Chapter 16

Primary health care, health systems resilience and environmental sustainability

Authors: Sara Allin, Miguel A. González Block and Emily Vargas

Key Messages
Primary health care (PHC) is critical to health systems resilience as it has the potential to:

• Mitigate care disruptions, support adaptation, and learning during shocks and stressors and contribute to
equitable and efficient access to health services.
• Create strong linkages, collaborations, and networks in communities and across sectors, thereby
strengthening solidarity and societal cohesion.
• Bring services closer to harder-to-reach communities who are disproportionately impacted by economic,
public health, climate change, and other shocks while broadening the range of accessible delivery options
during emergency responses through multidisciplinary provider teams.
• Strengthen population risk identification (e.g., risk stratification) through the classification of the whole
population informing responses to address health system threats and emergencies.

PHC is critical in building environmentally sustainable health systems and enabling the reduction of human made
environmental harm as well as reducing its impact:

• Climate change negatively impacts on human health worldwide. Directly, increased occurrence of extreme
weather events, such as heatwaves, wildfires, hurricanes, and floods, can lead to injuries, deaths, and the
spread of infectious diseases. Indirectly, climate change is leading to cardiovascular and respiratory
problems and other health issues for which PHC plays an important role.
• Four principles of sustainable PHC practice can minimize the need for healthcare as to reduce its
environmental impact and improve health outcomes: 1) prevention, 2) the empowerment of patients and
the public, and self-care, 3) efficient use of resources, and 4) preferential use of technologies and
interventions with lower environmental impact.
• PHC providers are often trusted stakeholders in the communities and can raise awareness of the linkages
between health, behavior, and environmental impact and related protection plans/measures to address
environmental and health hazards.
• The health sector is an important contributor to the carbon footprint, equivalent to about 3.6 to 8.1% of
European and 4.4% of global net emissions. This is due to the direct effects of health service activities,
energy consumption associated with minor surgery and buildings, as well as the manufacturing,

1
 transportation, packaging, disposal and waste generation of medicine, medical equipment, and supplies.
However, the carbon footprint can be substantially reduced, with the prospect of achieving net zero
emissions.

Section 1: Introduction

Primary health care (PHC), and its three core components (see chapter 1) (World Health Organization & United
Nations Children’s Fund, 2018) are critical to progress toward health system resilience and environmental
sustainability. By health systems resilience, we refer to the ability of health systems to constructively anticipate,
adapt to, and respond to a wide variety of shocks and stressors, such as pandemics, economic crises, or the chronic
and acute effects of climate change (Thomas, Sagan and Larkin, 2020). A resilient health system minimises the
negative consequences of disruptions, recovers as quickly as possible, and adapts by learning lessons from the
experience to become even better performing and more prepared (de Milliano et al., 2015; World Health
Organization, 2022b; OECD, 2023). The WHO operationalizes health systems resilience as “the process of
strengthening health systems to deliver quality individual and population health services […] by embedding
considerations for resilience within all health system elements” (McDarby et al., 2023). This chapter focusses on
the role of PHC in strengthening health system resilience and environmentally sustainable health systems, though
the ongoing process of doing so requires sustained action beyond PHC, including the need for learning health
systems (McDarby et al., 2023).

Resilience is built over time, and can be demonstrated across all stages of shocks, from preparation, absorption,
and recovery, to adaptation, and learning (Thomas et al., 2013; de Milliano et al., 2015; OECD, 2023). PHC can
contribute to mitigating the impact of the initial shock and to adaption and learning during emergencies (Lugten et
al., 2023). In the recovery stages, PHC has the potential to contribute to equitable and efficient access to health
services, and population health improvements (see Chapter 4). Through the essential public health functions
(EPHFs), it supports emergency preparedness and response (e.g., early surveillance and activation, effective case
management, appropriate triaging) (see Chapter 5) (McDarby et al., 2023). As such, a resilient health system can
also be seen as one of the outcomes of strengthened PHC (Bitton et al., 2017), making resilience an important area
for measuring, monitoring, and continual improvement (World Health Organization & United Nations Children’s
Fund, 2022; McDarby et al., 2023).

A resilient and environmentally sustainable health system is increasingly important in the face of climate change.
Environmentally sustainable health systems minimize negative environmental impacts and ultimately improve

2
health system efficiency, or the ability of the health system to optimize desired outcomes (World Health
Organization, 2017) (World Health Organization, 2017; Papanicolas et al., 2022). Moreover, PHC plays an important
role in the way we manage the environment with respect to health and well-being. Actions in governance, service
delivery, resource generation, and health financing can contribute to these goals (see chapters in Part II). Thus, the
health system has a critical role to play to mitigate the impact of climate change and to support the climate
adaptation of the health sector through new strategies for prevention, health promotion and health services. These
new strategies hold promise in contributing to system resilience.

Environmental sustainability strategies for PHC have the potential to contribute to reducing the health sector's
dependency on fossil fuels causing global warming, particularly if investments towards achieving Universal Health
Coverage (UHC) look after the environment (Pencheon and Wight, 2020). PHC will need to cope with the direct
effects of climate change such as heat waves and water shortages and their related challenges and health risks such
as infectious diseases, food insecurity, and pollution. Furthermore, PHC will need to cope with the surges and
changes of health service demand due to climate change, particularly among vulnerable groups and in LMIC and
remote rural areas. The health system is itself a substantial contributor of greenhouse gas emissions causing climate
change and PHC can do much to reduce its carbon footprint. Finally, PHC can contribute to co-benefits for
population health and the environment for example through health promotion and prevention at community level
(e.g., diets, active transport, behavioral risk factors, emissions, and air quality etc.) and awareness raising (Haines,
2017; WONCA-PHA, 2019; Gonzalez Holguera, Niwa and Senn, 2020).

This chapter shows how PHC can contribute to building resilient and environmentally sustainable health systems.
Section 2 describes evidence on the associations between, and mechanisms by which PHC can strengthen health
systems resilience and environmental sustainability. Section 3 illustrates country experience on how PHC impacted
health system resilience during the COVID-19 pandemic and how they are strengthening environmental
sustainability. Section 4 summarizes lessons learned and implementation challenges.

Section 2: Evidence review - PHC and health systems resilience and environmental sustainability

Health system resilience

Evidence from public health emergencies such as the COVID-19 pandemic, natural disasters and climate change
events emphasize the need to strengthen PHC to build health systems resilience (Tumusiime et al., 2020).

3
Observations of COVID-19 responses suggest there was inadequate orientation toward, and involvement of,
primary care facilities and strategies (Rasanathan and Evans, 2020; Li, Howe and Astier-Peña, 2021). This section
reviews the evidence of the associations between, and mechanisms by which PHC can strengthen health system
resilience.

PHC and effective response to shocks

Responses to shocks such as health emergencies can be supported by strong PHC, given its multi-disciplinary teams,
integrated public health functions, and strong connections to local communities (World Health Organization,
2022c). Ideally, the role of primary care and public health professionals during and following disaster responses in
rural and remote areas include all emergency and routine functions that are integral to resilience, including
surveillance, patient triage and the maintenance of essential services and infection control (Willson, FitzGerald and
Lim, 2021). Challenges in responding to extreme weather and climate events underscore the need to better
leverage the multidisciplinarity, and community-orientation of primary care teams and providers to coordinate
responses, and mitigate the inequitable impacts of health and climate emergencies (Ray et al., 2022).

Primary care and public health services largely contributed to COVID-19 responses globally through reducing the
patient burden in acute care settings and contributing to efficient emergency responses, including with COVID-19
testing, treatment, case management, and vaccination (Barış et al., 2022; OECD, 2023). PHC activities that
contributed to health systems resilience during the COVID-19 pandemic in a study of 28 countries were COVID-19
screening and assessment and referral to routine health services (Haldane et al., 2021). Experiences in the
European region emphasized the need to recognize and elevate the role of PHC in effective pandemic responses
and to “build back better” with strengthened health systems performance (Sagan et al., 2021).

Failure to deliver effective emergency responses has been linked to lack of clear PHC orientation. For example, in
Liberia, the Ebola Virus outbreak in 2014-15 led to significant disruptions to health services, and public health
responses lacked community engagement (Simen-Kapeu et al., 2021). Facilities were closed due to health worker
absenteeism, fear of becoming infected, and community distrust of health services. These experiences led to the
development of a new national policy on Community Health Services, with a stronger community orientation,
including the scale-up of the role of community health assistants, and the introduction of a community-event based
surveillance system (Simen-Kapeu et al., 2021).

