors at all levels of governance.14 As the covid-19 pandemic clarified, local health systems have a key role in establishing coordinated cross-sectoral response, engaging affected communities, and addressing urban risk and vulnerability to overcome inequities.15

Role of primary healthcare and health systems

Primary healthcare is even better placed than other local institutions to play a major role in integrating health and climate responses and promoting local action.16 This is because primary healthcare is located near peoples’ homes, with services often stretching across the entire city and connected to national health resources. It caters for a specific population group in a given geopolitical context. Primary care is the first and often the only point of contact with the health system for the community, especially for lower socioeconomic groups and informal settlements.17 Population density and proximity to primary care services facilitates understanding of place and population specific climate and health vulnerabilities. That allows for the identification of contextualised and locally relevant opportunities for health and climate action.3

Community health facilities have a vital role in fostering self-organisation and self-governance among residents, while also helping to build medical and public health support networks at various levels. This process ultimately strengthens the community’s overall resilience by enhancing skills, processes, and objectives. Primary healthcare provides contextualised, culturally appropriate prevention and care for vulnerable groups such as children, pregnant women, or people with non-communicable diseases. Universal public provisioning and coverage, including in disadvantaged areas and communities, means primary care can help confront socioeconomic inequality. Primary care services also reduce urban health inequities through coordinating services across the system and promoting cross-sectoral actions, addressing differential needs and cultures in service design and delivery.18

Primary healthcare workers are trusted by the communities they serve. Many live in those same communities. Primary healthcare has participation and solidarity as core values.1920 Its operations engage local committees and interest groups, as key actors for changing awareness and behaviours and for taking action and ownership. Local engagement with clear roles and responsibilities, including by primary healthcare, can strengthen the local response to other complex challenges such as conflict, climate, health, or geopolitical emergencies. This is a major resource in the response to emergencies, pandemics, conflict, and climate challenges.21

Primary healthcare provides a pre-existing means for the implementation of integrated climate, health, and equity action. It is therefore imperative that the IPCC acknowledges the role local health systems already play and levers primary healthcare to address urban climate and health risks (box 1). Primary healthcare oriented health systems must be designated as priority “means of implementation” and equipped and resourced to fulfil that role. The covid-19 pandemic showed the risk that underfunded health systems and overstretched local health workers will hamper efforts to ensure equity and deal with emergencies.19

Realising local health systems’ potential

Stronger actions for climate and health at the local level in cities requires a clear remit and adequate investment in primary healthcare’s capacities and tools, to integrate local climate and health equity actions as a core function. For its greatest impact, primary healthcare needs leadership and support at local, national, and international levels.

Internationally, there is a need to frame and endorse the links between climate, health, equity, and cities. This is still lacking in international policy instruments. For example, no decision document in the UN climate framework recognises that reducing greenhouse gases promotes positive health outcomes or identifies a health sector role in climate negotiations.23 Only 0.5% of international climate finance goes to health interventions, and health systems lack resources for climate adaptation. Cities are also generally marginalised from global platforms. Relevant international governance frameworks and targets issued since the IPCC’s fifth assessment report in 2014 such as the UN’s sustainable development goals, new urban agenda,24 and the Sendai framework for disaster risk reduction25 don’t explore fully the connections across health, equity, and climate decisions, or their local implications.

Analyses of national and urban climate strategies show little reference to local health systems,26 especially in low and middle income countries. Most national adaptation plans remain in environment departments with little health input.27 Those with a health focus have limited implementation despite recognition of health vulnerabilities from climate change. Most cities’ adaptation plans do not include health system adaptation as a policy aim,28^-with important health risks ignored. Only 30% of nationally determined contributions to reducing CO₂ emissions account for health benefits expected from mitigation. This is despite evidence that these benefits outweigh the costs of mitigation, such as in the co-benefits of reducing air pollution.29

Conversely, health systems have not yet made investments on climate and health at the scale they have done for certain diseases (AIDS, malaria, tuberculosis) or for vulnerable population groups (children). WHO assessments of health sector capacities to respond to climate change show that they are still weak, with little improvement since the IPCC’s fifth assessment report.23 Yet even where health professionals are aware of health and climate links and want to take responsibility to advise, they lack time, guidance, and training.30 Health systems need to ensure that local health facilities mitigate and adapt to climate change, by reducing energy poverty through renewable and off-grid energy solutions, improved waste management, or ventilation and insulation.31

These deficits can be addressed by health systems defining functions and capacities for linked urban climate and health interventions, and harnessing information systems to track climate related health effects and to plan interventions.4 A focused effort to maximise synergies with other sectors and scales of governance is essential.

Box 2 proposes policies and measures needed to achieve these changes, drawing on the evidence on primary healthcare’s contributions to urban health equity and climate mitigation. The proposals are evidence based, people centred, and equity focused. A strategy grounded in primary healthcare fulfils the duties of urban health systems for prevention and care in the context of increasing climate change risks. It makes a unique contribution to the local and global response to climate change. If adopted earlier, primary healthcare would have added a crucial dimension to the framing of climate resilient development used in the last IPCC report.32 It can still contribute substantially to the special report on cities, which is expected to be finalised in 2027, helping to resolve the disconnect between climate policies, social issues and people’s experience.33 It would create collaborative mechanisms and policy brokers,34 engage communities as active agents,35 and help to generate co-benefits across sectors for climate and for health. This provides a meaningful contribution to the implementation of the 2030 agenda.

Integrated response

The 2022 IPCC cities chapter raises important urban health equity issues. Its muted position on the role of health systems echoes the poorly developed articulation of the link between cities, climate, and health equity at global and national levels. This oversight could stem from an assumption—frequent in environment debates—that mitigation will automatically benefit health, with no need to engage the health sector specifically.36 Some may argue that local health systems and public sector health workers already have too much on their plates and that it does not make sense to add more demand by pushing for a stronger climate and health link. Others may suggest simply investing in health-in-all policy approaches for health systems to lever other sector roles. However, when these still focus on the health sector delivering biomedical models and hospital based care, they miss opportunities to bring the health sector into cross-sectoral urban work.20

There is an urgent need to equip urban primary healthcare and wider health systems to fully integrate equitable climate and health risk reduction into their core functions. Simultaneously other sectors aiming to improve urban climate resilience need to value the critical role of health systems to further their collective efforts. Such institutional realignment requires prioritisation and investment in local level capacities to plan for and respond to climate and health.22 The beneficiaries include the vast population living in smaller cities and informal settlements, who are exposed and vulnerable. They obtain little benefit from current climate related interventions, but live where primary healthcare oriented health systems are, or could be, present. Not investing in health systems and primary healthcare sidelines the expertise, capacities, and communities’ knowledge needed for holistic health and climate positive action. While such investment necessitates institutional change at global, national, and local scales, integrated urban climate and health policies are an essential response to the largest threat to public health in the 21st century.