Public Health Adaptation to Climate Change in OECD Countries

Climate change is a major challenge facing public health. National governments play a key role in public health adaptation to climate change, but there are competing views on what responsibilities and obligations this will—or should—include in different nations. This study aims to: (1) examine how national-level public health adaptation is occurring in Organization for Economic Cooperation and Development (OECD) countries; (2) examine the roles national governments are taking in public health adaptation; and (3) critically appraise three key governance dimensions of national-level health adaptation—cross-sectoral collaboration, vertical coordination and national health adaptation planning—and identify practical examples suited to different contexts. We systematically reviewed publicly available public health adaptation to climate change documents and webpages by national governments in ten OECD countries using systematic web searches, assessment of self-reporting, and content analysis. Our findings suggest national governments are primarily addressing infectious disease and heat-related risks posed by climate change, typically emphasizing capacity building or information-based groundwork initiatives. We find national governments are taking a variety of approaches to public health adaptation to climate change that do not follow expected convergence and divergence by governance structure. We discuss practical options for incorporating cross-sectoral collaboration, vertical coordination and national health adaptation planning into a variety of contexts and identify leaders national governments can look to to inform their public health adaptation planning. Following the adoption of the Paris Agreement and subsequent increased momentum for adaptation, research tracking adaptation is needed to define what health adaptation looks like in practice, reveal insights that can be taken up across states and sectors, and ensure policy orientated learning.


Appendix D: Health Adaptation Initiatives Classified by Adaptation Type
We classified each discrete public health adaptation initiative as one of five types of adaptation, adapted from Biagini et al. [3]: capacity building; management, planning & policy; practice & behaviour; information; and warning or observing systems. However, there is significant variation in the instruments or mechanisms used within each adaptation type. Table S4 shows all of the public health adaptation initiatives reviewed for the six countries with the highest number of initiatives reviewed broken down by sub-categories of the capacity building, information, and management, planning & policy adaptation types for each country. Practice & behaviour and warning or observing systems initiatives are also shown by country, but are not divided into sub-categories given the low number.  Note: For some health adaptation initiatives reviewed, the responsible department, agency or other body was not specified. Table S6. Background information on included countries' adaptation planning and health system.

Australia
Following the Council of Australian Governments (CoAG) request for a national adaptation framework in its Plan of Collaborative Action on Climate Change [4], the Department of Climate Change and Energy Efficiency prepared the country's National Climate Change Adaptation Framework in 2007 [5]. This framework was designed to outline a future agenda for collaboration between governments to support decision-makers [5]. The framework's two priority areas for potential action are: (1) Building understanding and adaptive capacity; and (2) Reducing vulnerability in key sectors and regions [5]. The framework states that a follow-up implementation plan would be developed in 2007, and that the Australian Health Ministers' Conference would develop and implement a national action plan on climate change and health by 2010 [5], however neither of these two documents were ultimately developed. The Australian Government did, however, release a climate change adaptation position paper in 2010, which sets out the Government's vision for adaptation and proposes practical steps [6]. The position paper outlines the national government role in adaptation as: maintaining a strong, flexible economy and a social safety net; leading national reform; managing Commonwealth assets and programs; and national science and information [6]. Though human health is not identified as one of the initial national priorities for adaptation action, it is a priority research theme for the National Climate Change Adaptation Research Facility [6].
Australia has a federal, decentralized and coordinated state structure [7,8]. The sub-national states have the primary responsibility for public health and the delivery of population health services, and receive funding from the national government [9,10]. Accordingly, the states have a stronger influence on the local level than the national government [9].