4
Reviews of the COVID-19 pandemic responses in Italy, one of the first and hardest hit countries in Europe, pointed
to the need to strengthen and invest in PHC to improve resilience by supporting early case detection and
management, relieving hospitals, and coordinating responses within and across regions (Plagg et al., 2021). In
Belgium, clinics led by primary care physicians supported COVID-19 testing and care (Verhoeven et al., 2020; OECD,
2023) and in Germany primary care providers played a key role in setting up outpatient infection centres and
coordinating care, maintaining communication within practice teams, facilitating preparedness (e.g., in the supply
of personal protection equipment - PPE), and in implementing action plans for crises, and supporting the working
conditions and mental health of employees (Stengel et al., 2022)(Litke et al., 2022). In South Africa, family
physicians implemented strategies during the COVID-19 pandemic to keep services open, contain virus spread, and
respond to the needs of vulnerable populations such as the homeless and people in residential care (Mash, 2022).

The PHC pillar of community engagement builds trust - a pivotal element for health system resilience

The community orientation of PHC can strengthen the responses to stressors and emergencies and helps protect
the most vulnerable groups. A scoping review of effective strategies for health system resilience identified the
importance of community engagement and of leveraging community resources to address crises, particularly in
LMICs (Forsgren et al., 2022).

Resilience of health systems in conflict-affected settings is particularly challenging; experts underscore the
importance of strengthening community health and community engagement through building trust and
empowerment during and after conflicts (Atallah et al., 2018; World Health Organization, 2021a). A study of Arab
communities in Israel showed that PHC supported communities’ ability to cope with health service changes and
disruptions during the COVID-19 pandemic and identified a correlation between satisfaction with and confidence
in primary care services and community resilience (Cohen et al., 2020). Proximity to communities can also support
tailored education and awareness campaigns. For example an intervention using community volunteers led by PHC
staff focused on preparing for natural disasters such as earthquakes and floods in Iran led to increases in emergency
preparedness (Ardalan et al., 2013).

Community engagement was noted as important, but lacking, in the response to Ebola in the Democratic Republic
of Congo (DRC). Community engagement needs to go beyond seeking to understand community needs and
perceptions to also involving communities in decision-making during emergency responses (Mayhew et al., 2021).

5
The unwillingness to concede decision-making power to communities by the national and international agencies
was associated with a failure to build trust between communities and providers (Mayhew et al., 2021).

A multi-professional health and care workforce is the bedrock for health system resilience.

The inclusion of a range of health professionals, including community health workers (CHW) and allied health
professionals, in multidisciplinary primary care teams contributes to meeting the needs of harder-to-reach
communities, particularly those living in rural areas, and broadens the range of accessible delivery options
(Bhaumik et al., 2020) (see also Chapter 8). In Australia, primary care practices that included general practitioners,
nurses and other allied health providers provided essential primary care services to their patients for both
preventive care as well as care for chronic conditions (Desborough et al., 2020). Similar observations were noted
in COVID-19 in the Eastern Mediterranean Region (Khalil, Mataria and Ravaghi, 2022). Given their strong
relationships with communities and knowledge of local context, they proved central for effective COVID-19
response (Haldane et al., 2021), e.g. by undertaking COVID-19 case management and contact tracing in Nigeria and
South Africa (Barış et al., 2022).

During the 2014 Ebola epidemic in West Africa CHWs were more effectively able to carry out Ebola-related activities
than outsiders (Miller et al., 2018). CHWs and allied primary care professionals were also critical after the
earthquake in 2005 in Pakistan and in refugee camps in Tanzania following the 1994 Rwanda genocide (Amiri et al.,
2022). CHWs support emergency responses by communicating with the public in ways that were more culturally
appropriate, understood, accepted and trusted (Boyce and Katz, 2019), contributing to the health literacy needed
for the adoption of preventive measures to minimize viral transmission during epidemics (Boyce and Katz, 2019;
Ballard, Bancroft and Nesbit, 2020). During the COVID-19 pandemic, in Vietnam, village health workers were key
to building community awareness of viral transmission as well as for contact tracing via local health stations
(Nguyen et al., 2020).

Several countries have increased the range of health care providers involved in PHC during pandemics. For example,
CHWs provided home-based care in Slovenia, UK and the United States of America (USA) during the COVID-19
pandemic (OECD, 2023). In the USA, home health aides were formally integrated into primary care teams and took
on expanded roles, especially in the care for veterans, providing a range of medical and emotional support
(Franzosa et al., 2022). During the H1N1 pandemic, community pharmacists worked closely with public health
agencies to strengthen prevention, and to support vaccination (Rosenfeld et al., 2011), a strategy that was

6
subsequently implemented during COVID-19 (OECD, 2023). Indeed, several countries expanded the role of
pharmacists to provide COVID-19 testing and vaccines (OECD, 2023) (see chapter 10).

Integration of primary care and essential public health functions is decisive for health system resilience.

The integration of EPHFs and primary care (see Chapter 5) improves emergency preparedness, emergency
response, and recovery from shocks (Tumusiime et al., 2020; Lugten et al., 2023). However, few health systems
have effectively achieved this integration (Kinder et al., 2021), whereby PHC contributes to public health data
collection to implement infectious diseases surveillance (e.g., to identify and contain outbreaks), and to carry out
population health assessments. During the COVID-19 pandemic, for example, in Spain and India primary care
providers’ involvement in public health operations supported surveillance, contact tracing and case management
(Kinder et al., 2021). In Colombia, North Macedonia and Vietnam, COVID-19 surveillance integrated with national
information systems facilitated local surveillance and contact tracing (Barış et al., 2022).

PHC mitigates care disruptions during shocks.

PHC-oriented service delivery helps to mitigate care disruptions related to shocks and challenges associated with
economic crises, epidemics and climate change, and to maintain essential services including vaccination, chronic
condition management, and mental health services (Barış et al., 2022). Experiences from Zimbabwe suggest that
the rapid deployment of health workers to rural areas allowed for continued delivery of services in harder-to-reach
areas during the economic downturn between 1997 and 2008 (Mashange et al., 2019). During the economic crisis
in Cuba in the 1990s, family physicians were central in reducing demand for hospital care which helped to sustain
capacity and minimize acute care disruptions (Foroughi et al., 2022). In the economic crisis following the debt
default in Greece in 2012, rural regions with stronger primary care facilities were better able to mitigate disruption
to hospital care (Foroughi et al., 2022).

COVID-19 related health services disruptions have been well documented and underscore that PHC fosters and
strengthens health system resilience. In the Indian state of Kerala, the integration of a tuberculosis (TB) control
programme into the work of primary care teams, enabled ongoing service provision (Khobragade et al., 2022). The
ongoing delivery of essential services may also help to mitigate inequitable health and social impacts of shocks. For
example, mobile primary care was used in many countries, prioritizing most deprived areas and to reach the most
vulnerable during and in the aftermath of the COVID-19 pandemic (Rousseau, Bevort and Ginot, 2020; OECD, 2023).

7
PHC at the heart of adaptation and learning to inform improvements during and while recovering from shocks.

The significant disruptions to essential health services due to COVID-19 also represented an unprecedented
opportunity for adaptation and rapid learning for PHC. One of the most rapid and transformative changes seen was
the shift from in-person to remote care. In the EU, over 40% of the population reported having received physician
care online or by telephone in 2021 (OECD, 2023). While remote care options often relied on conventional
telephone calls, digital tools were also implemented, i.e. smart phone applications, patient portals, interactive
chatbots, bedside video consultations, crisis and help lines, etc. (Matenge et al., 2022) (see chapter 11).

However, challenges in the use of remote care in an emergency context were experienced in various countries
regarding coordination across primary care, public health, and secondary care; as well as technical challenges; and
an inadequate attention to equity, diversity and patient-centeredness (Wong and Rigby, 2022). Concerns about the
lack of patient-centeredness were noted in the Canadian province of Quebec, where the experiences and
preferences of patients were not at the forefront of implementation of remote care, although satisfaction with
remote care options was high among patients with chronic conditions (Poitras et al., 2022). Inequitable access to
services through telehealth were particularly evident in LMICs, for example in Colombia, about one-third of the
population did not have access to broadband internet when the government introduced telehealth as part of the
COVID-19 response (Turner, 2022).

Environmental sustainability

The role of PHC in climate action

PHC is a key pillar in strengthening the climate change resiliency and environmental sustainability of the health
system for four reasons:
• Firstly, patterns of morbidity are evolving through changing climate, extreme weather events related to
global warming and other environmental changes, requiring new strategies for prevention, health
promotion and care.
• Secondly, PHC plays a central role in creating healthy societies and environments through health
promotion strategies that have the potential to mitigate negative impacts on the environment and to
contribute to positively change lifestyles.

8
 • Third, PHC must adapt to cope with the challenges that climate change is posing for service provision given
surges in the demand for care and exposure to its direct and indirect impacts, particularly in remote rural
areas and among marginalized populations that are most seriously affected by climate change.
• Fourth, the health system is itself a substantial contributor of greenhouse gas (GHG) emissions causing
climate change and PHC can reduce its carbon footprint, particularly through reducing its reliance on fossil
fuels and making environmentally sound investments (Pencheon and Wight, 2020).
• Lastly, the multisectoral component of PHC can be an important driver for environmental sustainability by
enabling and focusing action on upstream determinants of health, the environment and determinants of
climate change in an integrated and mainstreamed approach across all sectors.

The health impact of climate change

Global warming observed between 2000 and 2020 has been associated with an estimated average of 15.1
additional temperature-related deaths per million inhabitants per decade in most regions (Van Daalen et al., 2022).
Between 2030 and 2050, forecasts show approximately 250,000 deaths annually due to climate change–induced
increases in heat exposure among older people (Haines and Ebi, 2019). Heat and associated worsened air quality
can exacerbate chronic health conditions and is associated to increased mortalilty due to cardiovascular, renal,
respiratory diseases and diabetes, and nervous system disorders (Ebi et al., 2008). Heat exposure also undermines
people’s livelihoods and the social determinants of health by reducing labour capacity (Van Daalen et al., 2022).
Global warming is increasing the number of months in the year as well as the geographical range of malaria and
dengue (Kulkarni, Duguay and Ost, 2022) Furthermore, extreme weather events worsen the stability of global food
systems, exposing a greater number of people to hunger (Romanello et al., 2022). PHC therefore needs to address
the harmful health effects of climate change, particularly among the most vulnerable: older people; young children;
people with underlying chronic conditions; and underserved populations (Van Daalen et al., 2022).

The health sector is an important contributor to global GHG emmissions

The health sector is an important contributor to GHG emissions, equivalent to about 3.6% to 8.1% of European and
4.4% of global net emissions in 2014, with fossil fuel consumption being the main source of emissions, contributing
to over half of the health sector’s climate footprint (Health Care Without Harm, 2019). Up to 71% of emissions in
the health sector are derived from the health services’ supply chain, while the impact of patient travel is also
considerable, although not always measured in emission protocols. Emissions emanating directly from health

9
service facilities and vehicles make up 17% of the health sector’s worldwide footprint. Indirect emissions from
purchased energy sources such as electricity, steam, cooling, and heating comprise another 12% (Romanello et al.,
2022). The GHG emissions of primary care specifically have not been measured at the global level but are likely to
play a major role given the high volume of patient travel and the importance of medicines in its practice with
pharmaceutical manufacturing and distribution contributing significantly to GHG emissions.

Although individual healthcare facilities in LMICs tend to be more carbon intensive than that in HIC, mostly due to
greater reliance on fossil fuels, in per capita terms the top GHG emitters are the health sectors of the USA, Australia,
Switzerland, and Canada (Health Care Without Harm, 2019), with the USA being by far the highest, producing 57
times more GHG emissions per person than India. These inequalities in health sector emissions across HICs and
LMICs need to be taken into consideration to ensure equity in global efforts towards making health systems
sustainable, particularly given that those countries that have historically contributed most to global warming are
today also those less exposed to its impacts (Hickel and Slameršak, 2022).

The carbon footprint of the health sector in England has been studied for the longest period. In 2019, primary care
practices were responsible for 23% of total health sector emissions (CO2 equivalent), with acute care being
responsible for 52% of the total. Within primary care, 48% of emissions can be attributed to pharmaceuticals and
chemicals, 13% to metered dose inhalers (MDI) used for the treatment of asthma and COPD and 9% to personal
travel, including that of patients and health workers. With a commitment to achieve net zero emissions in the
health sector by 2040 in England, the NHS reduced the GHG emissions of health and social care services by 18.5%
since 2007, with much of this reduction occurring since 2013 as the UK electrical grid decarbonized (MacNeill,
McGain and Sherman, 2021).

PHC-oriented interventions to improve environmental sustainability

The sustainability of health service interventions has been proposed as a seventh domain of health care quality
evaluation (Institute of Medicine’s Quality of Health Care in America, 2001). being assessed in terms of the services
delivered today and foreseeable environmental constraints. Four principles of sustainable clinical practice have
been proposed aiming to first minimize the need for health care and then to reduce its environmental impact, while
maintaining or improving health outcomes: 1) prevention, 2) patient empowerment and self-care, 3) efficiency by
reducing travel and consumables, and 4) preferential use of technology and interventions with lower
environmental impact. The application of these principles can be assessed across the four key areas in the interface
between PHC and environmental sustainability: pharmaceutical prescriptions, diversification of health services

10
towards social prescriptions, increasing use of telehealth, and utilization of renewable energy (Mortimer et al.,
2018).

Prescribers could potentially be supported to make better choices towards the sustainable prescription of
pharmaceuticals if they are informed about the relative carbon footprint of drugs, enabling them to choose more
sustainable alternatives. Discouraging stockpiling and overconsumption, and regularly reviewing repeat
prescriptions can help to reduce waste (Rasheed et al., 2021). Community pharmacies can contribute to sustainable
prescription and reduction of wastage by collaborating in the therapeutic education, by delivering small quantities
at the start of treatment, by ensuring professional stock management and by committing to the return of drugs for
destruction. Patients can also contribute through proper management of their medicine stocks (Schneider, Sommer
and Senn, 2019).

PHC takes a holistic approach to people’s health and wellbeing through new approaches such as social prescribing
that supplements medical treatment with prescriptions that connect people to activities, groups, and services in
their community to meet their practical, social and emotional needs. Examples of social prescribing include: access
to employment support and debt reduction, social clubs, participation in physical activities, nutrition and arts
classes and weight management sessions. Social prescribing has the potential to improve patients’ health and
wellbeing while also reducing visits to health providers (British Medical Association, 2020). Social prescribing can
also lead to a reconsideration of the relationship between the environment and health.

Other contributions of PHC to reduce the health sector’s GHG emissions include increased use of remote consulting
and telehealth. In Sweden, for example, use of telehealth reduced GHG emissions between 40- and 70-fold by
avoiding transportation to treatment centres (Holmner et al., 2014). Combined with artificial intelligence,
telemedicine in primary care has the potential to further decrease healthcare’s GHG emissions as systems are
deployed to monitor patients with chronic conditions or to perform emergency assessment (triage) of patients
seeking medical attention at an acceptable level of accuracy and safety (Tsagkaris et al., 2021). To enable telehealth
solutions, sustainable electrification will also be critical to reduce the GHG emissions of the health sector,
particularly in LICs now lacking electricity (Dalglish, Poulsen and Winch, 2013)

PHC in health policy for the sustainability

Policies to reduce GHG emissions of housing and the built environment, transportation, agriculture, and food
systems can have important health co-benefits through their impact on disease prevention and health

11
improvement (Haines and Ebi, 2019). The PHC approach can therefore champion environmental policies while
framing their health co-benefits in terms of community values, traditional knowledge, and the precepts of
indigenous traditional knowledge systems, which in many cases address health and the environment as an
integrated whole (Redvers, 2021). Furthermore, PHC has an important role in environmental sustainability given
its holistic, interdisciplinary, and longitudinal approach to patients, communities, and the environment (Gonzalez-
Holguera et al., 2022).
The World Health Organization published in 2015 the ‘Operational framework for building climate resilient health
systems’ supporting resilience across the health system building blocks (World Health Organization, 2015); it is
currently being updated. This was followed at the 26th United Nations Climate Change Conference (COP26) in 2021
with a commitment by 64 countries to achieve low-carbon sustainable and resilient health systems, with 22 of the
committing to achieve net-zero GHG emissions between 2030 and 2050 (World Health Organization, 2022a).
Furthermore, a WHO survey found that 67% of countries had conducted or are conducting a climate change and
health vulnerability and adaptation assessment in 2021, while 75 to 77% of them have national health and climate
change plans and multi-sectoral collaboration on policies and programmes, although most countries face
insufficient financing for their implementation (World Health Organization, 2021b).

The focus of GHG abatement has so far been at the hospital level and, to a lesser extent, on pharmaceutical
production. Strategies in the USA are currently centered on voluntarily reducing hospital emissions, spearheaded
by specific hospital chains while in Scandinavia and the Netherlands efforts are under way to increase the use of
electrical vehicles by hospitals (Health Care Without Harm, 2019). England’s NHS was the first national health
service that committed to a carbon net zero health system in 2020 and was later supported by the first piece of
health legislation committing the health sector to net zero GHG emissions. In Latin America, hospitals are also
leading the way in measuring their climate footprints and making commitments towards reduction. In Africa and
Asia, the electrification of health centres with solar arrays has been reported for India, South Africa, South Korea
and Zimbabwe, among other countries (Health Care Without Harm, 2019). Numerous regulations and plans have
been formulated to reduce the climate footprint in the People’s Republic of China at national, provincial, and
municipal levels, yet efforts have focused on hospitals. Importantly, some pharmaceutical supply chain companies
have committed to 100% renewable electricity in their operations by 2050 or earlier (Health Care Without Harm,
2019).