Belgium
Coordination in multi-level governance is a key aspect of Belgium's climate change adaptation planning. The Commission Nationale de Climat (CNC) [National Climate Commission] was created as part of Article 3 of the 2003 Climate Cooperation Agreement to implement and monitor the Agreement, to harmonize the climate policies developed by the federal and regional governments and to create synergies between them [11]. The CNC is comprised of representatives from the federal and regional governments [12]. Under the instruction of the CNC, the federal and regional governments prepared the National Climate Change Adaptation Strategy together in 2010 [12]. In 2013 the federal government published a draft Projet de Plan Fédéral 'Adaptation aux changements climatiques' [Federal Plan Project 'Climate change adaptation'] [13], which was subsequently improved by a public consultation held in 2014 [14]. The Flemish Region published a draft Regional Plan for Adaptation to Climate Change in 2013, and the Walloon and Brussels regions are expected to finalize their plans soon [15]. Together, the finalized federal and regional government climate change adaptation plans will form the basis for a future National Adaptation Plan [15].
As a formerly centralized government that began the process of federalism over four decades ago, Belgium has a complex and unique system [16]. At the sub-national level, policy authority has been granted to three territorial authorities (regions) and to three linguistic communities [16]. Social security and health care have been contentious issues in debates of policy devolution in Belgium [16]. Decision-making and implementation of health care policy is fragmented among the federal and sub-national governments [17]. Health policy largely remains under the authority of the federal government, as part of its social security responsibility, but it is the communities that are responsible for public health [16]. At the federal level, the Environment Department of the Federal Public Service (FPS) Health, Food Chain Safety and Environment is responsible for matters concerning climate change [17].

Canada
The Federal Adaptation Policy Framework serves as Canada's adaptation strategy, and outlines the federal role in climate change adaptation: mainstreaming adaptation into policy, generating and sharing knowledge, and capacity building [18]. In 2005, the Canadian Intergovernmental Climate Change Impacts and Adaptation Working Group released the National Climate Change Adaptation Framework, a collaboration between federal and provincial departments and ministries, but the framework was not approved by the federal government and never followed up on [19,20]. Natural Resources Canada has published three vulnerability assessments since 2004 [21][22][23], alternating between sectoral and regional approaches, and Health Canada has also published a vulnerability assessment focussing on the health sector [24]. The Clean Air Agenda was developed in 2009 as part of the national government's efforts to tackle climate change and air pollution. Though otherwise focussed on mitigation, the adaptation theme of the Clean Air Agenda includes several adaptation programs led by Aboriginal Affairs and Northern Development Canada (AANDC), Natural Resources Canada, Health Canada, Environment Canada and the Public Health Agency of Canada.
Canada has a federal, decentralized system where health is primarily the responsibility of the 10 provinces and three territories [25]. Each province and territory has their own legislation and regulations for the governance of administration of health care, although the federal government does have some 'steering' responsibilities under the Canada Health Act [25]. Under this decentralized system, Canada's national-level approach to health adaptation has been to prepare vulnerability assessments and conduct research, then allow sub-national governments to use this information as they see fit.
France Adaptation first emerged in France with the founding of the Observatoire national sur les effets du réchauffement climatique [National observatory on the effects of global warming] (ONERC) in 2001, followed by the adoption of a national adaptation strategy in 2006 [26]. France was one of the first European countries to develop a national adaptation strategy (along with Spain and Finland) [27]. In 2011 France adopted a national climate change adaptation plan [26], which outlines five overarching objectives guiding French health adaptation to climate change:  Strengthen climate-health research  Establish or strengthen surveillance of risk factors that can be influenced by climatic conditions (extreme events)  Assess the risk of consequences to human health related to extreme events and appraise the health impacts of adaptation measures, particularly through the creation of the health and climate monitoring group  Develop preventative health measures taking into account the consequences of extreme events and adapt vigilance and warning systems  Raise awareness and educate all stakeholders through targeted training, information and communication Prior to the development of the national climate change adaptation plan, the Agence française de sécurité sanitaire des aliments (Afssa) [French food safety agency] also prepared a report on the evaluation of the risk of occurrence and development of animal diseases considering possible global warming [28]. Health is one of several priority sectors for adaptation in France, in part because of its crosscutting nature and implications for other sectors.
France has a unitary, coordinated, formally centralized government where health is primarily centralized to the national government [8,29]. Moreover, the 2004 Public Health Act firmly established the responsibility of the central state in public health matters, but also emphasized the role of the regional level for organizational issues [29].