12
Environmental sustainability & PHC: the role of the health workforce

PHC professionals can support health system adaptation to climate change through promoting healthy behaviours
and policies with low environmental impact, supporting intersectoral action to mitigate the GHG emissions of
health systems and society as a whole, and undertaking research and education on climate change and health
(Haines and Ebi, 2019). Health workers in primary care are being encouraged to address their own environmental
impact, prepare facilities for disaster situations and to promote health co-benefits tied to lifestyles (WONCA-PHA,
2019). Primary care providers are recognized for their trust within communities and can exert influence to support
favorable policies and create health co-benefits and can exert influence on health policy and planning to adapt
systems to climate change and to transform health education, research, and training (Xie et al., 2018).

Most health professionals understand that climate change is happening and is affecting the health of those they
care for. A 2020 online survey among eleven physician associations and among one nurse association in 11 middle-
and high-income countries, and among members of an international organization found that most respondents
have a basic understanding of the fact that climate change is happening and that it is caused by humans. Most
participants showed a high degree of engagement with the issue and believe that health professionals have a
responsibility to bring the health effects of climate change to the attention of the public and politicians (Kotcher et
al., 2021). A 2018 literature review on physician knowledge and attitudes to climate change found these
professionals have insufficient knowledge. Among USA physicians, most are convinced that climate change is
happening and is already beginning to affect the health of some of their patients, yet political polarization may be
associated with stauncher resistance from practitioners who deny climate change. Among Ethiopian health science
students, Indian medical residents, Cambodian health professionals, Chinese hospital-based nurses, and Chinese
public health professionals, a large majority of professionals perceived that climate change is harmful to health,
but their self-assessed knowledge was low, and their perceived need to learn more was high (Hathaway and
Maibach, 2018). A review of the literature on the role of health professionals in strategies to address climate change
on health between and 2021 found only two papers reporting on interventions aiming to improve their capabilities,
and neither focused specifically on PHC (Dupraz and Burnand, 2021).

Training health professionals on the health impacts of climate change is beginning to gain impetus, focusing for
now on curricular development and the launching of initial mass, online courses. Faculties of medicine have
integrated climate change and health within existing public health, clinical medicine, preventive health, and global
health courses (Green et al., 2009). Environmental literacy training has been proposed as an extension of
occupational and environmental medicine disciplines as well as rural and remote medical education and training

13
(Bell, 2010). While many online courses are now available on climate change and human health, the extent to which
they adequately cover the contribution of health services to GHG emissions and the extent to which they address
the adaptation of health services need to be analyzed..

Section 3: Country illustrations – plausible pathways to resilient and environmentally sustainable health systems
through PHC

Reviewing the experiences during the COVID-19 pandemic offers a compelling illustration of the critical role of PHC
in fostering health system resilience. The Mexico example demonstrates how a weakened PHC system led to low
levels of resilience during the COVID-19 pandemic. The Canada illustration points to ways in which PHC can
strengthen environmental sustainability.

Mexico: PHC and health system resilience during the COVID-19 pandemic

Countries with stronger primary care and public health systems were better placed to cope with the COVID-19
pandemic when it came (Sagan et al., 2021). Mexico was one of the countries that was hit most severely by the
COVID-19 pandemic and in part this related to the country’s weak primary care system. The high transmission rates
in Mexico were primarily attributed to delays in implementing physical distancing measures, mixed reactions
towards stay-at-home orders, and a phased reopening of the country (Tariq et al., 2021) and it had one of the
lowest per-capita COVID-19 testing rates globally, conducting only approximately 17 tests per 1000 people in total
(Pérez Ortega, 2020) (Pérez Ortega, 2020). As a result, and in spite of a moderately successful COVID-19 vaccination
campaign (González-Block, Gutiérrez-Calderón and Sarti, 2022), Mexico had the fourth highest number of excess
deaths due to COVID-19 globally, after India, the USA, and the Russian Federation (798,000 excess deaths) (Wang
et al., 2022). Nearly half of individuals diagnosed with COVID-19 had at least one co-morbidity, with hypertension
(20.1%) and diabetes (16.4%) being the most prevalent (Hernández-Galdamez et al., 2020). The greatest increase
of cause-specific mortality during the pandemic was observed for diabetes, respiratory infections, ischemic heart
disease and hypertensive diseases emphasizing the vulnerability of the population groups with these NCDs (Health
Metrics and Evaluation, 2023).

Challenges in primary care in Mexico relate to lack of integration of primary care units and specialists in hospitals.
Some patients are referred to secondary care unnecessarily, while other patients’ referrals are delayed. Moreover,
shortages of health professionals, limited working hours and lack of emergency care in primary care units are major
barriers to access to primary care(González-Block, Gutiérrez-Calderón and Sarti, 2022). These weaknesses in care
coordination across providers and payers and barriers in access to primary care and the highly fragmented patient

14
care pathway (González-Block, Gutiérrez-Calderón and Sarti, 2022) could in part explain the cause-specific excess
mortality observed during the COVID-19 pandemic. Indeed hospital deaths related to diabetes and ischemic heart
disease decreased by 46% and 47%, respectively, during the pandemic compared to the pre-pandemic period
(Palacio-Mejía et al., 2022), indicating that excess mortality occurred at home.

During the pandemic the Mexican Social Security Institute (IMSS), the public provider and insurance scheme for
private sector employees (covering half the population), significantly reduced the provision of primary care services
due to the curfew imposed on older health workers to protect them from infection and to the curtailment of
outpatient services to avoid congestions. In 2020, an estimated 8.74 million patient visits were lost, leading to a
drop bytwo-thirds in breast and cervical cancer screenings (79% and 68% of the total expected, respectively) and
to a reduction in over half of consultations for sick childcare and female contraceptive services. One-third of
consultations for diabetes, hypertension, and antenatal care were not provided. The pandemic severely affected
patient outcomes, with the percentage of diabetes and hypertension patients who were well-managed declining
by 22% and 17%, respectively (Doubova et al., 2021). Similar disruptions in health services were observed across
the public health sector, resulting in a 47% reduction in consultations (Fundar; Oxfam; CIEMP, no date).

In April 2021, the IMSS implemented a policy to recover from the effects of the pandemic including, among other
strategies, adjusting health services governance, optimizing service delivery, organizing weekend health services,
implementing telemedicine in select clinics, and strengthening preventive services and health promotion activities.
In November 2021 consultations for sick children and contraceptive use visits had recovered to only 49% and 64%
of pre-pandemic levels, respectively, while cervical and breast cancer screening recovered or even exceeded pre-
pandemic levels. Consultations for patients with controlled diabetes and hypertension attained 88% and 93% of
pre-pandemic levels, respectively. Overall, the effects of the recovery policy on service levels were mixed (Doubova
et al., 2022) which highlights the importance of strategies to resume essential services and catch up on missed
preventive care in primary care.

Primary care in Mexico is fragmented, as separate schemes funded by the federal government fund and provide
health services for private sector employees, public employees, and those not enrolled in public insurance.
Moreover, up to 39% of private sector IMSS beneficiaries lose their health coverage annually due to employment
loss in the formal private sector, requiring them to seek care in other public or private sector institutions. This
annual loss of cover affects 21% of formal private sector employees diagnosed with diabetes (Guerra et al., 2018).
Insufficient incentives exist for public providers to prioritize population health or strengthen their resilience in times

15
of crisis. Building resilience through strengthening PHC is essential as Mexico faces the impact of the climate
emergency and other future external shocks.

Canada: PHC and environmental sustainability

In Canada, efforts to strengthen the environmental sustainability of health systems is gaining momentum. Canada
is a high-income country known for its UHC, its strong primary care foundation that has been the focus of ongoing
investment and reform efforts, and its comparatively good health outcomes (Marchildon, Allin and Merkur, 2020).
The federal government has taken a lead role in raising the collective consciousness on the need for climate action
and in monitoring and decreasing GHG emissions. Yet it was not until the COP26 Health Program in 2021 when the
Government of Canada, along with about 60 other countries, identified the critical role of the health sector in
moving toward a low carbon economy. These efforts were in part inspired by achievements made in the United
Kingdom, specifically the reduction of carbon dioxide emissions by 18.5% in the National Health Service in a short
time (2007-2017). Also, estimates (from 2014) that Canada’s GHG were considerably higher (per capita) than the
OECD average (Xie et al., 2021); health services are estimated to contribute about 5% of Canada’s total annual
emissions (Pétrin-Desrosiers et al., 2022).

In Canada’s decentralized federation, the provincial governments are primarily responsible for administering and
financing their provincial health systems, and there are variations in the extent to which provinces are measuring
environmental impacts of their health systems and seeking to mitigate these impacts. The westernmost province
of British Columbia has longstanding climate change legislation which, though not specific to health care, sets
ambitious emissions reduction and infrastructure standards. Since 2019, the provincial commitment to addressing
climate change was extended to health systems, by outlining high-level requirements for health authorities to
develop and report on strategies for minimizing GHG and managing climate change risk in health care (Allin et al.,
2022). However, there is limited, and inconsistent data available to measure and track progress on environmental
impacts of health systems.