Ireland
Ireland's National Climate Change Adaptation Framework, adopted in 2012, guides the country's adaptation response, led by the Department of the Environment, Community and Local Government [30]. The Framework directs local authorities and key climate-sensitive sectors (identified as water, marine, agriculture, forestry, biodiversity, energy, transport, communications, insurance, heritage and health) to develop draft adaptation plans, to be published by mid-2014 [30]. The health sector has yet to publish its draft adaptation plan, but the Department of Health's Statement of Strategy 2015-2017 highlights a health sector climate change adaptation plan as a deliverable for that period [31].
The Department of the Environment, Community and Local Government leads and coordinates national adaptation policy to ensure coordination across scales and sectors, particularly for issues that cut across sectors [30]. Ireland describes its "multi-level governance approach" to adaptation as involving (among other aspects): preparing periodic reports on adaptation and anticipated long-range adaptation costs and avoided damages; engagement with key stakeholders to explore impacts and responses; procedures and capacity to undertake emergency response measures when extreme weather events occur; and continued research on climate change impacts [30]. Beyond these examples, the national government does not identify more explicitly how it will put into action the coordination across scales and sectors it describes.
Ireland has a unitary, centralized government and a national health insurance health care system [7,32]. In Ireland's health care system, the central government administers the provision of services and regulation, though this responsibility was previously held by decentralized regional health boards until a reform implemented in 2005 [33]. Public health services are also now centralized to the national government [33].
Luxembourg Luxembourg adopted a National Adaptation Strategy in 2011 which prioritizes biodiversity, water, agriculture and forestry [34]. The strategy does not address the health sector, but Luxembourg's Sixth National Communication to the UNFCCC discusses plans to include additional sectors, including health, to the strategy in the future [34].
Luxembourg has a unitary, centralized democracy [7]. The health care system is similarly centralized with little decentralization to the sub-national level [35].

New Zealand
In New Zealand statutory responsibility for consideration of climate change is devolved to local governments [36]. Under the Resource Management Act Section 7(i) amended in 2004, local governments are required to have particular regard for the effects of climate change [37]. Under this institutional arrangement, the central government sets frameworks but devolves powers and functions to sub-national governments [36]. The central New Zealand government has developed adaptation guidance documents for local governments [38], but has not published any national adaptation planning documents.
Though statutory responsibility for adaptation has been devolved to sub-national governments, New Zealand has the most centralized framework for public health, next to Singapore [10]. New Zealand's health system has undergone many reforms in recent decades, moving toward increased centralization [39]. The national government has more direct control over the health system and health services than most other highincome countries due to its concentrated constitutional power, its dominance over health funding, and in its role as the main provider of hospital services. Due to the lack of literature, it is unclear how the public health risks of climate change will be addressed given the conflicting mandates for local adaptation and national health planning.

Switzerland
In 2011 the Swiss federal government implemented the loi sur le CO2 [CO2 Act] (updated in 2013) which includes an article requiring coordination of adaptation measures [40]. The federal government (hereafter the Confederation) released its first adaptation strategy in 2012 [41], which was then further developed into an action plan in 2014 [42]. The Federal Office for the Environment (OFEV) is responsible for the overall development and cross-sectoral coordination of the national adaptation strategy and action plan, as well as vertical coordination with sub-national governments. It shares responsibility with the Federal Office of Public Health (OFSP) for health sector adaptation measures [41,42].
Switzerland is a federal, decentralized democracy, with 26 sub-national cantons [7]. The cantons have the most responsibility for the health system, and each canton has its own health policies and laws [43]. The Swiss health system is fragmented and thus lacks a consistent national health policy [43].
Adaptation to climate change in the health sector appears to have more mechanisms for coordination than the characterization of the Swiss health system overall. The Swiss adaptation action plan clearly lays out that the Confederation will work with sub-national governments and which sectors will work together on cross-sectoral issues [42]. The Confederation plans to support the cantons, municipalities and cities already working actively on adaptation by supplying targeted information. For instance, the Confederation prepared a climate change adaptation guidebook for Swiss municipalities, including consideration of health [44]. One of the Confederation's objectives is to collaborate by ensuring transfer of knowledge between levels and also to coordinate adaptation strategies and measures to ensure the needs of the cantons, cities and municipalities are included in the implementation and development of the national adaptation strategy, while ensuring that adaptation in Switzerland is performed consistently and efficiently. The cantons must submit reports every four to six years (beginning in 2015) to the OFEV detailing their planned or implemented adaptation measures. The OFEV will compile the results as a basis for coordination and consider them for further developing the national adaptation strategy [42].