There are notable efforts across Canada that leverage partnerships between researchers, practitioners, and
governments to support progress toward environmentally sustainable health systems. For example, the Canadian
Coalition for Green Health Care has been active since 2000 to support hospitals and other health organizations to
reduce healthcare’s environmental impact, with capacity building efforts, and routine reporting on trends in making
health systems more environmentally sustainable (Canadian Coalition for Green Health Care, 2021). The

16
Government of Canada recently invested in Creating a Sustainable Canadian Health System in a Climate Crisis
(CASCADES). CASCADES launched in 2021 with the broad aim of providing evidence-based guidelines and capacity
building /professional development activities to support the health care community to transition health systems to
net-zero emissions (CASCADES, 2023). Among other things they have developed a guide for sustainable PHC,
building on the work of the United Kingdom (Centre for sustainable healthcare, 2022) as well as detailed
“playbooks” to support climate conscious inhaler prescribing, and sustainable virtual care. As medicines are the
second largest polluters behind hospitals, contributing to more than a quarter of all estimated GHGs in health
systems in Canada (Eckelman, Sherman and MacNeill, 2018) these have been a key target for climate action in
healthcare.

Overuse of medicines and healthcare is a major concern in Canada. Canada is one of the top users of prescribed
medications globally (OECD Indicators, 2021). Also, there is considerable overuse of inappropriate health
interventions in Canada, though some progress has been made in recent years: over the period 2015-2020, there
was about a 10% decline in the volume of tests and treatments used/prescribed that were considered potentially
unnecessary or “low value” (Canadian Institute for Health Information, 2022). These improvements may reflect the
work of partnerships and initiatives such as Choosing Wisely Canada, funded by provincial medical associations and
professional colleges, as well as governments, which has developed recommendations, reports and toolkits for
family medicine (College of Family Physicians of Canada, 2022) and other specialties. Other pan-Canadian initiatives
seek to address over-and inappropriate prescribing in Canada, such as the Canadian Medication and
Appropriateness Deprescribing Network, funded by federal government health research agency (Canadian
Institutes for Health Research)(Canadian Medication Appropiateness and Deprescribing Network, 2017).

Social prescribing has also been gaining increased attention in Canada, again taking inspiration from the United
Kingdom, with a diverse array of initiatives underway across the country (Current state of social prescribing in
Canada, 2022) The Government of Canada, through the Public Health Agency of Canada, recently funded the
establishment of a Canadian Institute for Social Prescribing to support and “share practices that connect people to
community-based supports and services”(Canadian Institute for Social Prescribing, 2022); which has potential to
strengthen environmental sustainability in Canada’s health system. Though this and other initiatives underway in
Canada show some promise, there has been limited monitoring and evaluation of their impacts, and it is too soon
to tell whether and by how much Canada is strengthening climate resilience and progressing toward net zero
emissions in healthcare.

17
Section 4: Conclusion

The PHC approach has potential to improve health and strengthen health system resilience, while increasing
environmental sustainability. Experiences during COVID-19 provided numerous compelling illustrations of the ways
in which PHC was integral to effective, efficient, and equitable responses to the pandemic. As uncovered in our
evidence review and exemplified by the Mexico case study, the tragic health impacts of the pandemic might have
been mitigated in many countries had governments made more sustained progress toward the PHC approach prior
to the pandemic. Yet, disentangling the unique aspects of the components of the PHC approach on health systems
resilience is not straightforward, and conceptual and performance monitoring frameworks are only starting to
consider how to explicitly incorporate measures of resilience within ongoing monitoring and evaluation (McDarby
et al., 2023). Moreover, PHC can contribute to reduce the challenges to adaptation to climate change and mitigation
of its harmful impacts through the establishment of interdisciplinary partnerships that avoid adaptation failures,
siloed information channels and isolated governance (Haines and Ebi, 2019). To this end, it is critical to focus
monitoring of carbon emissions at the primary care level as well as to assess the role that health professionals and
communities can play to adapt health systems to global warming. However, sustainability is today mostly advanced
as a policy principle and as a recommendation, with few countries having developed specific interventions and
emission targets, and with few reports regarding performance.

The WHO recommends addressing climate change and health in the context of Water, Sanitation and Hygiene
(WASH) guidelines and of water and sanitation safety plans, with a major push to promote climate-resilient and
low carbon health care facilities supported on technical guidance (Godin et al., 2015). The recommendations
proposed by the British Medical Association to make PHC sustainable can be considered by other countries,
regardless of their income. These include: a focus on the green impact for health, adaptation of prescribing
patterns, the strengthening of social prescribing, reducing wastage through the reuse of instruments, the use of
remote consultations when feasible and improvements to infrastructure and premises to reduce their emissions
(British Medical Association, 2020). The adaptation of prescriptions should be supported by information on the
carbon-footprint of pharmaceuticals and medical devices. PHC can also invest in and advocate for the
decarbonization of local and national energy systems and the implementation of clean, renewable energy as well
as for the localization and decarbonization of distribution channels. Advocating for and promoting the health co-
benefits of environmental policies and of lifestyle changes should be a bulwark in the PHC approach (Health Care
Without Harm, 2019).

18
In LMICs, interventions to improve the technical efficiency of health systems broadly and primary care facilities and
transport specifically would lead to reducing environmental impacts while improving care and system resilience. In
HICs, some progress toward improved environmental efficiency has been achieved yet the high levels of healthcare
expenditure in some countries and wasteful practices offer many opportunities for reducing emissions, particularly
by reducing the use of unnecessary plastics, single use items, medicines, journeys, and unnecessary healthcare
interventions. However, short term efforts to improve efficiency, such as by limiting the spare capacity in the
system, may undermine longer term resilience by reducing the ability to manage surges in demand (OECD, 2023).
Therefore, it is important to think of efficiency broadly in terms of maximizing health outcomes with given
resources, considering short- and long-term health outcomes and resilience. Regardless of levels of economic
development, countries should place climate adaptations at the forefront of health policy and innovative strategies
should be evaluated both in terms of harm reduction and of the social value and health benefits they would have
for communities in addition to the direct health benefits from high-quality care (Lenzen et al., 2020).

There is a growing evidence base on the importance of PHC to strengthening health systems resilience,
environmental sustainability and health system efficiency, though further measurement and evaluation efforts are
needed to inform how to rebuild, learn, and recover from shocks such as the COVID-19 pandemic, to better prepare
for future crises, and to inform the ongoing efforts to strengthen health systems with PHC at their core.

References

Allin, S. et al. (2022) Sustainability and Resilience in the Canadian Health System. London: LSE Consulting.
Available at: https://www3.weforum.org/docs/WEF_PHSSR_Canada_2022.pdf.

Amiri, M. et al. (2022) ‘Health System Resilience in the Eastern Mediterranean Region: Perspective on the
Recent Lessons Learned’, Interactive Journal of Medical Research, 11(2), p. e41144. Available at:
https://doi.org/10.2196/41144.

Ardalan, A. et al. (2013) ‘Effectiveness of a Primary Health Care Program on Urban and Rural Community
Disaster Preparedness, Islamic Republic of Iran: A Community Intervention Trial’, Disaster Medicine and
Public Health Preparedness, 7(5), pp. 481–490. Available at: https://doi.org/10.1017/dmp.2013.93.

Arksey, H. and O’Malley, L. (2005) ‘Scoping studies: towards a methodological framework’, International
Journal of Social Research Methodology, 8(1), pp. 19–32. Available at:
https://doi.org/10.1080/1364557032000119616.

19
Atallah, D.G. et al. (2018) ‘Developing Equitable Primary Health Care in Conflict-Affected Settings: Expert
Perspectives From the Frontlines’, Qualitative Health Research, 28(1), pp. 98–111. Available at:
https://doi.org/10.1177/1049732317738972.

Ballard, M., Bancroft, E. and Nesbit, J. (2020) ‘Prioritising the role of community health workers in the
COVID-19 response’, BMJ Global Health. Available at:
https://docs.google.com/document/d/1quxz5up90vWcbxb6HNHJ_vpsdhKP70pfjxrROTla6Pc/edit#!

Barış, E. et al. (2022) Walking the Talk: Reimagining Primary Health Care after COVID-19. The World Bank.
Available at: https://doi.org/10.1596/978-1-4648-1768-7.

Bell, E.J. (2010) ‘Climate change: what competencies and which medical education and training
approaches?’, Bell BMC Medical Education, 10(31). Available at: https://doi.org/10.1186/1472-6920-10-
31.

Bhaumik, S. et al. (2020) ‘Community health workers for pandemic response: a rapid evidence synthesis’,
BMJ Global Health, 5(6), p. e002769. Available at: https://doi.org/10.1136/bmjgh-2020-002769.

Bitton, A. et al. (2017) ‘Primary Health Care as a Foundation for Strengthening Health Systems in Low- and
Middle-Income Countries’, Journal of General Internal Medicine, 32(5), pp. 566–571. Available at:
https://doi.org/10.1007/s11606-016-3898-5.