United Kingdom
The United Kingdom was among the first European countries to develop a national adaptation strategy [27]. The Climate Change Act 2008 set out a legislative framework for adaptation, requiring preparation of a National Adaptation Programme and undertaking of regular risk assessments by the government [45,46]. Despite this early legislation and planning work, the earliest health adaptation initiatives identified online are from two 2012 documents and comprise a climate change risk assessment, an assessment of the health effects of climate change in the UK, the creation of the Extreme Events and Health Protection Section (EEHPS) and the creation of the daily hazard assessment (early warning system) [47,48]. The health vulnerability assessment references a 2002 health vulnerability assessment [48], but the 2002 document is no longer available online, and was thus not included in this study.
Most health adaptation initiatives in the United Kingdom are implemented by Department of Health or other agencies that support it, including Public Health England (PHE) and the National Health Service (NHS). In a self-assessment of adaptive capacity, the Department of Health scored itself 7/25 against five levels of progress for each of five themes (leadership, policy and strategy, people, partnerships and processes) [45]. The Committee on Climate Change describes this score as "relatively low considering the significant risk that extreme weather events pose to public health and well-being" [45]. Most health adaptation initiatives are implemented or planned by partnerships between multiple agencies or departments, including several initiatives that include multiple sectors.
Health planning and policy is developed by the central government in the United Kingdom, but there is some decentralization in the implementation of the health system [49]. In a sample of 28 urban areas, 75% were found to consider health aspects in climate change adaptation measures [50]. From 2008 to 2011 the Department for Communities and Local Government implemented the National Indicator Set (NIS), which includes National Indicator (NI) 188: "Planning to Adapt to Climate Change." The rationale behind NI 188 was to "ensure local authority preparedness to manage risks to service delivery, the public, local communities, local infrastructure, businesses and the natural environment from a changing climate, and to make the most of new opportunities" [51]. Though the NIS was abolished in 2011, NI 188 demonstrates one planning instrument a centralized unitary government can use to promote, facilitate and influence adaptation among local authorities [51].

United States
In the last year, public health adaptation to climate change in the United States has made significant progress, driven in part by the President's executive order for each federal agency to prepare for climate change. Executive order 13514 "Federal Leadership in Environmental, Energy and Economic Performance" (October 2009) requires each federal agency to develop, implement and annually update an integrated Strategic Sustainability Performance Plan including an evaluation of the risks posed by climate change and the development of a climate change adaptation plan. The Department of Health and Human Services (DHHS) has subsequently developed a draft climate change adaptation plan and a finalized, comprehensive plan [52,53]. The DHHS adaptation plan is detailed, involves many departments and agencies (including the Department of Veteran Affairs, the National Association of City and County Health Officials (NACCHO) and the Association of State and Territorial Health Officials (ASTHO)), is part of a larger coordinated effort on adaptation (The Interagency Climate Change Adaptation Task Force was developed as part of the Executive Order), and places the DHHS in a leadership role in public health adaptation to climate change in the United States. Based on publically available information, 18 departments, agencies, divisions or offices report implementing or planning health adaptation initiatives, most falling under the jurisdiction of the DHHS. Typically many federal public health programs have a crisis orientation not suited to longer term issues [10], thus the DHHS's comprehensive climate change adaptation plan is a shift from the norm.
The United States is a federal, decentralized democracy where states have explicit authority to protect their residents' health under the US constitution [8,10]. The federal government also has a responsibility to promote public health, but ultimately it must rely on the states for compliance and implementation of federal guidelines [10]. Following the implementation of the Executive Order 13514 and the development of the Interagency Climate Change Adaptation Task Force, the federal government is taking a larger role in national planning and leadership [54]. Currently only 10 out of 50 American states have detailed health sector specific actions recommended, and those are predominantly coastal, democratic states [54]. To date, the federal government has not guided or coordinated state adaptation, and most of the leadership and resources for state adaptation has come from the state level [55].