Boyce, M.R. and Katz, R. (2019) ‘Community Health Workers and Pandemic Preparedness: Current and
Prospective Roles’, Frontiers in Public Health, 7, p. 62. Available at:
https://doi.org/10.3389/fpubh.2019.00062.

British Medical Association (2020) ‘Sustainable and environmentally friendly general practice’. Available
at: https://www.bma.org.uk/media/2570/bma-sustainable-and-environmentally-friendly-general-
practice-report-june-2020.pdf.

Canadian Coalition for Green Health Care (2021) The green health care report 2020-2021. Available at:
https://greenhealthcare.ca/wp-content/uploads/2021/06/The-Green-Health-Care-Report-2020-21.pdf.

Canadian Institute for Health Information (2022) ‘Overuse of Tests and Treatments in Canada — Progress
Report.’ Canadian Institute for Health Information. Available at:
https://www.cihi.ca/sites/default/files/document/overuse-of-tests-and-treatments-in-canada-report-
en.pdf.

Canadian Institute for Social Prescribing (2022) ‘what matters to you’. Available at:
https://www.socialprescribing.ca/.

Canadian Medication Appropiateness and Deprescribing Network (2017) ‘Do I still need this medication?’,
Do I still need this medication? Available at: https://www.deprescribingnetwork.ca/.

20
CASCADES (2023) ‘CASCADES supports Canada’s health care community to transition towards an
environmentally sustainable (net zero carbon emission) and resilient health system.’ Available at:
https://cascadescanada.ca/about/.

Centre for sustainable healthcare (2022) ‘What we do, guided by the principles of sustainable clinical
practice’. Available at: https://sustainablehealthcare.org.uk/what-we-do.

Cohen, O. et al. (2020) ‘Health-Care Services as a Platform for Building Community Resilience among
Minority Communities: An Israeli Pilot Study during the COVID-19 Outbreak’, International Journal of
Environmental Research and Public Health, 17(20), p. 7523. Available at:
https://doi.org/10.3390/ijerph17207523.

College of Family Physicians of Canada (2022) ‘Thirteen Test and Treatments to Question’, Family
Medicine. Available at: https://choosingwiselycanada.org/recommendation/family-medicine/.

Current state of social prescribing in Canada (2022). Summary Report. Available at:
https://www.bridgeable.com/wp-content/uploads/Bridgeable-CISP-Social-Prescribing-Phase-1-
Summary-Report.pdf.

Dalglish, S.L., Poulsen, M.N. and Winch, P.J. (2013) ‘Localization of health systems in low- and middle-
income countries in response to long-term increases in energy prices’, Globalization and Health, 9(1), p.
56. Available at: https://doi.org/10.1186/1744-8603-9-56.

Desborough, J. et al. (2020) ‘Australia’s national COVID -19 primary care response’, Medical Journal of
Australia, 213(3), p. 104. Available at: https://doi.org/10.5694/mja2.50693.

Doubova, S.V. et al. (2021) ‘Disruption in essential health services in Mexico during COVID-19: an
interrupted time series analysis of health information system data’, BMJ Global Health, 6(9), p. e006204.
Available at: https://doi.org/10.1136/bmjgh-2021-006204.

Doubova, S.V. et al. (2022) ‘The road to recovery: an interrupted time series analysis of policy intervention
to restore essential health services in Mexico during the COVID-19 pandemic’, Journal of Global Health,
12, p. 05033. Available at: https://doi.org/10.7189/jogh.12.05033.

Dupraz, J. and Burnand, B. (2021) ‘Role of Health Professionals Regarding the Impact of Climate Change
on Health—An Exploratory Review’, International Journal of Environmental Research and Public Health,
18(6), p. 3222. Available at: https://doi.org/10.3390/ijerph18063222.

Ebi, K.L. et al. (2008) Effects of Global Change on Human Health. Washington, DC, USA: U.S. Climate
Change Science Program and the Subcommittee on Global Change Research, U.S. Environmental
Protection Agency (Analyses of the effects of global change on human health and welfare and human
systems).

Eckelman, M.J., Sherman, J.D. and MacNeill, A.J. (2018) ‘Life cycle environmental emissions and health
damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis’,

21
PLOS Medicine. Edited by J.A. Patz, 15(7), p. e1002623. Available at:
https://doi.org/10.1371/journal.pmed.1002623.

Foroughi, Z. et al. (2022) ‘Hospitals during economic crisis: a systematic review based on resilience system
capacities framework’, BMC Health Services Research, 22(1), p. 977. Available at:
https://doi.org/10.1186/s12913-022-08316-4.

Forsgren, L. et al. (2022) ‘Health systems resilience in practice: a scoping review to identify strategies for
building resilience’, BMC Health Services Research, 22(1), p. 1173. Available at:
https://doi.org/10.1186/s12913-022-08544-8.

Franzosa, E. et al. (2022) ‘Home Health Aides’ Increased Role in Supporting Older Veterans and Primary
Healthcare Teams During COVID-19: a Qualitative Analysis’, Journal of General Internal Medicine, 37(8),
pp. 1830–1837. Available at: https://doi.org/10.1007/s11606-021-07271-w.

Fundar; Oxfam; CIEMP (no date) ‘La Vacuna contra la desigualdad’. Available at:
https://lavacunacontraladesigualdad.org/.

Godin, K. et al. (2015) ‘Applying systematic review search methods to the grey literature: a case study
examining guidelines for school-based breakfast programs in Canada’, Systematic Reviews, 4(1), p. 138.
Available at: https://doi.org/10.1186/s13643-015-0125-0.

Gonzalez Holguera, J., Niwa, N. and Senn, N. (2020) ‘Health & Environment Co-benefits: concepts and
recommendations for clinical practice’, Health and Environment [Preprint]. Available at:
https://www.revmed.ch/view/727724/5691286/RMS_714-2_5.pd.

González-Block, M.Á., Gutiérrez-Calderón, E. and Sarti, E. (2022) ‘COVID-19 Vaccination Hesitancy in

Mexico City among Healthy Adults and Adults with Chronic Diseases: A Survey of Complacency,
Confidence, and Convenience Challenges in the Transition to Endemic Control’, Vaccines, 10(11), p. 1944.
Available at: https://doi.org/10.3390/vaccines10111944.

Gonzalez-Holguera, J. et al. (2022) ‘Translating Planetary Health Principles Into Sustainable Primary Care
Services’, Frontiers in Public Health, 10, p. 931212. Available at:
https://doi.org/10.3389/fpubh.2022.931212.

Green, E.I.H. et al. (2009) ‘Preparing Australian medical students for climate change’, Australian Family
Physician, 38(9), pp. 726–729.

Guerra, G. et al. (2018) ‘Loss of job-related right to healthcare associated with employment turnover:
challenges for the Mexican health system’, BMC Health Services Research, 18(1), p. 457. Available at:
https://doi.org/10.1186/s12913-018-3283-7.

Haines, A. (2017) ‘Health co-benefits of climate action’, The Lancet Planetary Health, 1(1), pp. e4–e5.
Available at: https://doi.org/10.1016/S2542-5196(17)30003-7.

22
Haines, A. and Ebi, K. (2019) ‘The Imperative for Climate Action to Protect Health’, New England Journal
of Medicine. Edited by C.G. Solomon, 380(3), pp. 263–273. Available at:
https://doi.org/10.1056/NEJMra1807873.

Haldane, V. et al. (2021) ‘Health systems resilience in managing the COVID-19 pandemic: lessons from 28
countries’, Nature Medicine, 27(6), pp. 964–980. Available at: https://doi.org/10.1038/s41591-021-
01381-y.

Hathaway, J. and Maibach, E.W. (2018) ‘Health Implications of Climate Change: a Review of the Literature
About the Perception of the Public and Health Professionals’, Current Environmental Health Reports, 5(1),
pp. 197–204. Available at: https://doi.org/10.1007/s40572-018-0190-3.

Health Care Without Harm (2019) ‘Helath Care´s climate footprint’. ARUP. Available at:
https://www.arup.com/perspectives/publications/research/section/healthcares-climate-footprint.

Health Metrics and Evaluation (2023) Global Burden of Disease (GBD). Health Metrics and Evaluation
(IHME). Available at: https://www.healthdata.org/gbd.

Hernández-Galdamez, D.R. et al. (2020) ‘Increased Risk of Hospitalization and Death in Patients with
COVID-19 and Pre-existing Noncommunicable Diseases and Modifiable Risk Factors in Mexico’, Archives
of Medical Research, 51(7), pp. 683–689. Available at: https://doi.org/10.1016/j.arcmed.2020.07.003.

Hickel, J. and Slameršak, A. (2022) ‘Existing climate mitigation scenarios perpetuate colonial inequalities’,
Lancet Planet Health, 6, pp. e628-31.

Holmner, Å. et al. (2014) ‘Carbon Footprint of Telemedicine Solutions - Unexplored Opportunity for
Reducing Carbon Emissions in the Health Sector’, PLoS ONE. Edited by I. Linkov, 9(9), p. e105040. Available
at: https://doi.org/10.1371/journal.pone.0105040.

Institute of Medicine’s Quality of Health Care in America (2001) Crossing the Quality Chasm: A New Health
System for the 21st Century. Washington, D.C.: National Academies Press, p. 10027. Available at:
https://doi.org/10.17226/10027.

Khalil, M., Mataria, A. and Ravaghi, H. (2022) ‘Building resilient hospitals in the Eastern Mediterranean
Region: lessons from the COVID-19 pandemic’, BMJ Global Health, 7(Suppl 3), p. e008754. Available at:
https://doi.org/10.1136/bmjgh-2022-008754.

Khobragade, R.N. et al. (2022) ‘Health system resilience: Ensuring TB services during COVID-19 pandemic
in Kerala, India’, Indian Journal of Tuberculosis, 69(4), pp. 427–431. Available at:
https://doi.org/10.1016/j.ijtb.2021.10.004.

Kinder, K. et al. (2021) ‘Integrating primary care and public health to enhance response to a pandemic’,
Primary Health Care Research & Development, 22, p. e27. Available at:
https://doi.org/10.1017/S1463423621000311.

23
Kotcher, J. et al. (2021) ‘Views of health professionals on climate change and health: a multinational
survey study’, The Lancet Planetary Health, 5(5), pp. e316–e323. Available at:
https://doi.org/10.1016/S2542-5196(21)00053-X.

Kulkarni, M.A., Duguay, C. and Ost, K. (2022) ‘Charting the evidence for climate change impacts on the
global spread of malaria and dengue and adaptive responses: a scoping review of reviews’, Globalization
and Health, 18(1), p. 1. Available at: https://doi.org/10.1186/s12992-021-00793-2.

Lenzen, M. et al. (2020) ‘The environmental footprint of health care: a global assessment’, The Lancet
Planetary Health, 4(7), pp. e271–e279. Available at: https://doi.org/10.1016/S2542-5196(20)30121-2.

Li, D., Howe, A.C. and Astier-Peña, M.-P. (2021) ‘Primary health care response in the management of
pandemics: Learnings from the COVID-19 pandemic’, Atención Primaria, 53, p. 102226. Available at:
https://doi.org/10.1016/j.aprim.2021.102226.

Litke, N. et al. (2022) ‘Building resilience in German primary care practices: a qualitative study’, BMC
Primary Care, 23(1), p. 221. Available at: https://doi.org/10.1186/s12875-022-01834-4.

Lugten, E. et al. (2023) ‘From fragility to resilience: A systems approach to strengthen primary health care’,
Frontiers in Public Health, 10, p. 1073617. Available at: https://doi.org/10.3389/fpubh.2022.1073617.

MacNeill, A.J., McGain, F. and Sherman, J.D. (2021) ‘Planetary health care: a framework for sustainable
health systems’, The Lancet Planetary Health, 5(2), pp. e66–e68. Available at:
https://doi.org/10.1016/S2542-5196(21)00005-X.

Marchildon, G.P., Allin, S. and Merkur, S. (2020) ‘Canada: Health System Review’, Health Systems in
Transition, 22(3), pp. 1–194.

Mash, R. (2022) ‘The contribution of family physicians to African health systems’, African Journal of
Primary Health Care & Family Medicine, 14(1). Available at: https://doi.org/10.4102/phcfm.v14i1.3651.

Mashange, W. et al. (2019) ‘Flexibility of deployment: challenges and policy options for retaining health
workers during crisis in Zimbabwe’, Human Resources for Health, 17(1), p. 39. Available at:
https://doi.org/10.1186/s12960-019-0369-1.

Matenge, S. et al. (2022) ‘Ensuring the continuation of routine primary care during the COVID-19
pandemic: a review of the international literature’, Family Practice, 39(4), pp. 747–761. Available at:
https://doi.org/10.1093/fampra/cmab115.

Mayhew, S.H. et al. (2021) ‘Responding to the 2018–2020 Ebola Virus Outbreak in the Democratic
Republic of the Congo: Rethinking Humanitarian Approaches’, Risk Management and Healthcare Policy,
Volume 14, pp. 1731–1747. Available at: https://doi.org/10.2147/RMHP.S219295.

McDarby, G. et al. (2023) ‘A synthesis of concepts of resilience to inform operationalization of health

systems resilience in recovery from disruptive public health events including COVID-19’, Frontiers in Public
Health, 11, p. 1105537. Available at: https://doi.org/10.3389/fpubh.2023.1105537.

24
Miller, N.P. et al. (2018) ‘Community health workers during the Ebola outbreak in Guinea, Liberia, and
Sierra Leone’, Journal of Global Health, 8(2), p. 020601. Available at:
https://doi.org/10.7189/jogh.08.020601.

de Milliano, C. et al. (2015) ‘Resilience: The Holy Grail or Yet Another Hype?’, in P. Gibbons and H.-J.
Heintze (eds) The Humanitarian Challenge. Cham: Springer International Publishing, pp. 17–30. Available
at: https://doi.org/10.1007/978-3-319-13470-3_2.

Morris, M., Boruff, J.T. and Gore, G.C. (2017) ‘Scoping reviews: establishing the role of the librarian’,
Journal of the Medical Library Association, 104(4). Available at: https://doi.org/10.5195/jmla.2016.156.

Mortimer, F. et al. (2018) ‘Sustainability in quality improvement: redefining value’, Future Healthcare
Journal, 5(2), pp. 88–93. Available at: https://doi.org/10.7861/futurehosp.5-2-88.

Nguyen, N.P.T. et al. (2020) ‘Preventive behavior of Vietnamese people in response to the COVID-19
pandemic’, PLOS ONE. Edited by J.C. West, 15(9), p. e0238830. Available at:
https://doi.org/10.1371/journal.pone.0238830.

OECD (2023) Ready for the Next Crisis? Investing in Health System Resilience. OECD (OECD Health Policy
Studies). Available at: https://doi.org/10.1787/1e53cf80-en.

OECD Indicators (2021) ‘Pharmaceutical consumption’, Health at a Glance 2021. Available at:
https://www.oecd-ilibrary.org/sites/5689c05c-en/index.html?itemId=/content/component/5689c05c-
en.

Ouzzani, M. et al. (2016) ‘Rayyan—a web and mobile app for systematic reviews’, Systematic Reviews,
5(1), p. 210. Available at: https://doi.org/10.1186/s13643-016-0384-4.

Palacio-Mejía, L.S. et al. (2022) ‘Leading causes of excess mortality in Mexico during the COVID-19
pandemic 2020–2021: A death certificates study in a middle-income country’, The Lancet Regional Health
- Americas, 13, p. 100303. Available at: https://doi.org/10.1016/j.lana.2022.100303.

Papanicolas, L. et al. (2022) Health system performance assessment: a framework for policy analysis.
Geneva: World Health Organization. Available at:
https://apps.who.int/iris/bitstream/handle/10665/352686/9789240042476-
eng.pdf?sequence=1&isAllowed=y.

Paul, J. and Criado, A.R. (2020) ‘The art of writing literature review: What do we know and what do we
need to know?’, International Business Review, 29(4), p. 101717. Available at:
https://doi.org/10.1016/j.ibusrev.2020.101717.

Pencheon, D. and Wight, J. (2020) ‘Making healthcare and health systems net zero’, BMJ, p. m970.
Available at: https://doi.org/10.1136/bmj.m970.

25
Pérez Ortega, R. (2020) ‘Mexico’s coronavirus czar faces criticism as COVID-19 surges’, Scienceinsider, 9
December. Available at: https://www.science.org/content/article/mexico-s-coronavirus-czar-faces-
criticism-covid-19-surges.

Pétrin-Desrosiers, C. et al. (2022) ‘Policy brief for Canada’. The Lancet Countdown on Health and Climate
Change. Available at:
https://cpha.ca/sites/default/files/uploads/advocacy/2022_lancet/2022_Lancet_Countdown_Canada_P
olicy_Brief_e.pdf.

Plagg, B. et al. (2021) ‘Primary Health Care and Hospital Management During COVID-19: Lessons from
Lombardy’, Risk Management and Healthcare Policy, Volume 14, pp. 3987–3992. Available at:
https://doi.org/10.2147/RMHP.S315880.

Poitras, M.-E. et al. (2022) ‘Chronic conditions patient’s perception of post-COVID-19 pandemic
teleconsulting continuation in primary care clinics: a qualitative descriptive study’, BMJ Open, 12(12), p.
e066871. Available at: https://doi.org/10.1136/bmjopen-2022-066871.

Rasanathan, K. and Evans, T.G. (2020) ‘Primary health care, the Declaration of Astana and COVID-19’,
Bulletin of the World Health Organization, 98(11), pp. 801–808. Available at:
https://doi.org/10.2471/BLT.20.252932.

Rasheed, F.N. et al. (2021) ‘Decarbonising healthcare in low and middle income countries: potential
pathways to net zero emissions’, BMJ, p. n1284. Available at: https://doi.org/10.1136/bmj.n1284.

Ray, S. et al. (2022) ‘Climate change, disaster management and primary health care in Zimbabwe’, African
Journal of Primary Health Care & Family Medicine, 14(1). Available at:
https://doi.org/10.4102/phcfm.v14i1.3684.

Redvers, N. (2021) ‘Patient-Planetary Health Co-benefit Prescribing: Emerging Considerations for Health
Policy and Health Professional Practice’, Frontiers in Public Health, 9, p. 678545. Available at:
https://doi.org/10.3389/fpubh.2021.678545.

Romanello, M. et al. (2022) ‘The 2022 report of the Lancet Countdown on health and climate change:
health at the mercy of fossil fuels’, The Lancet, 400(10363), pp. 1619–1654. Available at:
https://doi.org/10.1016/S0140-6736(22)01540-9.

Rosenfeld, L.A. et al. (2011) ‘Extending the Reach: Local Health Department Collaboration With
Community Pharmacies in Palm Beach County, Florida for H1N1 Influenza Pandemic Response’, Journal
of Public Health Management and Practice, 17(5), pp. 439–448. Available at:
https://doi.org/10.1097/PHH.0b013e31821138ae.

Rousseau, A., Bevort, H. and Ginot, L. (2020) ‘La santé publique au risque de la COVID19 : du premier
retour d’expérience à la formulation de nouvelles exigences collectives:’, Santé Publique, Vol. 32(2), pp.
183–187. Available at: https://doi.org/10.3917/spub.202.0183.

26
Sagan, A. et al. (2021) Health systems resilience during COVID-19 lessons for building back better.
Copenhagen, Denmark: WHO Regional Office for Europe.

Schneider, M.P., Sommer, J. and Senn, N. (2019) ‘[Sustainable drug prescription: shared perspectives
between physicians and pharmacists]’, Revue Medicale Suisse, 15(650), pp. 942–946.

Simen-Kapeu, A. et al. (2021) ‘Strengthening the community health program in Liberia: Lessons learned
from a health system approach to inform program design and better prepare for future shocks’, Journal
of Global Health, 11, p. 07002. Available at: https://doi.org/10.7189/jogh.11.07002.

Stengel, S. et al. (2022) ‘Resilience of the primary health care system – German primary care practitioners’
perspectives during the early COVID-19 pandemic’, BMC Primary Care, 23(1), p. 203. Available at:
https://doi.org/10.1186/s12875-022-01786-9.

Tariq, A. et al. (2021) ‘Transmission dynamics and forecasts of the COVID-19 pandemic in Mexico, March-
December 2020’, PLOS ONE. Edited by M. Adrish, 16(7), p. e0254826. Available at:
https://doi.org/10.1371/journal.pone.0254826.

Thomas, S. et al. (2013) ‘A framework for assessing health system resilience in an economic crisis: Ireland
as a test case’, BMC Health Services Research, 13(1), p. 450. Available at: https://doi.org/10.1186/1472-
6963-13-450.

Thomas, S., Sagan, A. and Larkin, J. (2020) Strengthening health systems resilience. World Health
Organization and European Observatory on Health Systems and Policies. Available at:
https://apps.who.int/iris/bitstream/handle/10665/332441/Policy-brief%2036-1997-8073-
eng.pdf?sequence=1&isAllowed=y.

Tsagkaris, C. et al. (2021) ‘Using telemedicine for a lower carbon footprint in healthcare: A twofold tale of
healing’, The Journal of Climate Change and Health, 1, p. 100006. Available at:
https://doi.org/10.1016/j.joclim.2021.100006.

Tumusiime, P. et al. (2020) ‘Building health system resilience in the context of primary health care
revitalization for attainment of UHC: proceedings from the Fifth Health Sector Directors’ Policy and
Planning Meeting for the WHO African Region’, BMC Proceedings, 14(S19), p. 16. Available at:
https://doi.org/10.1186/s12919-020-00203-2.

Turner, S. (2022) ‘“We are all vulnerable, we are all fragile”: COVID-19 as opportunity for, or constraint
on, health service resilience in Colombia?’, Public Management Review, pp. 1–22. Available at:
https://doi.org/10.1080/14719037.2022.2052944.

Van Daalen, K.R. et al. (2022) ‘The 2022 Europe report of the Lancet Countdown on health and climate
change: towards a climate resilient future’, The Lancet Public Health, 7(11), pp. e942–e965. Available at:
https://doi.org/10.1016/S2468-2667(22)00197-9.

27
Verhoeven, V. et al. (2020) ‘Impact of the COVID-19 pandemic on the core functions of primary care: will
the cure be worse than the disease? A qualitative interview study in Flemish GPs’, BMJ Open, 10(6), p.
e039674. Available at: https://doi.org/10.1136/bmjopen-2020-039674.

Wang, H. et al. (2022) ‘Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis
of COVID-19-related mortality, 2020–21’, The Lancet, 399(10334), pp. 1513–1536. Available at:
https://doi.org/10.1016/S0140-6736(21)02796-3.

Willson, K.A., FitzGerald, G.J. and Lim, D. (2021) ‘Disaster Management in Rural and Remote Primary
Health Care: A Scoping Review’, Prehospital and Disaster Medicine, 36(3), pp. 362–369. Available at:
https://doi.org/10.1017/S1049023X21000200.

WONCA-PHA (2019) ‘Declaration calling for family doctors of the world to act on planetary health’.
Available at: https://www.icgp.ie/speck/properties/asset/asset.cfm?type=Document&id=CA708B09-
F3D6-4191-BE7B265B3CE8DA9D&property=document&filename=2019_Planetary_health_-
_WONCA.pdf&revision=tip&mimetype=application%2Fpdf&app=icgp&disposition=inline.

Wong, Z.S.-Y. and Rigby, M. (2022) ‘Identifying and addressing digital health risks associated with
emergency pandemic response: Problem identification, scoping review, and directions toward evidence-
based evaluation’, International Journal of Medical Informatics, 157, p. 104639. Available at:
https://doi.org/10.1016/j.ijmedinf.2021.104639.

World Health Organization (2015) Operational framework for building climate resilient health systems.
Geneva: World Health Organization. Available at: https://apps.who.int/iris/handle/10665/189951
(Accessed: 29 May 2023).

World Health Organization (2017) Environmentally sustainable health systems: a strategic document.
WHO Regional Office for Europe. Available at: https://www.who.int/publications/i/item/WHO-EURO-
2017-2241-41996-57723.

World Health Organization (2021a) Building health systems resilience for universal health coverage and
health security during the COVID-19 pandemic and beyond: WHO position paper. Geneva. Available at:
(WHO/UHL/PHCSP/2021.01.

World Health Organization (2021b) WHO health and climate change global survey report. Geneva.
Available at: https://apps.who.int/iris/bitstream/handle/10665/348068/9789240038509-
eng.pdf;sequence=1.

World Health Organization (2022a) Alliance for Transformative Action on Climate and Health (ATACH).
Available at: https://www.who.int/initiatives/alliance-for-transformative-action-on-climate-and-
health/country-commitments.

World Health Organization (2022b) ‘Health systems resilience toolkit: a WHO global public health good to
support building and strengthening of sustainable health systems resilience in countries with various
contexts’. Available at: https://www.who.int/publications/i/item/9789240048751.

28
World Health Organization (2022c) Primary health care: making our commitments happen. Realizing the
potential of primary health care: lessons learned from the COVID-19 pandemic and implications for future
directions in the WHO European Region. Copenhagen, Denmark: WHO Regional Office for Europe.
Available at: https://reliefweb.int/report/world/primary-health-care-making-our-commitments-happen-
realizing-potential-primary-health-care-lessons-learned-covid-19-pandemic-and-implications-future-
directions-who-european-region.

World Health Organization & United Nations Children’s Fund (2018) A vision for primary health care in
the 21st century: towards universal health coverage and the Sustainable Development Goals. Available
at: https://apps.who.int/iris/handle/10665/328065.

World Health Organization & United Nations Children’s Fund (2022) ‘Primary health care measurement
framework and indicators: monitoring health systems through a primary health care lens’. Available at:
https://www.who.int/publications/i/item/9789240044210.

Xie, E. et al. (2018) ‘Challenges and opportunities in planetary health for primary care providers’, The
Lancet Planetary Health, 2(5), pp. e185–e187. Available at: https://doi.org/10.1016/S2542-
5196(18)30055-X.

Xie, E. et al. (2021) ‘Acting on climate change for a healthier future: Critical role for primary care in
Canada’, Canadian Family Physician, 67(10), pp. 725–730. Available at:
https://doi.org/10.46747/cfp.6710725.

29